Every finding on record at Plantation Manor Nursing Home

Based on observations, record review, interviews and review of a facility policy titled, CALL LIGHT, the facility failed to ensure Resident Identifier (RI) #69's call light was in reach for RI #69 to summon staff as needed. This deficient practice was observed on three of three days of the survey and affected RI #69, one of 22 sampled residents. Findings Include: Review of an undated facility policy titled, CALL LIGHT, revealed the following: Purpose: To respond to resident's request and needs. RI #69 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Dementia and Adjustment Disorder with Mixed Anxiety and Depressed Mood. Review of RI #69's at risk for falls care plan, with an initiated date of 06/26/2024, had an intervention to keep RI #69's call light in reach and encourage resident to use for assistance. On 02/18/2026 at 8:00 AM, RI #69 was observed lying in bed with the call light on the floor beneath the bed. On 02/19/2026 at 7:56 AM, RI #69 was again observed lying in bed. RI #69's call light was on the floor beneath the bed. On 02/20/2026 at 9:03 AM, RI #69 was observed lying in bed. The call light was observed on the floor at the head of RI #69's bed. On 02/20/2026 at 2:28 PM, the surveyor conducted an interview with RI #69's assigned Certified Nursing Assistant (CNA) for the 7-3 shift, CNA #8. When asked where a resident's call light should be positioned, CNA #8 said within the resident's reach. CNA #8 said RI #69's call light was on the floor. CNA #8 said RI #69 used his/her call light and it would be important to ensure a resident's call light was within their reach so they could call for help when they needed help. On 02/20/2026 at 4:31 PM, the surveyor conducted an interview with the Director of Nursing (DON). When asked where a resident's call light should be positioned, the DON said within the resident's reach. The DON said it would be important to ensure a resident's call light was within the resident's reach so they could tell staff if they needed anything.

Based on interview, medical record review and a review of a facility policy titled, Activities of Daily Living (ADL) CARE POLICY PROCEDURE, the facility failed to ensure Resident Identifier (RI) #11 a resident dependent on staff for bathing was provided a shower as scheduled for January and February of 2026. This deficient practice affected RI #11; one of two residents sampled for ADL Care. This deficient practice was cited as a result of the investigation of complaint/report number 2742518.Findings Include:A review a facility policy titled, ADL CARE POLICY AND PROCEDURE, with no effective date, documented: PURPOSE: Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity.STANDARD: Guidelines for the provision of hygiene and grooming services are: . shower, tub, complete bed bath.PROCESS: II. Essential Pointsa. Resident preferences for time of day, type of bath and frequency of bath should be honored, .RI #11 was admitted to the facility on [DATE] with a diagnosis of Displaced Fracture of Fifth Metatarsal Bone, Left Foot, Initial Encounter for Closed Fracture. RI #11 was discharged on 02/04/2026. On 01/28/2026 an anonymous complainant alleged that RI #11 had been at the facility for two weeks and only received two baths.RI #11's MDS (Minimal Data Set) with an ARD (Assessment Reference Data) of 01/19/2026 revealed on section GG that resident required substantial/maximal assistance with shower/bathe self. RI #11's Care Plan Report revealed: . Requires limited to total assistance with all ADL's . date initiated 01/04/2026. Interventions. Assist with bath per scheduled and prn. A review of RI #11's Documentation Survey Report for the months of January and February of 2026 revealed no documentation that resident received a shower or bathed self while a resident at the facility. On 02/20/2026 at 9:05 AM an interview was conducted with the Director of Nursing (DON). The DON said that RI #11's shower days were Tuesdays, Thursdays, and Saturdays during the 3PM to 11PM, shift. The DON said staff documented showers provided on the resident's ADL sheet. The DON was asked to review the ADL sheet and she said there was no documented evidence that RI #11 received his/her shower as scheduled during her admission, from 01/13/2026 to 02/04/2026.

Based on observations, interviews, and review of the facility policy titled Catheter Care the facility failed to ensure that Resident Identifier (RI) #77's urinary drainage bag from his/her catheter was maintained in accordance with professional standards of practice and in a manner to prevent infection and maintain dignity. Specifically RI #77's urinary drainage bag observed on a floor mat and without a privacy cover. This placed the drainage system at risk for contamination and resident at risk of urinary tract infection. This deficient practice affected one of three residents observed for urinary catheter maintenance and incontinent care.Findings Include:A review of a facility policy titled, Catheter Care with no effective date revealed:Catheter Care Policy: It is the policy of this facility to ensure residents . receive appropriate catheter care and maintain their dignity .2. catheter drainage bags will be covered at all times.9. Ensure drainage is located below the level of the bladder to discourage backflow of urine.RI #77 was admitted to the facility on [DATE].RI #77's diagnoses to include: Protein-Calorie Malnutrition, Chronic Systolic Congestive Heart Failure, and Muscle Weakness (Generalized). On 02/18/2026 at 9:26 AM during on an observation of RI #77, it was observed that RI #77's urinary drainage bag was on a blue mat on the floor and uncovered. On 02/20/2026, at 11:01 AM an interview with Licensed Practical Nurse (LPN) #15. She stated the catheter bag was not covered. When asked about the facility's protocol for hanging a Foley catheter drainage bag, LPN #15 stated the bag should be hooked to the bed frame. She further acknowledged that placing the catheter bag on the floor could cause infection.On 02/20/2026 at 12:25 PM an interview was conducted with RN #3, Assistant Director of Nursing (ADON) who said she had worked as ADON and Infection Control Nurse for 23 years. RN #3 said staff should use a clamp to hook foley catheter bags to the resident's bed frame.

Based on observations, interviews, record reviews, and the facility policy titled, Weight Monitoring, the facility failed to ensure Resident Identifier (RI) #23, a resident with a history of weight loss, received his/her frozen treat and Ensure as recommended by the Registered Dietitian (RD). At the lunch meal on 02/18/2026, RI #23 did not receive his/her frozen treat and Ensure, and at the lunch meal on 02/20/2026, RI #23 did not receive his/her Ensure. This deficient practice affected RI #23, one of five residents sampled for nutrition.Findings Include: Review of a facility policy titled, Weight Monitoring, with a Copyright date of 2025, revealed the following: . Compliance Guidelines: . The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: . c. Developing and consistently implementing approaches. 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns. The care plan should address the following, to the extent possible: c. Identify resident-specific interventions. 4. Interventions will be. implemented, . consistent with the resident's assessed needs, . RI #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type II Diabetes Mellitus with Hyperglycemia, Generalized Anxiety Disorder and Gastro-Esophageal Reflux Disease with Esophagitis. A review of the RD's Nutritional Recommendations, dated 12/12/2025, revealed RI #23 had a readmission weight loss and a frozen treat was recommended to be given every day due to weight loss. RI #23's at risk nutritional decline and weight change care plan, with an initiated date of 09/25/2025 revealed the intervention to add a supplement was initiated on 12/13/2025. RI #23's Nutrition/Dietary Note, dated 01/02/2026 revealed RI #23 was currently receiving oral nutrition and a frozen treat due to his/her history of weight loss. The note included the following weights for RI #23:12/05/2025-157 pounds11/18/2025- 166 pounds A review of the RD's Nutritional Recommendations, dated 01/02/2025, revealed the RD recommended to continue RI #23's Plan of Care. On 02/18/2026 at 1:13 PM an observation was conducted of RI #23's lunch meal being served. The served meal did not include either supplement. RI #23's frozen nutritional treat and strawberry Ensure was not served during the lunch meal. On 02/20/2026 at 9:07AM an interview was conducted with Licensed Practical Nurse (LPN) #4. The LPN said the kitchen was responsible for providing RI #23 with his/her daily supplements. A review of RI #23's meal tray card for 02/20/2026 revealed RI #23 was to receive the supplements, A Frozen Nutritional Treat and a Strawberry Ensure at the lunch meal. On 02/20/2026 at 12:38 PM an observation was conducted of RI #23's lunch meal being served by Certified Nursing Assistant (CNA) #5. The served meal did not include either supplement. CNA #5 went to the lunch meal cart and returned with RI #23's frozen nutrition treat and did not provide the Ensure. On 02/20/2026 at 12:46 PM an interview was conducted with CNA #5 who said most times the supplements were on the resident's tray, or they would send them up on a separate tray and the staff knew who received what supplement. CNA #5 RI #23's ice cream was sent with the lunch cart and RI #23's Ensure was not. On 02/20/2026 at 4:33 PM an interview was conducted with the Director of Nursing (DON) who confirmed that RI #23 was a resident with weight loss. The DON said RI #23 was ordered the frozen treat and Ensure Plus for the weight loss. The DON said according to RI #23's meal tray card he/she should receive the supplements at lunch time. The DON said dietary and nursing would be responsible to ensure RI #23 received his/her supplements. The DON said nursing would be responsible because if staff saw something that was not on the tray staff went and got it. The DON said it was important for RI #23 to receive his/her supplements because RI #23 had loss weight. On 02/20/2026 at 4:40 PM an interview was conducted with the Dietary Manager (DM). When asked if a resident received a supplement would the supplement come from her department, the DM said yes. The DM said according to RI #23's meal tray card, RI #23 was to receive supplements at lunch time. The DM said a resident would receive a frozen nutritional treat and an Ensure for weight loss. The DM said it would be important for a resident to receive their supplements as ordered so they would not lose more weight. On 02/20/2026 at 5:04 PM a telephone interview was conducted with the RD who said it would be important for the RD recommendations to be followed because that was what the resident was assessed as needing. The RD said even though RI #23 was over his/her Ideal Body Weight, she (the RD) would still address the weight loss. The RD said the supplements were ordered for RI #23's weight loss.

