Every finding on record at PruittHealth- Rock Hill

Based on observation, interview, and review of facility policy, the facility failed to ensure sanitary conditions were maintained in the kitchen by positioning a garbage/refuse cart containing visible waste in close proximity to clean food service items during active tray assembly in one (1) of one (1) kitchen observed. This practice created the potential for contamination of clean trays and plate covers and increased the risk for foodborne illness and infection transmission.Findings include:Record review of facility policy titled, Waste Disposal: Dietary Services last revised 04/11/16 revealed, It is the policy of PruittHealth for the Dietary Department to dispose of waste in an effective manner in order to prevent a breeding place for insects, rodents, and transmission of diseases. This policy applies to all dietary partners employed by PruittHealth. Garbage disposal areas should be separate from food prep areas.Record review of facility policy titled, Dishroom Sanitation last revised 03/22/16 revealed, It is the policy of PruittHealth that the dish room must be maintained in a clean and sanitary condition. Dishwashing and sanitizing procedures will be available in the Dietary Department. This policy applies to all dietary partners employed by PruittHealth. Both full and empty dish racks are to be stored on a dish rack dolly, cart, or under a shelf in the dish room at all times. Dish racks should not be stored on the floor.On 2/17/2026 at 10:36 AM, during a walkthrough of the kitchen and dishwashing area, observation revealed a large trash/garbage cart containing visible waste positioned adjacent to a rack of clean plate covers. The trash cart was open and located next to racks of clean food service tray covers on the kitchen floor near the food service area during active dishwashing.On 2/18/2026 at approximately 10:50 AM, a second observation during lunch tray preparation revealed the same trash/garbage cart containing visible waste positioned adjacent to clean plate covers stored on the kitchen floor. The cart was also located in close proximity to racks of clean food service trays and the active lunch tray assembly area. The Dietitian was observed assisting with tray preparation at the time. The refuse cart remained positioned near clean food service items within the kitchen.During an interview on 2/18/26 at approximately 11:00 AM, the Dietitian stated the trash bin was kept in the kitchen because there was no alternative location to store it while the Kitchen Manager (KM) removed food debris from plates, pre-rinsed soiled dishware, and loaded the high-temperature dishwashing machine.During an interview on 2/19/26 at approximately 12:20 PM, the KM stated he was using the trash bin in that location temporarily for one day because he was working alone. He further stated that normal practice is to dispose of trash in a designated bin and remove it appropriately, and that keeping the bin in that location is not standard procedure. Despite observations made on two separate days, the KM maintained this was not usual practice.During an interview on 2/19/26 at 6:45 PM, the Administrator stated garbage is expected to be stored outside of the kitchen and not maintained on the kitchen floor. Upon review of the observations, she further acknowledged the refuse bin was not appropriately placed and should not have been maintained in that area.

Based on observation, interview, and review of facility policy, the facility failed to maintain the refuse disposal area in a sanitary and safe manner by failing to ensure dumpster doors remained closed in two (2) of two (2) dumpsters observed. The facility's failure to keep refuse container doors closed had the potential to attract pests and create unsanitary conditions, increasing the risk of environmental contamination.Findings include:Review of facility policy titled, Waste Disposal: Dietary Services, last revised 04/11/2016, revealed, It is the policy of PruittHealth for the Dietary Department to dispose of waste in an effective manner in order to prevent a breeding place for insects, rodents, and transmission of diseases. Garbage disposal areas should be separate from food prep areas.On 2/18/2026 at approximately 10:15 AM, the Housekeeping Supervisor escorted the surveyor to the refuse area and provided a tour of the facility's garbage storage area. Observation revealed two (2) garbage dumpsters with doors open and one cardboard compactor with the black lid flipped over the back of the container, exposing cardboard contents to environmental elements. Specifically, one dumpster had a single door open, and the second dumpster, located closest to the facility, had both side doors open.During the tour of the facility's garbage storage area, the Housekeeping Supervisor stated, Those are supposed to be closed; I think I have some gloves on me. I'll close those, and immediately proceeded to close the dumpster doors. No attempt was made to close the cardboard compactor lid.On 2/18/2026 at approximately 2:48 PM, a second observation of the dumpster visible from a facility hallway window revealed the dumpster door again open.On 2/19/2026 at approximately 3:28 PM, a third observation revealed the same dumpster located outside the facility, within view from a hallway window, with the door open.During an interview on 2/19/2026 at approximately 6:45 p.m., the Administrator stated that dumpster doors are expected to remain closed and that refuse areas should be maintained in a clean and sanitary condition to prevent contamination.