Based on observations and interviews the facility failed to ensure infection control practices were implemented when staff stored unlabeled and uncovered bath basins and bed pans in a shared bathroom. These practices demonstrated improper storage of resident care items and created the potential for cross-contamination.This had the potential to affect RI #77, 1 of 22 sampled residents.Findings Include:On 02/19/2026 at 8:16 AM, observation of a bathroom revealed six bath basins and two bedpans stored without resident identification and without protective covering. One bedpan was observed on the windowsill with a roll of tissue placed inside of the bedpan.On 02/20/2026, at 11:19 AM an interview was conducted with LPN #15 who said she did not know if bed pans were single use items. LPN #15 said bath basins should be washed, dried with a paper towel, placed in a plastic bag, and labeled for the appropriate resident. When asked whether unlabeled and improperly stored bedpans and bath basins could increase the risk of cross-contamination, LPN #15 responded, yes and acknowledged a need for a better labeling system. LPN #15 accompanied surveyor to the shared bathroom and LPN #15 confirmed six bath basins and two bedpans were in the shared bathroom of RI #77. LPN #15 confirmed that one bedpan was in the windowsill and contained a roll of toilet tissue.On 02/20/2026, at 12:40 PM, Registered Nurse (RN) #3, Assistant Director of Nursing (ADON)/Infection Control Nurse stated bed pans were single-use and thrown away after use. The ADON said bath basins were to be washed, dried, placed in a clean garbage bag, labeled with resident's name and stored in the resident's drawer. The ADON confirmed that six bath basins and two bedpans were in the shared bathroom and were not labeled with a resident's name, not stored in bags, and that one of the bedpans contained a roll of toilet tissue. this was not facility procedure. When asked about infection control risks, the ADON stated, uncovered and improperly stored items in shared bathrooms create contamination risks and can lead to infection.

Based on observations, interviews, a review of pest control invoices and a facility document titled, Resident Rights, the facility failed to maintain an effective pest control program as evidenced by dead and alive roaches observed on 12/08-10/2022. This deficient practice had the potential to affect all 87 residents living at the facility on 3 of 3 units. Findings include: A review of an undated facility document titled; Resident Rights revealed: Policy: . 8. Safe environment. The resident has a right to a safe, clean comfortable and homelike environment, . A review of Pest control invoices revealed: . YOUR INVOICE FOR SERVICE ON 08/10/2022 . DESCRIPTION . Monthly . . Service Date: 09/14/2022 . TECHNICIAN COMMENTS: I removed all spider webs from the front entrance with a Webster. I performed an exterior inspection treatment. I also have spoken to (Name of Maintenance Director) before service and there are no issues. . Service Date: 11/04/2022 . TECHNICIAN COMMENTS: I removed all spider webs from the front entrance with a Webster. I performed an exterior inspection treatment. I also inspected and treated the interior common areas. . Service Date: 12/1/2022 . TECHNICIAN COMMENTS: I removed all spider webs from the front entrance with a Webster. I performed an exterior inspection treatment. I also have spoken to (Name of Maintenance Director) and there are having issues with cockroaches. I have treated the room. None of the invoices indicated the pest control company had been called out to address roaches until 12/1/2022 On 12/08/2022 at 5:05 PM, an observation was made of Unit one. Approximately 10 feet from the resident's television, there was a roach that had been smashed on the floor. The roach was dark brown with two wings approximately 1 inch long. During this observation, Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA), said it looked like a water bug that's dead. EI #5 said she had seen roaches just like this one, as she picked the roach up off of the floor, every day. On 12/09/2022 at 6:07 AM, another observation was made of Unit one. A roach was observed approximately 1-1 1/4 inches long running down the hall. The roach went into a resident room. EI #4, the Maintenance Director, joined the observation tour at 6:22 AM in Area of Location (AL) 23. There was a dead mouse in a mouse trap that was stiff and had some cobwebs on it. The next observation with EI #4 was in AL 24. There was a dead roach observed up-side down on the floor. At 6:40 AM, EI #4 killed a roach at AL 29. He described it as 1/4-1/2 inch long. On tour of the facility on 12/09/2022 at 10:42AM, with EI #4, EI #4 admitted they had reported it to him about 3 weeks earlier that there was problems with roaches, and he had called the pest company. EI #4 had no documentation or invoices that the pest control company was notified the facility had roaches until 12/01/2022. A second interview was conducted on 12/09/2022 at 11:24 AM with EI #4, the Maintenance Director. EI #4 admitted he could not logically say their pest control program was effective if they were seeing pest alive or dead in the building. EI #4 added they should not see any live ones if it was effective. An observation was made on 12/09/2022 at 12:09 PM during an interview with EI #6, a housekeeper. A roach was observed on the wall 2 feet away in AL 31. EI #6 reported she sees live or dead roaches about two times a week. EI #6 said she swept up a dead roach the past Wednesday that a resident had killed. She said it was about an inch long and 1/2 inch wide. EI #6 said she tells her housekeeping manager, and she sees nothing being done to prevent the roaches, so they just keep sweeping them up. An interview was conducted on 12/09/2022 at 1:56 PM with EI #7, a housekeeper. EI #7 said, she sees one or two dead roaches a week. EI #7 said she had seen dead and live roaches in the halls and the last time was one day during the previous week. EI #7 said, she told her supervisor, and her supervisor notifies maintenance after she reports seeing roaches. An interview was conducted on 12/09/2022 at 2:24 PM with EI #8, a housekeeper that assigned to Unit one. EI #8 said, she has seen dead and live roaches in the shower daily. EI #8 said if they were alive, she killed them with her broom, swept them up with a dustpan, put them in a 7 X 10 trash can liner and takes them out to the dumpster. EI #8 said she reported her housekeeping supervisor to make him aware and he makes the maintenance supervisor aware. EI #8 reported she had seen large roaches in the AL 29 shower when she worked that hall. EI #8 said she had seen roaches too often, adding every day she worked. EI #8 said she saw dead and live ones.When EI #8 stated she reported the roaches to her supervisor and since the start of the survey, they were addressing the issue of roaches. A follow-up interview was conducted on 12/09/2022 at 3:17 PM with EI #5, a Certified Nursing Assistant. EI #5 said she has seen roaches alive and dead in the shower, once she turned the lights on, they scattered. EI #5 said this occurred every shift that she worked. EI #5 said she sees dead and live roaches in halls and in the resident's rooms. EI #5 said she kills them every day, then she gets the broom and sweeps them up. EI #5 added she kills the live ones if she can. EI #5 said she have not seen housekeeping or maintenance supervisors doing anything to prevent or control the roaches until this day. EI #5 said the pest control man came today (12/09/2022). EI #5 said, the concern of roaches being in resident areas daily they could get on the resident, and roaches carry diseases. An interview was conducted on 12/09/2022 at 3:41 PM with EI #9, a housekeeper. EI #9 reported when she sees live and dead roaches in showers. EI #9 said she gets them up and it is mostly dead water bugs that she observes. EI #9 said she sees dead and live roaches in the halls and resident's rooms at least a couple of times a week. EI #9 said she reports seeing the roaches to her supervisor and afterward she has seen maintenance staff spraying. An interview was conducted on 12/09/2022 at 4:04 PM with EI #10, a Licensed Practical Nurse (LPN). EI #10 said she has worked the 100 hall/Unit one for 5 years. EI #10 said she has seen big water bugs in the showers, but she does not check the showers, daily but at least monthly. EI #10 said she reported it to EI #4, the Maintenance Director. EI #10 said, she reported seeing dead and live roaches in the halls and resident rooms twice a week. EI #10 said EI #4 calls the pest control company when she notifies him of roaches and the pest control serviceman has come out at least 3 times in the last 2 years. EI #10 said she did not think pest control was effective or the roaches would not keep coming back. An interview was conducted on 12/09/2022 at 5:41 PM with EI #11, the Housekeeping Supervisor. EI #11 said they see dead roaches in the hallways, and they sweep them up. EI #11 said the last time he saw a dead roach on the hallway floors was on the previous Monday. EI #11 said he went to the closet, got a broom, then swept the roach up. EI #11 said he sees roaches on the floor once or twice a week. EI #11 said he tells EI 4, the Maintenance Director and EI #4 calls the pest control company. EI #11 said, EI #4 spraying for roaches maybe weekly. EI #11 claimed the pest control program was effective even though he reported seeing roaches once or twice a week. A follow-up interview was conducted on 12/09/2022 at 6:06 PM with EI #4, the Maintenance Director. EI #4 said the pest control company sprays for roaches monthly and if they are needed. EI #4 stated he had not called the pest control company out for roaches in the last 90 days but once. EI #4 said, he puts out bait for roaches and ants. EI #4 states the last time he utilized the roach bait was 6-8 months ago and the ant bait maybe twice in the last year. EI #4 denied that he had sprayed for roaches. EI #4 was asked how many invoices he had showing the pest control company had been to the facility in the last 90 days and he said three routine monthly visits. EI #4 admitted the only invoice that indicated he had made the company aware of bugs was on 12/1/2022. EI #4 said, he had no other documentation of the pest control company being notified of roaches. An observation was made on 12/10/2022 at 5:31 AM on Unit one of a dead roach approximately 2 feet from the nurses' desk. The insect was dark in colored and approximately 3/4 inch long. Also, at AL 29, a dead roach was observed that was 1/2-3/4 inch long. An interview was conducted on 12/10/22 at 6:10 AM with EI #12, a Registered Nurse. EI #12 said, she has seen one or two water bugs a week and they were alive. She reported they were by the door near the nurses' station. EI #12 admitted she did not tell anyone, but probably should have notified maintenance staff. EI #12 said the roaches were being controlled but the pest control program could be more effective. An interview was conducted on 12/10/2022 at 6:24 AM with EI #13, a CNA. EI #13said she sees roaches, they were mostly in the hallway, but some were in the rooms. EI #13 said she saw a one dead roach a week ago. EI #13 said she sees roaches maybe every other week. EI #13 said, the pest control program effectiveness would be worse if they were not doing anything. An interview was conducted on 12/10/2022 at 8:40 AM with EI #3, the Activities Director who facilitates Resident Council meetings. EI #3 reported that she notified EI #4, the Maintenance Director, on 8/29/22 of the bugs in (Area Location 9) that was reported to her in the Resident Council meeting. An interview was conducted on 12/10/2022 7:23 AM with EI #2, the Director of Nursing. EI #2 said she had seen roaches in the showers. EI #2 said the frequency was sporadic, once a month. EI #2 said she reported it to maintenance staff and the Administrator. EI #2 admitted she had seen roaches in the halls. EI #2 said the pest control program was not effective due to how often she and staff had reported seeing roaches. An interview was conducted on 12/10/2022 at 10:15 AM with EI #1, the Administrator. EI #1 said he had not seen any live roaches, but EI #1 did say he had seen some dead roaches. EI #1 said the pest control program was effective if the roaches seen were dead, but not if they were alive. This deficiency was cited as a result of the investigations of complaint/report numbers AL00042239

Based on interviews, review of Resident Council Meeting minutes, the facility's grievance log, an undated facility policy titled, Resident Rights and a facility document titled, GRIEVANCES AND COMPLAINTS POLICY AND PROCEDURES, the facility failed to ensure grievances voiced during Resident Council meetings were addressed promptly and resolved. These grievances were voiced by residents from two of three units of the facility population. Findings include: A review of an undated facility document titled, GRIEVANCES AND COMPLAINTS POLICY AND PROCEDURES revealed, . POLICY: It is the policy of this facility to assist residents, representatives, and other interested family members . in filing grievances and complaints . 4. The Administrator had delegated the responsibility of grievances and or complaint investigation to the Social Service Director. A review of the undated facility policy titled; Resident Rights revealed: . Policy . 9. Grievances. The resident has the right to: a. voice grievances to the facility . b. The resident has the right to, and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Grievances for the months of December 2021 through November 2022 revealed no grievances were filed in correlation with the grievances voiced during the Resident Council meetings held monthly. The following grievances were voiced during the facility's resident council meeting: 12/28/2021 the attendees voiced the shower rooms needed to be cleaned more. 1/28/2022 the attendees voiced housekeeping needed to put more paper towels in rooms. 2/28/2022 the attendees voiced housekeeping needed to clean the East Wing more, a lot of trash in garbage. 3/28/2022 the attendees voiced housekeeping needed to sweep and mop the floors more. 6/28/2022 the attendees voiced housekeeping - West Wing was not being cleaned regularly, needed mopping. An interview was conducted on 12/10/2022 at 8:40 AM with Employee Identifier (EI) #3, the Activities Director who facilitates the Resident Council Meetings. EI #3 reported when the complaints were made during the meetings, she should have notified the Social Service staff member and address the issue with all department heads. EI #3 reported she had no documentation of what she did regarding the resident complaints. In addition, EI #3 reported she had not reported any grievances regarding housekeeping complaints voiced by residents. EI #3 admitted she did not know she was supposed to file a grievance. EI #3 said the concern of residents complaining about housekeeping for months and she did not file a grievance on their behalf . Therefore, the complaints was not corrected. EI #3 admitted the facility policy indicated staff should file a grievance when complaints were made known to them. An interview was conducted on 12/10/2022 at 8:49AM with EI #14, the Social Service Designee. EI #14 said that grievances were being addressed without formal filing of a grievance. EI #14 stated if complaints were voiced by residents at resident council meetings, she would go to the resident, talk, and discuss it with them and try to solve the problem. EI #14 said if complaints were about housekeeping, she would go and talk to the department head of housekeeping. EI #14 said the housekeeping complaint in January there was no documentation, they just take care of the complaint. EI #14 said, she tried so take care of complaints herself if she could. EI #14 said she could not explain why there were complaints voiced in February and March if it had been resolved. EI #14 stated the complaint were fixed at the time, but it happened again. EI #14 said she had no documentation, and she knows if it was not documented it was not done. An interview was conducted on 12/10/2022 at 7:23 AM with Employee Identifier (EI) #2, the Director of Nursing. EI #2 said, she was not aware of complaints of the west wing not being cleaned regularly and needing to be mopped. Also, EI #2 said she was not aware of the complaints in March that there was a need for more sweeping and mopping. EI #2 said these complaints should have been addressed to the Administrator and housekeeping supervisor. This deficiency was cited as a result of the investigations of complaint/report numbers AL00042239.

Based on observations, an interview, review of the Maintenance Director's Job Description and review of a facility document titled, Resident Rights, the facility failed to ensure resident areas were properly maintained as evidenced by: 1. corroded faucets in 12 of 50 sinks designated for resident use; 2. 6 of 33 toilets with seats in need of repair; 3. molding was falling away from the walls in 2 of 33 toilet rooms; 4. paint that was peeling, bubbling up or flaking off in 6 of 33 toilet rooms. This affected 12 of 50 sinks, 6 of 33 toilet seats, molding on walls in 2 of 33 toilet rooms and paint in 6 of 33 toilet rooms on 3 of 3 halls. Findings include: A review of the job description for the Maintenance Director revealed: . JOB DESCRIPTION . Position Purpose Directs the day-to-day activities of the Maintenance Department . to assure the facility is maintained in a safe and comfortable manner. Ensures proper planning, direction, participation, and supervision of both preventative and unplanned maintenance and repair activities in the facility, . A review of an undated facility document titled; Resident Rights revealed: Policy: . 8. Safe environment. The resident has a right to a safe, clean comfortable and homelike environment, . On 12/9/2022 at 10:42 AM, an observation made with Employee Identifier (EI) #4, Maintenance Director. The following observations were discussed with EI #4 in: Area of Location (AL): AL 1 - the faucet was corroded and toilet seat had chips. AL 2 - the molding at the bottom was falling away from the wall and the faucet was corroded. AL 4 - there was a missing piece of metal from the faucet and there was corrosion. AL 5 - the molding was missing at the bottom of two walls, there was buckling sheet rock on the wall, and the faucet was corroded. EI #4 used a piece of tissue to wipe the corrosion and describes with rough surface and flaking off. AL 6 - toilet paper roll holder was missing, the faucet was heavily corroded with some of the metal broken off at the left side of the faucet, and the toilet seat was separating. AL 7 - the faucet was corroded. AL 8 - the faucet was corroded. AL 9 - the faucet was corroded and the toilet seat was loose. AL 10 - the paint was peeling and flaking off of the tiles in the bathroom. AL 11 - the paint was flaking off the tiles near the base of the floor in the bathroom. AL 12 - the faucet in the room was corroded, there was exposed sheet-rock to the right-side corner by the faucet, and paint was peeling away from the wall. AL 13 - the toilet seat was separating at the inner ring. AL 14 - there was no spacer on toilet seat lid, paint was flaking and peeling off of the tiles. AL 15 - the paint was peeling off of the tiles. AL 16 - the faucet was corroded and the toilet seat support mounted bars had spots of rust where the paint was missing. These areas were directly beside the toilet seat where residents would sit. AL 18 - the faucet was corroded. AL 19 - there were exposed plumbing pipes with no tiles covering them. AL 20 - the faucet in the room was corroded and paint was flaking off and peeling from tiles in bathroom. AL 21 - shared toilet room the paint was flaking and peeling off. AL 22 - the faucet and sink were rusted in the shared toilet room. These were the descriptions given by EI #4. An interview was conducted on 12/09/2022 at 11:24 AM with EI #4, the Maintenance Director. EI #4 reported his responsibilities were to ensure the facility was maintained in a comfortable and safe manner. EI #4 added he was to ensure preventive and unplanned maintenance was performed. EI #4 describe the buildup of corrosion observed on faucets and he described it as hard, rough texture and flaky. EI #4 said he inspects rooms for potentially needed repairs once a month. EI #4 had no documentation of his observations of toilet seats or faucets. EI #4 reported the concerns of the maintenance issues he observed during tour were that it was not clean and comfortable. EI #4 said the faucets were not in good repair. This deficiency was cited as a result of the investigations of complaint/report numbers AL00042239

Based on observations, interviews and a review of facility policies titled, Work Attire Guidelines, Hand Washing, and Cleaning Dishes/Dish Machine, the facility failed to ensure: 1. staff braids were completely enclosed inside of her hair net while at the tray line; 2. staff changed an apron (personal protective equipment) and washed her hands when going from a dirty task to another task and; 3. resident plates were not placed on wet trays and covered with wet domes. This had the potential to affect 95 of 95 residents who received meals from the kitchen. Findings Include: 1) A review of a facility guideline titled, Work Attire Guidelines revealed: Hair Restraints Wear a . hair restraint when in a food-prep area. This can keep hair from falling into food and onto food-contact services . On 3/4/2020 at 11:30 a.m., a worker was at the tray line asking staff to put her hair net on the back of her braids. The worker's braids were hanging down her back and not in a hair net at the tray line. On 3/04/2020 at 1:32 p.m., an interview was conducted with (Employee Identifier) EI #5, dietary aide. EI #5 was asked why was she at the tray line with her braids hanging down her back. EI #5 replied, she was waiting for someone to put her hair up for her. EI #5 was asked why did she ask staff to help her put her hair in a net at the tray line. EI #5 replied, she did not know. EI #5 was asked why did she come back to the tray line with her braids hanging out of her hair net. EI #5 replied, she did not know they had fallen. EI #5 was asked why should she not ask staff to help her put her braids up in a hair net at the tray line. EI #5 replied because she was around food. EI #5 was asked who should have hair nets on in the kitchen. EI #5 replied, everyone. EI #5 was asked should a hair net enclose all of her hair. EI #5 replied, yes ma'am. 2) A review of a facility guideline titled, Work Attire Guidelines revealed: . Remove aprons when leaving prep area. A review of a facility policy titled, Hand Washing revealed . Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing . When to wash hands . After engaging in other activities that contaminate the hands. On 3/04/2020 at 11:02 a.m., an observation was made of EI #6, the Cook. EI #6 was on the dirty side of the dish room. EI #6 was putting and pushing dirty dishes into the dishwasher. EI #6 was rinsing dirty dishes off, wearing an apron, and the water was splashing on her apron. After leaving the dish room, EI #6 changed gloves and washed her hands. EI #6 cleaned a table with a dish cloth and left the kitchen. At 11:05 a.m., EI #6 came back into the kitchen and did not wash her hands, nor change her apron. EI #6 put on a clean pair of gloves and took the temperature of the baked chicken. EI #6 then put rolls in a pan. During this observation EI #6 did not pull off the apron that was worn while she was washing dirty dishes. On 3/04/2020 at 1:56 p.m., an interview was conducted with EI #6. EI #6 was asked what did she do when she went to the dirty side of the dish room. EI #6 replied, she washed her pureed bowl. EI #6 was asked what PPE did she have on. EI #6 replied, an apron. EI #6 was asked did she change her apron. EI #6 replied, after she was informed about her mistake. EI #6 was asked did she put rolls in a pan before taking off her apron. EI #6 replied, yes. EI #6 was asked why did she not change her dirty apron. EI #6 replied, she was in a hurry. EI #6 was asked when washing down the table with a dish cloth, what did she do next. EI #6 replied, she put on gloves without washing her hands. EI #6 was asked when should she wash her hands in the kitchen. EI #6 replied, after every task. EI #6 was asked why should she wash her hands in the kitchen. EI #6 replied, to stop the spread of food borne illness. 3) A review of a facility policy titled, Cleaning Dishes/Dish Machine with a year date of 2013 revealed: . Procedure: . 9. Allow the dishes to air dry on the dish rack. 3/04/2020 at 11:30 a.m., trays were brought to the tray line wet. EI #6 put plates on five wet trays and then covered them with three wet domes. On 3/04/2020 at 1:57 p.m., an interview was conducted with EI #6. EI #6 was asked what was wet at the tray line. EI #6 replied, the trays and the domes. EI #6 was asked why were the trays and domes wet. EI #6 replied, they did not have time to dry. EI #6 was asked who was responsible for making sure they were dry. EI #6 replied, dietary aide and everybody. EI #6 was asked why should dishes be dry at the tray line. EI #6 replied, to stop food borne bacteria growth. EI #6 was asked how should dishes be allowed to dry. EI #6 replied, air dry. On 3/04/2020 at 2:03 p.m., an interview was conducted with EI #7, dining services. EI #7 was asked what did she observe at the tray line wet. EI #7 replied, a couple of trays and a couple of domes. EI #7 was asked who was responsible for making sure dishes were dry at the tray line today. EI #7 replied, that would have been herself. EI #7 was asked why were dishes wet. EI #7 replied, there was no excuse and she was sorry. EI #7 was asked why was it important that dishes were dry at the tray line. EI #7 replied, because of cross contamination and bacteria can build up. EI #7 continued to say the resident's immune system was very weak, and their job was to make sure the temperatures were good and everything was sanitized. EI #7 was asked how should dishes be allowed to dry. EI #7 replied, air dry.