Based on observation, interviews, and record review, the facility failed to maintain 1 of 1 laundry washers in a safe operating condition. Specifically, the facility failed to ensure that 2 filters were cleaned daily for the UniMac washer.Findings include:On 02/18/26 at approximately 10:00 AM, a tour of the laundry room revealed that 2 of 2 filters on the Unimac washer were dusty and filled with black debris. A manufacturer's sign posted below the filters reads, clean filter daily.Review of an Alliance Laundry Systems Washer Manufacturer guidelines revealed: Maintenance End of Day4. If applicable, clean the AC invert drive filter. a. Remove the external plastic cover which contains the filter. b. Remove the foam filter from the cover.c. Wash the filter with warm water and allow air to dry. Filter can be vacuumed clean.During an interview on 02/18/26 at approximately 10:09 AM, the Laundry Assistant, reports that the maintenance department cleans the dryer lint filters and stated she was unaware washer filters were to be cleaned.During an interview on 02/18/26 at approximately 10:15 AM the floor tech/maintenance assistant stated, it was the laundry staff's responsibility to keep dryer and washer filters clean, and he mainly does the facility floors. Floor tech reports he sometimes assists in maintenance as needed, but his job is mainly a floor tech.During an interview on 02/18/26 at approximately 10:30 AM the Laundry Supervisor acknowledged the washer filters are dirty and need cleaning. Laundry supervisor stated she educated staff on how to clean washer filters using a small brush. Laundry supervisor reports she currently does not have a cleaning log sheet for the washer, but will implement a log sheet. Laundry supervisor states that because the facility has 1 washer, maintenance of the washer is a priority.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure the Electronic Medical Record (EMR) accurately reflected the Resident's Advance Directives. Specifically Resident (R)23 and (R)128 did not have advance directives that matched their Physician Orders. Findings include: Review of the facility policy titled Advanced Directives: South Carolina last revised on [DATE], revealed, This healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advanced Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advanced Directives executed in accordance with state law will be honored by the healthcare center. Procedure: 5. Revocation of Advance Directive: The healthcare center shall enter in the patient/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center. 1.Review of R128's Face Sheet revealed R128 was admitted to the facility on [DATE], with diagnoses including but not limited to: peripheral vascular disease, heart failure, anxiety disorder, acute kidney failure and plural effusion. Review of R128's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R128 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicates that she is cognitively intact. Review of R128's Nurses Note dated [DATE], revealed, Patient [R128] decided she wants hospice care. Social Worker informed facility nurse and NP [Nurse Practitioner] as well as hospice staff. It was decided that patient will go under hospice care tomorrow. Review of R128's Physician Orders for February 2026, an order for Full Code. Review of R128's DNR Authorization Form for Patient/Resident with Decision - Making Capacity: States of Florida, North Carolina and South Carolina dated [DATE] revealed resident was informed of and understood the risks and benefits of Cardiopulmonary Resuscitation (CPR) and requested that CPR not be initiated in the event of cardiopulmonary resuscitation. This form was signed by the physician on [DATE]. Review of R128's Care Plan last reviewed/revised on [DATE], revealed, Advanced Directive: Allow Natural Death- Do not attempt resuscitation. Advise patient/resident and or appointed healthcare representative to provide copies to the facility of an updated Advanced Directives, all staff to be made aware of patient/resident wishes. During an interview on [DATE] at 03:30PM with Registered Nurse (RN) 3, revealed, He is familiar with R128. He revealed that the nurse must explain what a DNR is to the resident and/or responsible party. The consent is signed by the resident or responsible party. He further revealed that two physicians sign the DNR paperwork to make it valid. He revealed that R128 has been a DNR for a week. During an interview on [DATE] at 04:00PM the MDS Nurse/RN revealed that Social Services usually takes care of the Code orders. When a resident is admitted , we put orders in for a Full Code until all of the paperwork is signed and the orders are written. Social Services gets all of the paperwork done and the code status orders signed. MDS Nurse verified that resident was made a Do Not Resuscitate on [DATE]. MDS Nurse also verified that resident had an active order for a Full Code on [DATE]. MDS nurse stated the Social Worker asked me to put the order in for a Do Not Resuscitate in today and I did. I do not know what happened. It usually does not take that long, and it should not take that long. During an interview on [DATE] at 04:55PM the Director of Nursing (DON) revealed, If we have an order for advanced directives from Hospice or the physician, the nurse should put in the order and Social Services should update the banner. That should occur within 24 hours of obtaining the order or whatever the policy states. This was a failure of the nurse to follow through with Hospice orders when received. Social Services failed to update the banner according to the active advanced directives order for this resident. 2. Review of R23's EMR revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; hypertension, dementia, insomnia, and depression. Review of R23's Quarterly MDS with an ARD of [DATE] indicated he had a BIMS score of 05 indicated he was cognitively impaired. Review of R23's Physician Orders for February 2026 indicated Full Code, with a start date of [DATE]. Review of R23's banner on his EMR indicated R23 was a DNR. Review of Advance Directives documents attached in the EMR indicated R23's Responsible Party (RP) had elected for R23 to be a DNR on [DATE]. During an interview with Licensed Practical Nurse (LPN)1 on [DATE] at 2:02 PM, she confirmed the process for identifying a Resident's code status. LPN1 was asked to view R23's orders in which she confirmed R23's code status did not match between the orders and what was located on the banner in the EMR. She stated the expectation would be for the orders to be audited and accurate. During an interview with Social Services on [DATE] at 3:42 PM, she confirmed that either Social Services or the Nurse collects advance directives data. She stated only the Nurses can change orders, but the banner and care plan can be updated by Social Services. She confirmed the inaccuracy in code status documentation for R23. During an interview on [DATE] at 4:04 PM, the Director of Nursing (DON) stated she had been made aware of the discrepancies and it was her expectation that the medical record was accurate. During an interview with the Administrator on [DATE] at 9:10 AM, she stated it is her expectation that the medical record is accurate and processes will be implemented to ensure this.

Based on record review, review of the facility policy and interviews, the facility failed to ensure written notification of the bed hold policy, including reserve bed payment requirements, was provided to the resident and/or the resident's representative for one of one Resident (R)1 reviewed for hospitalization.Findings Include:Review of the facility policy titled, Bed Hold Authorization Form: South Carolina last revised 12/6/22 revealed, Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy will be issued at the time of any transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family and/or undersigned parties, not to include the healthcare center, is provided with written notification within 24 hours of the transfer. The requirement is met if the patient/resident's copy of the notice is sent with other papers accompanying the patient/resident to the hospital.On 2/19/26 at approximately 8:58 AM, a closed record review revealed R1 was admitted to the facility on [DATE] and transferred via EMS to the hospital on 1/5/26. The resident did not return to the facility following the transfer.Further review of the closed record revealed no documentation demonstrating that written notification of the facility's bed hold policy was provided to R1 or the resident's representative at the time of transfer, sent with transfer paperwork, or issued within 24 hours as required by facility policy.During an interview on 2/19/26 at approximately 3:50 PM, the Social Services Worker stated she was unable to locate documentation of a bed hold notification for R1 and would need to conduct further review.During an interview on 2/19/26 at approximately 6:45 PM, the Administrator confirmed that neither she nor the Social Services Worker were able to locate or provide documentation demonstrating that written notice of the facility's bed hold policy had been provided to R1 or the resident's representative at the time of transfer or thereafter. The Administrator stated the nurse who discharged the resident had two additional discharges that same day and described it as a busy day.