Based on record reviews, interviews and review of the facility policy titled, MEDICATION ADMINISTRATION, the facility failed to ensure that the Licensed Nurse signed off medication given on June 14, 15, 16 and 17, 2019 on the MAR (Medication Administration Record), for (Resident Identifier) RI #200. This affected one (1) of five (5) resident who's MAR was reviewed for medication administration. Findings include: A review of the facility's policy titled, MEDICATION ADMINISTRATION, with no date revealed, . Policy Explanation and Compliance Guidelines: . 17 . Sign MAR after administered . RI #200 was admitted to the facility on [DATE] for Encounter for other specified aftercare, Unspecified [MEDICAL CONDITION] of the liver, and Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION]. A review of RI #200's Physicians orders, dated 5/24/2019 revealed . [MEDICATION NAME] 10 mg (tab) tablet give 1 tab by mouth twice a day . [MEDICATION NAME] 10(g) gram/15(ml) milliliter GIVE 45 ml by mouth . three times a day . [MEDICATION NAME] 20(mg) milligram give 1 tablet by mouth daily/prn (as needed) . [MEDICATION NAME] 550 MG TAB . give 1 tab by mouth twice daily . On 03/05/2020 at 9:37 a.m., an interview was conducted with EI #1 (Employee Identifier) Registered Nurse ( RN). EI #1was the RN assigned to RI # 200's on the 3-11 evening shift on June 16, 2019. EI #1 was asked, was she familiar with RI #200. EI #1 replied, she remembered that name. EI #1 was asked, why was RI #200 taking the [MEDICATION NAME]. EI #1 replied, RI #200 was taking it for a beta blocker. EI #1 was asked why RI #200's [MEDICATION NAME] was not given on June 16, 2019, 4 PM dosage. EI #1 replied, she always gave her medication. EI #1 further stated she may have forgot to sign it out. EI #1 was asked why would a nurse not give a resident their medication. EI #1 replied, if the doctor wanted to hold it for any reason. EI #1 was asked why was the resident taking the [MEDICATION NAME]. EI #1 replied, she could not remember. EI #1 was asked why was the [MEDICATION NAME] not given on June 16, 2019, 4 PM dosage. EI #1 replied, she forgot to sign it out. EI #1 further stated she always gave the resident's medications. On 03/05/2020 at 9:52 a.m., an interview was conducted with EI #2 (a Licensed Practical Nurse) LPN. EI #2 was the LPN assigned to RI #200 on the 3-11evening shift June 17, 2019. EI #2 was asked why was RI #200 taking the [MEDICATION NAME]. EI #2 replied, she could not remember. EI #2 was asked why was the [MEDICATION NAME] not given on June 17, 2019, 4 PM dosage. EI #2 replied, she did not remember. EI #2 stated, she always tried to sign her medications out as she gave them. EI #2 was asked what would be the concern if RI # 200 did not take the [MEDICATION NAME]. EI #2 replied, it could effect the resident's health. EI #2 was asked why was RI #200 taking the [MEDICATION NAME]. EI #2 replied, she was not sure. EI#2 was asked why was the [MEDICATION NAME] not given on June 17, 2019, 4 PM dosage. EI# 2 replied, she always gave her medications, and she just forgot to sign out the medication. EI #2 was asked what reason would a resident not receive their medication. EI #2 replied, if the medication was not there or the resident not available. On 03/05/2020 at 10:09 a.m., an interview was conducted with EI #3, RN. EI #3 was asked did she remember RI #200. EI #3 was the RN assigned to RI #200 on the 7-3 morning shift June 14, 2019. EI#3 replied, yes. EI #3 was asked why was RI #200 taking the [MEDICATION NAME]. EI #3 replied, blood pressure. EI#3 was asked why was the [MEDICATION NAME] not given on June 14, 2019, 8 AM dosage. EI # 3 replied, if RI #200 was in the facility she would have gave the medication. EI #3 was asked why was the medications not signed off. EI #3 replied, she over looked it. EI #3 was asked why was RI #200 taking the [MEDICATION NAME]. EI #3 replied, she could not remember. EI #3 was asked why was the [MEDICATION NAME] not given on June 14, 2019, 8 AM dosage. EI #3 replied, if it was ordered, she gave it. EI #3 was asked what reason would a resident not receive their medication. EI #3 replied, only if they refused the medication. On 03/05/2020 at 10:47 a.m., an interview was conducted with EI #4 RN (Director of Nursing) DON. EI #4 was asked how important was it for a nurse to give the medication to a resident. EI #4 replied, very important. EI #4 was asked should the nurse sign out a medication after he/she give it to the resident. EI#4 replied, yes they should. EI #4 was asked why should the nurse sign out medications after she/he gave it to a resident. EI #4 replied, to show that they gave it. EI #4 was asked why would a nurse not sign out a medication on the MAR. EI #4 replied. various reasons, EI #4 further stated it could be a human error, or she forgot. EI #4 was asked why would a nurse not give a resident their medication. EI #4 replied, if the doctor has written an order to not give the medication. EI #4 was asked what was the facility policy on documentation of medication. EI #4 that the nurse should sign the MAR after she gave a medication.

Based on observation, interview and facility policies titled, Oxygen Concentrator and Oxygen Administration, facility failed to ensure Resident #54's nasal cannula tubing was labeled with a date and the tubing connecting the concentrator with the water bottle were not out of date. This had a potential to affect of one of three residents observed receiving oxygen therapy. Findings include: A review of the facility's policy titled, OXYGEN CONCENTRATOR, with no effective date, revealed: . Policy Explanation and Compliance Guidelines: 5. Care of the Concentrator . c. i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. .iii. If applicable, change nebulizer tubing and delivery devices every seventy-two hours. A review of the facility titled, Oxygen Administration, with no effective date, revealed: . Policy Explanation and Compliance Guidelines: . 5. d. If applicable, change nebulizer tubing and delivery devices every 72 hours and as needed if they become soiled or contaminated . RI# 54 was admitted to facility on 10/13/17 and readmitted on [DATE] with [DIAGNOSES REDACTED].>[MEDICAL CONDITION], acute and chronic [MEDICAL CONDITION] with hypercapnia, acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and obstructive sleep apnea. On 04/30/19 at 09:56 am, the Surveyor observed Resident # 54 with oxygen, per nasal cannula, with no date on the nasal cannula tubing. The tubing connecting the concentrator and water bottle, dated 2/11/19, was handwritten on the tubing. The water bottle was dated 4/26/19. On 04/30/19 at 12:04 pm, the Surveyor observed Resident # 54 with oxygen per nasal cannula, with no date on the cannula tubing and a date of 2/11/19 was handwritten on the tubing connecting the concentrator and the water bottle. On 05/01/19 at 04:19 pm, the Surveyor observed Resident # 54 with oxygen in use by nasal cannula. No date was written on the nasal cannula tubing or the tubing connecting the concentrator with the water bottle. The water bottle was dated 5/1/19. On 05/02/19 01:18 PM, the Surveyor interviewed the Director of Nursing Employee Identifier (EI) #1. The Surveyor asked how often was the nasal cannula tubing and concentrator tubing changed. EI #1 replied, once a week. The Surveyor asked did they have a place to document the tubing changes. EI #1 replied, no. It should be written on the tubing. The Surveyor asked, if there was oxygen tubing that was dated for (MONTH) 11, 2019, handwritten, what would that date represent. EI#1 replied, that would be the date that it was changed. The Surveyor asked, if the oxygen tubing was dated (MONTH) 11, 2019, and was observed on 4/30/19, would that be considered correct, per facility policy. EI #1 replied, no it would not. The Surveyor asked, what specific tubing was changed weekly. EI #1 replied, the nasal cannula. The tubing connecting the concentrator to the water bottle was changed every three to four days. The Surveyor asked, was it a requirement of the staff to hand write the date of change on the tubing. EI #1 replied, yes. The Surveyor asked, how did they know if the tubing had been changed. EI #1 replied, by the date written on the tube. The Surveyor asked, what was the potential harm in not changing the oxygen tubing. EI #1 replied, infection.

Based on observations, interviews, and a review of the facility's policy and procedure titled, HANDWASHING the facility failed to ensure EI (Employee Identifier) #9, a dietary worker, performed hand washing when going from the dirty dish washing area to the clean dish washing area and when storing clean dishes after working in the dirty dish area. This was observed on one of three survey days and had the potential to affect all ninety-seven residents receiving meals from the kitchen. Findings Include: A review of an undated facility policy titled, HANDWASHING revealed: Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures . 1. When to Wash Hands: . After handling soiled equipment or utensils. After engaging in other activities that contaminate the hands. On 04/18/18 at 03:00 PM, an observation of the dish washing process was made. EI #9 entered into the dish washing area. EI #9 was observed to place dirty dishes into the dish rack, then placed the dirty dishes into the dish washer and without washing his hands pulled clean dishes out of dish washer. EI #9 continued to load dirty dishes into the dish racks and move to the clean dish area and pick up clean dishes and took them to the storage area in the kitchen. EI #9 was never observed washing his hands in between movement from dirty to clean areas. EI #9 left the washing area and on return, stopped and tied his shoe, then continued into the clean dish area and never washed his hands. An interview was conducted with dietary worker, EI #9 on 04/18/18 at 4:38 PM. EI #9 was asked what was the facility policy for dish washing. EI #9 replied the dirty dishes had to be run through the dish washer and the clean dishes could not be put back with the dirty dishes because that was cross contamination. EI #9 also said he had to wash his hands when he touched the dirty dishes before he could touch the clean dishes. EI #9 was asked if he had followed the facility policy while washing dishes that day. EI #9 replied, no he did not. EI #9 also said he kept forgetting to wash his hands. EI #9 was informed of the observation made of him entering the dish washing area, placing dirty dishes in the washing racks, placing them into the dish washer, then going into the clean dish area and putting away clean dishes. EI #9 was asked if that was what he did. EI #9 replied yes that was what he did. EI #9 said he forgot to wash his hands. An interview was conducted with the Dietary Manager, EI #8 on 4/19/18 at 6:49 PM. EI #8 was asked what was observed on 4/18/18, during dish washing, after the lunch meal and before the dinner meal was served. EI #8 said the wash aide, EI #9, crossed over from the dirty dish washing side to the clean dish washing side multiple times without washing his hands. EI #8 also said EI #9 bent down to tie his shoe and did not wash his hands prior to returning to the clean dish washing side. EI #8 continued and said EI #9 started putting up the clean dishes. EI #8 was asked what was the problem/concern with handling dishes in the manner observed by this surveyor on 4/18/18. EI #8 replied a potential for cross contamination, infection control, food borne illness and bacterial growth. EI #8 was asked why should hand washing be performed when moving from the dirty dish area to the clean dish area. EI #8 replied to prevent cross contamination. EI #8 continued and said the policy was they should wash their hands anytime there was potential for cross contamination.

Based on an interview, a review of the medical record, and a review of a facility policy titled, Conducting an Accurate Resident Assessment, the facility failed to ensure side rails were coded accurately on RI (Resident Identifier) #45's Quarterly MDS (Minimum Data Set) dated 3/2/18. This affected RI #45, one of twenty-three residents whose MDS assessments were reviewed. Findings Include: A review of an undated facility policy titled, Conducting an Accurate Resident Assessment, revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of Assessments means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial status . Policy Explanation and Compliance Guidelines: . 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. A review of the medical record for RI #45 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed RI #45 used bed rails as a restraint daily. A review of a physician's orders [REDACTED]. 1/2 (half) side rail in place for T&P (Turning and Positioning) . A review of RI #45's care plan, with a next review date of 6/8/18, revealed: Problem/Need . REQUIRES limited to Total ASSISTANCE WITH ADLs (Activities of Daily Living) . Approaches . siderails in place for safety & (and) T&P . An interview was conducted with EI (Employee Identifier) #4, the LPN (Licensed Practical Nurse)/MDS Coordinator, on 4/19/18 at 3:54 PM. EI #4 was asked who was responsible for ensuring restraints were coded correctly. EI #4 answered, Me. EI #4 was asked why did RI #45 use bed rails. EI #4 answered for turning and positioning and also related to a history of [MEDICAL CONDITION]. EI #4 was asked what did the care plan indicate the rails were used for and she replied for turning, re-positioning, and safety. EI #4 was asked if the rails were coded correctly on the Quarterly MDS and she answered no. EI #4 was asked why not. EI #4 answered because they were not used as a restraint. EI #4 was asked what was the facility's policy regarding accuracy of assessments. EI #4 answered everything should be checked for accuracy before the assessment was submitted. EI #4 was asked what was the concern of an assessment being coded incorrectly. EI #4 answered the care plan might not be accurate.

Based on medical record review, interviews, and a review of a facility policy titled, BED RAILS, the facility failed to ensure a bed rail assessment was completed prior to use of bed rails for RI (Resident Identifier) #45. This affected RI #45, one of three residents sampled for bed rail use. Findings Include: A review of an undated facility policy titled, BED RAILS revealed: Policy: The facility must ensure that residents treatment and care in accordance with professional standards if (of) practice, the comprehensive person-centered care plan, and the resident's choices. Policy Explanation and Compliance Guidelines: . 2. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements: a. Assess the resident for risk of entrapment from bed rails prior to installation. 7. The facility will conduct ongoing assessments to evaluate risks and assure the bed rails is used to meet the residents' needs. A review of the medical record for RI #45 revealed a re-admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE], revealed RI #45 used bed rails as a restraint daily. A review of a physician's orders [REDACTED]. 1/2 (half) side rail in place for T&P (Turning and Positioning) . A review of RI #45's care plan, with a next review date of 6/8/18, revealed: Problem/Need . REQUIRES limited to Total ASSISTANCE WITH ADLs (Activities of Daily Living) . Approaches . siderails in place for safety & (and) T&P . A review of the medical record revealed no bed rail assessment was completed for RI #45. An interview was conducted with EI (Employee Identifier) #1, a LPN (Licensed Practical Nurse), on 4/19/18 at 12:26 PM. EI #1 was asked who was responsible for ensuring bed rail assessments were completed. EI #1 answered that he did them when residents were admitted to the facility. EI #1 was asked who was responsible for the assessment after admission. EI #1 answered staff would let him know and he would do it. EI #1 was asked if he was notified of the new rails for RI #45. EI #1 answered no and added he knew changes were made to the mattress and that was what he did. EI #1 was asked when should assessments be done for bed rail use and he answered as soon as bed rails were ordered. EI #1 was asked why should bed rail assessments be completed. EI #1 answered for safety and ongoing assessments to see if the resident's immobility had increased. EI #1 was asked what was the concern of not assessing a resident prior to use of bed rails. EI #1 answered the resident may not get the needed assistance from them. An interview was conducted with EI #5, the Director of Nursing, on 4/19/18 at 4:19 PM. EI #5 was asked who was responsible for ensuring bed rail assessments were completed. EI #5 answered EI #1. EI #5 was asked who was responsible for bed rail assessments after admission and she responded EI #1. EI #5 was asked if EI #1 was notified of the new bed rails for RI #45 and she answered yes. EI #5 was asked when should the assessments be completed for bed rail use. EI #5 answered when use began and per manufacturer's guidelines. EI #5 was asked why should bed rail assessments be completed. EI #5 answered to make sure residents do not become entrapped or restrained. EI #5 was asked what was the concern of not assessing a resident prior to the use of bed rails. EI #5 answered to make sure staff were doing what was appropriate for the resident.

Based on medical record review, interviews, and a review of a facility policy titled, Incident and Accident Report, the facility failed to ensure an incident/accident report regarding a fall RI (Resident Identifier) #45 sustained on 2/14/18 was done. This affected RI #45, one of two residents sampled for falls. Findings Include: A review of an undated facility policy titled, Incident and Accident Report, revealed: Purpose: Incident and accident reports are filled out to study the cause of an accident or incident and to take corrective action. Policy: The incident and accident form is to be filled out immediately by LPN (Licensed Practical Nurse) Charge Nurse, department head or supervisor when notified of an injury or accident. Procedure: A. If an incident or accident occurs: . 4. If the incident involved a resident, chart the information required including: Sponsor (who and when Notified) Time the physician was notified Resident vital signs . During the review of the fall reports, the surveyor was made aware by the facility RI #45 had a fall on 2/14/18. A review of RI #45's medical record revealed no incident/accident report for the fall sustained on 2/14/18. An interview was conducted with EI (Employee Identifier) #6, a LPN (Licensed Practical Nurse), on 4/19/18 at 3:33 PM. EI #6 was asked who was responsible for documenting resident information in the medical record and she answered, The Nurse. EI #6 was asked who should have documented the fall RI #45 had on 2/14/18. EI #6 answered, The Nurse that responded. EI #6 was asked who was the nurse that responded and she answered, Me, I was the Nurse. EI #6 was asked why was this not done. EI #6 answered, I had started it and had a medical emergency and had to leave the facility. EI #6 was asked what she documented prior to leaving. EI #6 answered she had documented everything except for the notification part and she had not gotten the witness statement. EI #6 was asked where was that documentation. EI #6 answered, We think it must have gotten lost. EI #6 was asked where she last saw the incident form. EI #6 answered, In the med room on East wing on the desk. EI #6 was asked what was the facility's policy regarding complete and accurate documentation in the medical record and she answered, For it to be done and correctly. EI #6 was asked what was the concern of documentation not being entered into the medical record. EI #6 answered, Patient safety because we need to know. EI #6 was asked who was responsible for ensuring documentation was completed and accurate and she answered everyone that documented. An interview was conducted with EI #5, the DON (Director of Nursing), on 4/19/18 at 3:46 PM. EI #5 was asked who was responsible for documenting resident information in the medical record and she answered, The Charge Nurses. EI #5 was asked who should have documented the fall RI #45 had on 2/14/18. EI #5 answered, The Charge Nurse. EI #5 was asked who was the Charge Nurse and she answered EI #6. EI #5 was asked why this was not done and she answered, I don't know. EI #5 was asked what was the facility's policy regarding completed and accurate documentation in the medical record. EI #5 answered, That it should be done and accurate. EI #5 was asked what was the concern of documentation not entered into the medical record. EI #5 answered, That something may have happened that no one is aware of. EI #5 was asked who conduced fall investigations and she answered, The Charge Nurse initiates including witness statements and the restorative nurse initiates interventions. EI #5 was asked if was done for RI #45's fall and she answered yes, but it was not documented. EI #6 was asked how can verification be obtained that a fall was investigated if there was no documentation. EI #5 repeated there was no documentation. EI #5 was asked who was responsible for ensuring documentation was completed and accurate. EI #5 stated she was responsible.