Based on review of facility policy, record reviews and interviews, the facility failed to complete the admission Minimum Data Set (MDS) within 14 calendar days after admission for Resident (R)130 1 of 1 residents reviewed for comprehensive assessment and timing.Findings include: Review of the facility policy titled, MDS Assessment Accuracy, revealed, Policy Statement: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (ARD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident.Review of R130's Face Sheet revealed the facility admitted R130 on 01/30/26 with diagnoses including but not limited to: displaced intertrochanteric fracture of left femur, dementia, encephalopathy, dysphagia, and cerebral infarction.Review of R130's admission MDS located under the MDS tab in the EMR revealed MDS 02/05/26 In Process.During an interview conducted on 02/19/26 at 4:38 PM the MDS Nurse revealed [R130's] admission MDS has not been completed. It should have been completed by now. During an interview conducted on 02/19/26 at 05:15 PM the Director of Nursing revealed, they know better than that. The MDS nurse schedules the completion dates for the MDS. She should make sure they are completed on time.

Based on record review, interview, and facility policy review, the facility failed to initiate a baseline care plan related to therapy services and wound care for Resident (R)123 one of three residents reviewed for wound care. Findings include:Review of the facility's policy titled, Care Plans, revised 10/21/25, revealed Procedure: New admission Baseline Plan of Care 1. Upon a new admission, a baseline care plan will be developed by the admitting nurse/nurses in conjunction with the other IDT, the patient/resident and/or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of R123's Face Sheet revealed R123 was admitted to the facility on [DATE], with diagnoses including but not limited to: cellulitis of left lower limb, type 2 diabetes mellitus with diabetic neuropathy, and cerebral palsy.Review of R123's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 01/25/26 coded the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R123 is cognitively intact.Review of R123's Baseline Care Plan located under Care Plan tab in the EMR, revealed a baseline care plan was not initiated 01/19/26 for wound care or therapy services.On 02/19/26 at 01:05PM interview with MDS nurse revealed that she is familiar with R123 and she has a surgical cite that will not heal. The MDS nurse verified that there is no care plan for addressing R123's wound progress or treatments. MDS nurse verified that R123 should have a care plan that addresses the resident's wound.On 02/19/26 at 05:55PM interview with the Director of Nursing revealed that the MDS nurses and the IDT team should initiate the baseline care plan within twenty-four or forty-eight hours after a resident is admitted . They dropped the ball here.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure a care plan was completed and implemented for Resident (R)2 related to activities for one of three residents reviewed for care plans. Findings include: Review of the facility's policy titled, Care Plans, with a revised dated of 10/21/25 revealed 2. A comprehensive person-centered care plan will be developed by the interdisciplinary team for each patient/resident within seven days after the completion of the comprehensive assessment. 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of R2's Face Sheet located in the Electronic Medical Record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to; diabetes, hypertension, and dysarthria. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/25 indicated she has a Brief Interview of Mental Status (BIMS) score of 15, indicating she is cognitively intact. During an interview on 02/17/26 at 11:43 AM, R2 stated she was unaware of what activities the facility provided. She states that no one has ever came and offered her to attend activities. She stated, I hear things going on out there, but no one has invited me yet. Observation of R2's room indicated no presence of an activities calendar. Review of R2's Assessments, located in the EMR revealed no Activities assessment was completed. Review of R2's care plan did not indicate activities, or the need for activities as a problem. During continuous observations of R2 on 02/17/26, 02/18/26, and 02/19/26, R2 remained in her room, in bed with no activities in place, other than her television. During an interview with the Activities Director (AD) on 02/19/26 at 8:53 AM, she stated on admission, she typically does an assessment and then visits daily throughout the facility. She stated she is the only one in the Activities department, so often time she utilizes volunteers. When asked to provide documentation related to R2's assessments and R2's activity attendance, the AD was unable to locate the documents. Upon reviewing the EMR, the AD stated she must've missed this resident and acknowledged R2 did not have any assessments or care plans relative to activities. During an interview with the Administrator on 02/19/26 at 9:10 AM, she stated it is her expectation for all residents to have activities assessments completed within 48 hours of admission and care plans as required, so that their likes and dislikes can be honored.