Based on observations, interview, and a review of a facility policy titled, MEGA RULE REVIEW TOOL, the facility failed to ensure postings for the local and state ombudsman included an electronic mailing address. This was observed on one of three survey days and had the potential to affect all ninety-eight residents that reside in the facility. Findings Include: A review of an undated facility document titled, MEGA RULE REVIEW TOOL, revealed: . Resident Rights . Furnish a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and information agencies, resident advocacy groups . the State Long-Term Care Ombudsman program . An observation was made on 4/17/18 at 2:57 PM of the Ombudsman poster in the main lobby and on the east wing. The posters did not have the Ombudsman's email address listed. An observation was made on 4/17/18 at 5:15 PM of three posters with the Ombudsman's information. The Ombudsman's email address was not listed in the information. An interview was conducted with EI (Employee Identifier) #3, the Social Services designee, on 4/19/18 at 12:34 PM. EI #3 was asked who was responsible for ensuring contact information posted in the facility was complete and she answered, Me. EI #3 was asked what postings should be available to the residents and visitors. EI #3 answered, We have to have the local and state ombudsman, the elder abuse neglect exploitation hotline, and complaint hotline. EI #3 was asked what should those postings include. EI #3 answered, Name, address, email address, and phone number. EI #3 was asked had all of those requirements been included on the posters in the facility during the survey. EI #3 answered, Not the email address. EI #3 was asked what was the concern of posted contact information not including an email address. EI #3 answered, If they couldn't reach them on the phone, they may be able to reach them via email.

Based on record reviews, an interview, and a review of a facility policy titled, IN-SERVICE TRAINING POLICY, the facility failed to ensure evidence could be provided for four CNAs (Certified Nursing Assistants) receiving 12 hours of mandatory annual training. This was observed in four of four CNA training records reviewed. Findings Include: A review of an undated facility policy titled, IN-SERVICE TRAINING POLICY, revealed: Employees will receive training (in-service) according to (Name of Facility) INCs (Incorporation's) requirements, and state and federal requirements. Procedure . D The facility will provide at least 12 hours of in-service training annually to include dementia & (and) abuse training. A review of inservice sign-in sheets provided to the surveyor revealed four CNAs names had been highlighted. However, there were no documented start/end times or number of hours for the in-services that were provided. There was no evidence of how many in-service hours the CNA's had obtained. An interview was conducted with EI (Employee Identifier) #7, the ADON (Assistant Director of Nursing), on 4/19/18 at 1:16 PM. EI #7 was asked who was responsible for ensuring CNAs received 12 hours of continuing education each year. EI #7 answered, I am. EI #7 was asked who was responsible for ensuring CNAs received training to include abuse and dementia care and she stated she was responsible. EI #7 was asked had CNAs received training to include abuse and dementia care and she answered, Yes. EI #7 was asked if she could provide evidence of the number of hours of training the CNAs had received and she answered, No. EI #7 was asked what was the facility's policy regarding annual training for CNAs. EI #7 answered, That they should receive 12 hours of inservice training per calendar year. EI #7 was asked what was the concern of not being able to verify CNAs had received 12 hours of training. EI #7 answered, I would not be able to prove that they got the training.

Based on observations, an interview, and a review of a facility policy titled, Nurse Staffing Posting Information the facility failed to ensure staffing hours were posted for shifts worked on two of three survey days. This had the potential to affect all ninety-eight residents residing in the facility. Findings Include: A review of a facility policy titled, Nurse Staffing Posting, with a copyright date of (YEAR), revealed: . Policy: It is the policy of this facility to make staffing information readily available in a readable format to resident and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: . d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. An observation was made on 4/17/18 at 2:57 PM of a dry erase board at the center nurse's station. The following shifts were identified: 10:30 PM-7:00 AM; 6:30 AM-3:00 PM; and 2:30 PM-11:00 PM. The names of staff were on the board according to the shifts to be worked, but there were no hours posted for the 10:30 PM-7:00 AM shift. An observation was made on 4/17/18 at 4:52 PM of the dry erase board. The posting of hours worked for 10:30 PM-7:00 AM and 6:30 AM-3:00 PM shifts was not completed. An observation was made on 4/18/18 at 11:46 AM of the board where staffing was to be posted. There were no hours documented as worked on the board for the 10:30 PM-7:00 AM shift at that time. An observation was made on 4/18/18 at 4:48 PM of the staff posting board. There were no entries for hours worked for any of these shifts: 10:30 PM-7:00 AM, 6:30 AM-3:00 PM, and 2:30 PM-11:00 PM shifts. An interview was conducted on 4/18/18 at 4:57 PM with EI (Employee Identifier) #7, the ADON (Assistant Director of Nursing). EI #7 was asked who was responsible for posting the staffing hours. EI #7 reported she was responsible. EI #7 was asked where in the building were staffing hours posted. EI #7 answered at the front desk (center station) on the left wall. The surveyor and ADON observed the board at the front desk. EI #7 was asked if anything (hours) had been posted the past two days and she answered no. EI #7 was asked should the hours have been posted and she answered yes, after each shift. EI #7 was asked why and she answered so people would know how many actual hours were worked.

Based on interview, review of employee files, and the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, the facility failed to ensure all employees considered for potential hire were screened to include reference checks before being allowed to work in the facility. This affected three of six employee files reviewed. This deficient practice had the potential to affect all 88 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 3/6/2017 indicated the facility had a total of 88 residents. Findings include: Review of the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, with a revised date of 12/1/2016 revealed the following: .Compliance Guidelines: .3. Screening-Facility will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers . d. Background, reference . check should be conducted on employees prior to or at the time of employment, . EI (Employee Identifier) #1 LPN (Licensed Practical Nurse), was hired at the facility on 10/12/2016. EI #2 CNA (Certified Nursing Assistant) was hired at the facility on 10/21/2016. A review of EI #1 and #2's employee files revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 3:40 p.m. EI #4, ADON (Assistant Director of Nursing), responsible for reference checks on nursing staff, was asked about the facility policy for checking references prior to hire. EI #4 said, all employees should have a reference check prior to being hired. When asked about documentation of reference checks for EI #1 and #2, EI #4 said, she usually documented beside the reference listed on the application, but she failed to document those. When asked where she documented the date and time of the reference check, EI #4 replied, she did not document the date and time, and only documented the reference check was okay. When asked why it was important to perform reference checks before hire of potential employees, EI #4 said, she may learn something about a potential employee that may be beneficial to the facility. EI #3, a House Keeper was hired at the facility on 10/31/2016. Review of EI #3's file revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 4:00 p.m. EI #5, Environmental Service Manager, was asked who verified employee screening was completed prior to hire. EI #5 replied, the company contracted for house keeping employees sends the completed screening to him. When asked why EI #3's reference checks were not done before EI #3 started to work, EI #5 said, he did not notice the reference checks were not done.

Based on interview, review of employee files, and the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, the facility failed to ensure the abuse policy was fully implemented for the element of Screening, to include reference checks of all potential employees prior to hire. Three of six employee files reviewed did not include reference checks. This deficient practice had the potential to affect all 88 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 3/6/2017 indicated the facility had a total of 88 residents. Findings include: Review of the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, with a revised date of 12/1/2016 revealed the following: .Compliance Guidelines: . 3. Screening-Facility will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, .d. reference .check should be conducted on employees prior to or at the time of employment, . EI (Employee Identifier) #1 LPN (Licensed Practical Nurse), was hired at the facility on 10/12/2016. EI #2 CNA (Certified Nursing Assistant) was hired at the facility on 10/21/2016. A review of EI #1 and #2's employee files revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 3:40 p.m. EI #4, ADON (Assistant Director of Nursing), responsible for reference checks on nursing staff, was asked about the facility policy for checking references prior to hire. EI #4 said, all employees should have a reference check prior to being hired. When asked where the documentation of reference checks was for EI #1 and #2, EI #4 said, she usually documented beside the reference listed on the application, but she failed to document those. EI #3, a House Keeper was hired at the facility on 10/31/2016. Review of EI #3's file revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 4:00 p.m. EI #5, Environmental Service Manager, was asked who verified employee screening was completed prior to hire. EI #5 replied, the company contracted for house keeping employees sends the completed screening to him. When asked why EI #3's reference checks were not done before EI #3 started to work, EI #5 said, he did not notice the reference checks were not done. On 3/8/2017 at 6:00 p.m., EI #6 Abuse Coordinator, was asked what steps were taken to screen potential employee hires for a history of reported abuse. EI #6 said, reference checks were included in the screening. When asked why potential employees were hired prior to reference checks, EI #6 replied, I don't know. When asked who was responsible to ensure the abuse policy was followed, EI #6 stated, I am responsible. EI #6 said, it was important to check all potential hires references to make sure references were accurate and employees were truthful about their past employment experience.

Based on observations, interviews and review of Resident Identifier (RI) #1's medical records, facility staff failed to follow the plan of care by failing to "Use two persons for all transfers" when transferring the resident. On 9/23/10, on the 11-7 shift, EI (Employee Identifier) #1 attempted to transfer RI #1 from the bed to a wheelchair without assistance, which resulted in the resident receiving a laceration to the forehead after she fell on her face. RI #1 was transferred to a local hospital and a CT (Computed Tomography) scan revealed the resident also had a [MEDICAL CONDITION] spine. Further the facility failed to ensure the bed alarm was attached to RI #1 when she was in bed. On 9/28/10 at 7:31 p.m., the surveyor observed RI #1 lying in bed. The bed alarm was laying on RI #1 ' s night stand. According to an LPN (Licensed Practical Nurse), EI #8, she (EI #8) had taken the alarm off at supper time for RI #1 to eat and had forgotten to reattach the alarm. On 9/28/10 and 9/29/10, the surveyor observed RI #1's call light not in a location that she could easily reach. This deficient practice affected one of three residents sampled for falls. Findings include: 1. RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan, with a problem onset date of 08/16/10, for RI #1documented, "(RI #1) is at risk for falls R/T (related to) Hx (history) of falls, Diabetes, Depression, Arthritis ... and Confusion ...", revealed the following Approaches: "Use two + persons for all transfers ..." Also documented on this care plan was an approach of " Bed/Chair alarm " dated 8/20(10). RI #1's Admission Minimum Data Set (MDS) assessment, with a reference date of 8/23/10, identified RI #1 to have short and long term memory problems, and moderately impaired cognitive skills for daily decision-making. RI #1 was also assessed as being totally dependent with bed mobility, transfers, personal hygiene, dressing, eating, toilet use, bathing and locomotion on and off the unit with one person physical assist. RI #1 was also identified to be totally incontinent of bowel and bladder. Under Section G3; Test for Balance, RI #1's balance while standing and balance while sitting - position and trunk control was coded as "not able to attempt test without physical help." Under Section G4; Functional Limitation in Range of Motion, RI #1 was identified to have no limitations to the hand, legs, and feet. Under Section G; Modes of Transfer, RI #1 was identified to used bed rails for bed mobility or transfer. Under Section J4; Accidents, RI #1 was identified as having a fall in the past 30 days. Review of RI #1's nurses notes (NN) documents: "9/23/10 at 5:00a (a.m.) Called to room by CNA (Employee #1) - resident lying on floor face down - 'help me.' Large amt (amount) of blood noted from forehead. Alert, verbally responsive but confused. CNA stated while transporting from bed to W/C (wheelchair) - instructed res (resident) to sit down in W/C positioned behind - res leaned forward instead & (and) fell face down. Has laceration to R (right) arm & L (Left) finger. Res positioned on back - 0 (no) C/O (complain of) pain or discomfort @ (at) this time... 505 a (5:05 a.m.) Ambulance called to transport res to (local hospital) ER, daughter (name of daughter) notified @ this time of transfer to (local hospital) ER for evaluation. 520 am (5:20 a.m.) Transported to (local hospital) ER..." On 9/28/10 at 7:45 p.m., the surveyor conducted an interview with EI #2 (a CNA assigned to care for RI #1 on the 3p - 11p shift). The surveyor asked EI #2 how many people are required to transfer RI #1 according to her care plan? EI #2 answered, one. On 9/29/10 at 6:00 p.m., the surveyor conducted an interview with EI #6 (a CNA also assigned to care for RI #1 on the 3p-11p shift). The surveyor asked EI #6 where would she find the information about RI #1 or any other resident related to transfers ...? EI #6 replied, on the ADL (Activity of Daily Living) book- "CNA Care Record." On 9/29/10 at 6:25 p.m., the surveyor conducted an interview with EI #1 (a CNA assigned to care for RI #1 on the 11p-7a shift). The surveyor asked EI #1 was she assigned to care for RI #1 on 9/23/10 on the 11-7 shift? EI #1 confirmed she was assigned to RI #1. EI #1 stated she was assisting RI #1 from the bed to the wheelchair by herself on the 11 p - 7a shift. The surveyor asked EI #1 what happened when she got RI #1 out of bed on 9/23/10? EI #1 stated, she assisted RI #1 to the side of the bed, held RI #1 under her left arm and told RI #1 to turn and sit down in the wheelchair. EI #1 stated RI #1 did turn and then she squatted down in a sitting position, then she leaned forward and fell on the floor." The surveyor asked EI #1 was RI #1 a one person transfer or two person transfer and assist? EI #1 stated, "One person can transfer her." The surveyor asked EI #1 what does RI #1's care plan direct the CNA's and other staff on how to transfer her? EI #1 stated, "I guess one person to transfer, that's all I know." The surveyor asked EI #1 where would you find information related to transferring your residents assigned to you? EI #1 stated, on the careplan. The surveyor asked EI #1 did she look at RI #1's care plan to see whether she required one or two persons to transfer her? EI #1 stated, "No I did not." The surveyor asked EI #1 did RI #1 receive any injuries when she fell on [DATE], the morning she (EI #1) transferred her (RI #1) by herself? EI #1 stated, "Yes, she got a cut on her forehead and a skin tear to her hand. I am not sure which hand. That's all I could see at the time of the fall." On 9/30/10 at 9:03 a.m., the surveyor conducted an interview with the facility's administrative staff (the Administrator, DON (Director of Nursing) and the ADON (Assistant Director of Nursing)). The surveyor asked the administrative staff how do the CNA's know where to look for information related to their resident's ADL's ... transfers ...? The facility's administrative staff stated, "In the residents ADL book-CNA Care Record." On 9/30/10 at 9:45 a.m., the surveyor conducted an interview with EI #3 (an LPN (Licensed Practical Nurse) assigned to care for RI #1 on the 11p-7a shift). The surveyor asked EI #3 how many people were required to transfer RI #1? EI #3 stated, "It should be a two person assist." The surveyor asked EI #3 did EI #1 have anyone to assist her in transferring RI #1 on 9/23/10? EI #3 stated, "No." The surveyor asked EI #3 how do the CNA's know that a resident required one or two person to assist in transferring? EI #3 stated, "It should be on the ADL record or care plan so they (the CNA's) know what they need to do." The surveyor asked EI #3 did EI #1 tell her she had transferred RI #1 by herself when she (RI #1) fell on [DATE]? EI #3 stated, "Yes she did." The surveyor asked EI #3 did EI #1 know two people were required to transfer RI #1? EI #3 stated, "I don't think she did." On 9/30/10 at 3:01 p.m., the surveyor conducted an interview with EI #7 (a CNA assigned to care for RI #1 on the 7a - 3p shift). The surveyor asked EI #7 how many people are required to transfer RI #1? EI #7 stated, "Two." The surveyor asked EI #7 where would the surveyor find that information about transfers? EI #7 stated, "On the CNA Care Record. It's in the ADL book." On 9/30/10 at 3:15 p.m., the surveyor conducted an interview with EI #5 (the care plan coordinator). The surveyor asked EI #5 how do the CNA's know where to look for information relating to the residents transfers ..." EI #5 stated, "It's on the CNA Care Record. It's in their (the CNA's) charting book kept at the nursing station. All the CNA's have access to the book and should look at it before caring for the resident. A facility's form for RI #1 titled "C.N.A. Care Record" (no date or update), identified RI #1's transfers were to be performed by "Assist of two." 2. A review of a care plan with a problem onset dated of 8/16/2010, for RI #1 titled: "Mrs. ___ is at risk for falls R/T (related to) Hx (history) of falls, Diabetes, Depression, Arthritis... and Confusion. "Goals & Target Date: Maximize Mrs ___ Freedom to be mobile with minimal risk of injury, identify risk factors for falls or injury that can be altered or reduced, use the least restrictive method of supporting Mrs. ___ mobility, Reduce the risk of falls x (times) 90 days." A new "Approach" dated 8/20/10, included "Bed / Chair alarm... encourage safety precautions..." On 9/28/10 at 7:31 p.m., the surveyor observed RI #1 lying in bed. RI #1 had just received care from EI #2. The surveyor observed RI #1's bed alarm on the night stand and not attached to the resident. The surveyor informed the charge nurse, EI #8, that RI #1's bed alarm was not attached to the resident. EI #8 stated, "I took the alarm off at supper time for her to eat. I forgot to put it back on." Also, the surveyor observed the call light on the floor out of reach. The surveyor asked EI #8 what time was supper served? EI #8 stated,"Around 6:00 p.m., I guess it hasn't been that long." EI #8 attached the clip of the alarm string to RI #1's clothing and placed the alarm on the resident pillow. The alarm was not anchored to the bed frame, head of bed or side rail to ensure it would activate (sound) if the string was detached from the monitor box. The surveyor informed the DON (Director Of Nursing) and Administrator of this concern. At 7:45 p.m. the surveyor observed one of two siderails were elevated. The right side rail next to the wall was down and call light not with reach. On 9/29/10 at 10:30 a.m., the surveyor observed RI #1 out of bed sitting up in her wheel chair in her room. The call light was observed positioned on the night stand behind RI #1, out of the resident reach. The facility staff failed to implement preventive practices from RI #1's careplan to ensure falls would not occur. This deficiency was cited as a result of the investigation of complaint/report number (#) AL 261.

Based on interviews, medical record review, and review of a facility policy and procedure titled "Fall Prevention Program", a facility staff member failed to transfer Resident Identifier (RI) #1 (with two person physical assistance) from the bed to a wheel chair. On 9/23/10 at approximately 5 a.m. during the (11p - 7a) shift, a CNA (Certified Nursing Assistant), Employee Identifier (EI) #1, transferred RI #1 by herself which resulted in the resident falling on her face and sustaining a laceration to the forehead. RI #1 required emergency medical interventions and was transferred to a local ER (emergency room ) for evaluation. A CT (Computed Tomography) scan dated 9/23/10, revealed "Findings: There is a fracture of the nasal spine. The globes and orbits are intact. There is mild left frontal sinus disease. The paranasal sinuses are other wise clear. No other facial fractures are noted. The patient is edentulous." RI #1 returned to the facility on [DATE] at 8:00 a.m., with 21 sutures intact to her forehead. This deficient practice affected RI #1, one (1) of three (3) sampled residents for falls/fractures. Findings Include: The facilty's policy and procedure for falls titled "Fall Prevention Program" (no date), documented the following: "This program emphasizes assessment, identification and intervention of resident falls while utilizing the least restrictive method possible to keep the resident safe. The program identifies the factors that place residents at risk for falls, promotes preventative practices for residents care planning and identifies the main components include: fall risk assessment, interventions, documentation and regular assessment and evaluation... To prevent fall, if able, To reduce and / or minimize injury and complications when a fall occurs... Team Members: Responsible for weekly communication, identifying resident at risk for falls and injury and developing interventions. Responsible for ensuring the monitoring system are in place and functioning according to the resident care plan... Procedure 7. Once the resident experiences a fall, PT (Physical Therapy) or OT (Occupational Therapy) will screen and evaluate / treat per (by) physicians orders. The unit manager and interdisciplinary team IDT) will review the documentation, evaluate the possible cause of the fall and create or change care plan interventions. Information will be communicated to the appropriate unit and / or restorative team. 8. Residents who experiences multiple falls, regardless of interventions and are subject to possible injury, may be evaluated for a less restrictive device. If this is assessed to be necessary, the resident physician and family will be notified and the appropriate action(s) taken. Investigation... Measures will be put in place to minimize the risk of negative outcomes or inappropriate staff involvement..." RI #1 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. A Review of RI #1's medical record revealed the Admission Minimum Data Set (MDS) assessment dated [DATE], identified RI #1 to have short and long term memory problems, and moderately impaired cognitive skills for daily - decision-making - decisions poor. Also, the MDS identified RI #1 needed total assistance and one person physical assist with transfers, personal hygiene, dressing, eating, toilet use, bathing, and locomotion on and off the unit. RI #1 was assessed to be totally incontinent of bowel and bladder. Under Section G3; "Test for Balance", RI #1's balance while standing and balance while sitting - position and trunk control was assessed as not able to attempt test without physical help. Under Section G4; Functional Limitation in Range of Motion, RI #1 was identified to have no limitations to the hand, leg, and foot on both sides. Under Section G6; Modes of Transfer, RI #1 was identified to use bed rails for bed mobility and transfer. Under Section J4; Accidents, RI #1 was identified as having a fall in the past 30 days. During the last seven days of the MDS assessment period, section O4; - Medications, documented RI #1 received an antianxiety, antidepressant and diuretic during this assessment period. The "Fall Risk Assessment" dated 9/9/10, 9/16/10 and 9/23/10, revealed, "...If the total score is 10 or greater, the resident should be considered at High Risk for potential falls..." RI #1's total score was 12. RI #1's Resident Assessment Protocol (RAP) dated 8/23/10, triggered for falls and a "Fall" care plan was developed. The RAP worksheet dated 8/23/10, documented, "RAP triggered due to the following MDS responses: J4a - fell in past 30 days. (Medications taken in the past 7 days) O4b Antianxiety and O4c -Antidepressant. Staff notes: Mrs. ___ is at risk for falls. She has a Hx (history) of falls and she is taking psychotropic meds (medications). She is bed / chair bound and chair alarm is in place for safety. She is monitored closely by staff. Continue plan of care." A review of RI #1's care plan with a problem onset dated of 8/16/2010, titled: "Mrs. ___ is at risk for falls R/T (related to) Hx (history) of falls, Diabetes, Depression, Arthritis... and Confusion revealed the following: "Goals & Target Date: Maximize Mrs ___ Freedom to be mobile with minimal risk of injury, identify risk factors for falls or injury that can be altered or reduced, use the least restrictive method of supporting Mrs. ___ mobility, Reduce the risk of falls x (times) 90 days." The "Approaches" included "Use two + (plus) persons for all transfers, ...encourage safety precautions." On 8/19/10, the "Fall" care plan dated 9/1/10, documented RI #1 had experienced a fall. Information from the care plan revealed, "8/19/10, Resident found on floor in room be side bed in a sitting position." There were no evidence in the medical record that RI #1 was injured as a result of this fall. The care plan was updated to included a new approach dated 8/20/10, for a "Bed / Chair alarm." On 8/29/10, (no time) the following was documented on RI #1's care plan. The Fall care plan dated 9/1/10, titled: "Mrs. ___ is at risk for falls R/T (related to) Hx of falls, Diabetes, Depression, Arthritis... and Confusion... Sponsor and CNA were assisting resident up to W/C (wheel chair) when resident was unable to stand. W/C tangled with resident's leg and resident received skin tear to lower L (left) leg. Sponsor and CNA slid resident to floor." The care plan was updated to include "Instruct staff to get other staff if needed during transfers." On 9/28/10 at 7:45 p.m., the surveyor conducted an interview with EI #2 (the staff member assisting the sponsor transferring RI #1 on the 3 p.m. to 11 p.m. shift on 8/29/10). The surveyor asked EI #2 did RI #1 receive an injury on 8/29/10? EI #2 stated, "Yes sir, she got a skin tear on her leg. Right shin area when she fell ." The surveyor asked EI #2 how did RI #1 receive the skin tear? EI #2 stated, "Me and her daughter (sponsor) was transferring (RI #1) from the bed to the W/C at (sponsor) request. The (sponsor) said (RI #1) eats better sitting up. But, I told (the sponsor) that (RI #1) eats fine in the bed. But (the sponsor) insisted on getting (RI #1) up. So, she (the sponsor) started the transfer, then I told her that (RI #1) was not in any condition to get up in the chair, but the sponsor refused and started the transfer, so I assisted. (RI #1's) leg started sliding apart, in a splint position. I saw (RI #1's) go under the W/C. I saw the blood coming from her right shin. Then I told (the sponsor) to wait, we can not put her (RI #1) back to bed because she was heavy and (the Sponsor) was pulling (RI #1) in the opposite direction. So, we eased her (RI #1) to the floor to keep her from falling." The surveyor asked EI #2 how many persons are required to transfer RI #1? EI #2 stated, "On that day two. But, the requirement is one. On this day (RI #1) was weak, she wasn't acting like herself..." The surveyor asked EI #2 how many people are required to transfer RI #1 according to her careplan? EI #1 stated, "One." The surveyor asked EI #2 was RI #1 able to walk alone? EI #2 stated, "Yes, when she first got here (on admission). She (RI #1) could stand up and walk to the bathroom. But, on this day August 29, 2010, Sunday, she was different and not able to walk." The surveyor asked EI #2 did RI #1 have any falls prior to this day (8/29/10)? EI #2 stated, "No, not that I am aware of, none at all." RI #1's "C.N.A. Care Record" (no date or update), a form used by the direct care providers (CNA's), to inform them of the type care a resident requires identified RI #1's "Transfers" were to be performed by "Assist of two." Review of RI #1's nurses notes (NN) documents: "9/23/10 at 5:00a (a.m.) Called to room by CNA - resident lying on floor face down - 'help me.' Large amt (amount) of blood noted from forehead, Alert , verbally responsive but confused. CNA stated while transporting from bed to W/C - instructed res (resident) to sit down in W/C positioned behind - res leaned forward instead & (and) fell face down. Has laceration to R (right) arm & L (Left) finger. Res positioned on back - 0 (no) C/O (complain of) pain or discomfort @ (at) this time... 505 a (5:05 a.m.) Ambulance called to transport res to (local hospital) ER, daughter (name of daughter) notified @ this time of transfer to (local hospital) ER for evaluation. 520 am (5:20 a.m.) Transported to (local hospital) ER..." A physician's orders [REDACTED]. "Transfer to (name of local ER) for evaluation of fall." A review of records for RI #1 from the local ER titled "Emergency Physician Record" dated 9/23/10 at 0545 (5:45 a.m.), documents: "Chief complaint ... location of pain / injuries: Head... Physical exam ... 21 stitches (facial diagram indicating injury to forehead)." The CT (Computed Tomography) scan dated 9/23/10, revealed "Findings: There a fracture of the nasal spine. The globes and orbits are intact. There is mild left frontal sinus disease. The paranasal sinuses are other wise clear. No other facial fractures are noted. The patient is edentulous." NN dated 9/23/10 at 12 noon documented, "Resident returned from (local hospital) @ 8:00 a.m. resume orders... This nurse counted 21 stitches (sutures) on forehead. C/O pain gave 1000 mg (milligrams) of Tylenol. Husband at bedside..." Physician orders [REDACTED]." On 9/29/10 at 12:10 p.m., the surveyor conducted an interview with the facility's administrative staff, including the Director Of Nursing (DON), Administrator, and the care plan coordinator. The surveyor asked why do RI #1 care plan for falls dated 8/16/10, say to use 2 + (plus) person for all transfers? The DON said she thought the care plan said to use 1 person for all transfers. The surveyor showed the staff present the care plan dated 8/16/10 (RI #1's initial care plan), identifying that RI #1 needed 2 + person for all transfers. The DON said, I see what you are saying. The care plan do say use 2 people for all transfers. On 9/29/10 at 1:45 p.m., the surveyor conducted an interview with the OT, the Rehab Director and DON. The surveyor asked the OT when was she notified that RI #1 needed an OT screening for an evaluation to use her wheel chair related to her history of falls? The OT said, she had not been notified about that. The surveyor asked the OT was RI #1 screened on admission for PT and OT to treat as indicated per (by) physician's orders [REDACTED]. The OT said she did not have doctors orders for that. The surveyor asked the OT when is she expected to evaluate a resident after numerous falls? The OT said, there are no set limits for falls as far as she knows. The OT said, she will see a resident if they got a referral and she had not receive a referral on RI #1. On 9/29/10 at 6:25 p.m., the surveyor conducted an interview with EI #1 (a CNA assigned to care for RI #1 on the 11p - 7a shift). The surveyor asked EI #1 was she assigned to care for RI #1 on 9/23/10 on th 11-7 shift? EI #1 stated "Yes, I was assigned to her. I was assisting (RI #1) from the bed to the wheelchair by myself during the transfer on the 11 p - 7a shift." The surveyor asked EI #1 what happened when she got RI #1 out of bed on 9/23/10? EI #1 stated, "I assisted her (RI #1) to the side of the bed. Then I held her under her left arm and told her to turn and sit down in the wheelchair. She did turn and then she squatted down in a sitting position, then she leaned forward and fell on the floor." The surveyor asked EI #1 was RI #1 a one person transfer or two person transfer and assist? EI #1 stated, "One person can transfer her." The surveyor asked EI #1 what does RI #1's careplan direct the CNA's and other staff on how to transfer her? EI #1 stated, "I guess one person to transfer, that's all I know." The surveyor asked EI #1 did RI #1 have any previous falls in the facility? EI #1 stated, yes. The surveyor asked EI #1 any falls with injuries? EI #1 stated, I am not sure. The surveyor asked EI #1 where would you find information related to transferring your residents assigned to you? EI #1 stated, on the careplan. The surveyor asked EI #1 did she look at RI #1's careplan to see whether she required one or two persons to transfer her? EI #1 stated, "No I did not." The surveyor asked EI #1 did RI #1 receive any injuries when she fell on [DATE], the morning she (EI #1) transferred her (RI #1) by herself? EI #1 stated, "Yes, she got a cut on her forehead and a skin tear to her hand. I am not sure which hand. That's all I could see at the time of the fall." On 9/30/10 at 9:03 a.m., the surveyor conducted an interview with the facility's administrative staff (the Administrator, DON (Director of Nursing) and the ADON (Assistant Director of Nursing)). The surveyor asked the administrative staff how do the CNA's know where to look for information related to their resident's ADL's ... transfers ...? The facility's administrative staff stated, "In the residents ADL book for "CNA Care Record." The surveyor asked the Administrative staff was RI #1's "CNA Care Record" updated after her 8/29/10 fall, to include 2 person transfer? The DON stated, Yes, but there is no date when it was updated. In the section "Transfer" it's checked for Assist of two. RI #1's Fall care plans dated 8/16/10, 9/1/10, 9/9/10 and the "C.N.A. Care Record" revealed RI #1 needed "Assist of two" with transfers. This deficiency was cited as a result of the investigation of complaint/report number (#) AL 261.