Based on review of the facility's policy, record review, observations, and interviews, the facility failed to ensure a dependent resident (R)83 received adequate Activities of Daily Living (ADL) care to match her preferences.Findings include:Review of the facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs) with a reviewed date of 11/17/25 indicated, It is required for Activities of Daily Living (ADL) care given by Certified Nursing Assistants and Nurses to be documented under Care Assist in patient's/resident's Electronic Healthcare Record (EHR). For the healthcare centers not utilizing EHR, all documentation will be completed using the CNA ADL Flow Sheet Form.Review of the facesheet located on the EHR indicated R83 was admitted to the facility on [DATE] with diagnoses including but not limited to urinary tract infection, cognitive communication deficit, type 2 diabetes and hypertension.Review of R83's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R83 has a Brief Interview for Mental Status (BIMS) score of 3, indicating she was cognitively impaired. Review of Section F of the MDS indicated F0400: Interview for Daily Preferences: C. how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Was answered as 2. Somewhat important.Review of R83's care plan indicated the problem category, ADLs Functional Status/Rehabilitation Potential ADL Decline related to recent hospitalization and muscle weakness with a start date of 01/01/26. Approaches were listed as Ensure resident's hair is combed. Provide assistance when needed. Provide showers per schedule.During a telephone interview with R83's Responsible Party (RP) on 02/17/26 at 12:15 PM, she indicated R83 has not had a shower or her hair washed since admission, she has only been offered a bed bath.During observations of R83 on 02/17/26 at 12:10 PM and 02/18/26 at 9:45 AM, she was observed lying in bed, dressed in a hospital gown. Her hair appeared greasy and unkempt. An interview was attempted with no success.During an interview with Certified Nursing Assistant (CNA)1 on 02/17/26 at 4:16 PM, he stated, We only give showers when we have enough staff. We are short-staffed so no one is getting a shower today. The last time I gave a shower was last Thursday, I believe. It's hard to give showers if no one is here, and that's always. We have a schedule, but it's not followed so we do what we can.During a tour with CNA1 on 02/17/26 at 4:17 PM revealed a shower room on unit with a functioning shower. He stated half of the room was being used for storage. There was one additional shower room. There are three in total, but one is currently being worked on.During an interview with Licensed Practical Nurse (LPN)1 on 02/17/26 at 4:45 PM, she provided shower sheets. Review of the shower sheets from 01/26/26-02/18/26 indicated no dates had been signed off as showers given. LPN1 stated CNAs are also supposed to document in Point of Care (POC) if showers were given.During a second interview with LPN1 on 02/18/26 at 10:00 AM, she stated the nurses usually make the assignments for the CNAs. On the shower sheets, whomever is highlighted indicates who gets a shower on that day. The CNAs should sign off once given. If a resident refuses, staff should alert the Nurse so that it can be documented. She confirmed there was no documentation of R83's showers or having her hair washed. There were also no documented refusals for showers or hair washing.Review of R83's POC ADL log for 01/01/26-02/18/26 indicated under bathing, BED or PART. LPN1 confirmed this meant either a bed bath or partial bath. If a shower had been given, it would indicate SHOWER.Review of the Unit 2 Shower Schedule posted at the Nurses' station did not indicate when R83 was scheduled for showers.During an interview with the Director of Nursing (DON) on 02/18/26 at 4:04 PM, she stated it is her expectation for the Unit Managers to manage the floor staff. They are responsible for ensuring residents are receiving what they need and for CNAs to ensure documentation is adequate.During an interview with the Administrator on 02/19/26 at 9:10 AM she stated, We have had some staffing challenges. We do not use agency staff. The expectation is that residents receive a shower at least three times a week. Due to staffing, we offer showers at least once a week, but we ensure everyone gets a bed bath. This will be made a priority. We have other staff working in other areas who are certified as CNAs that we may pull to assist.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to assess Resident (R)2 for the needs and/or provide activities that met her interests.Findings include: Review of the facility's policy titled, Activities Program, with a reviewed date of 11/17/25 revealed, Policy Statement: The Health Care Center provides an ongoing program of Activities designed to meet the physical, mental, and psychosocial well-being of each resident while offering a rich array of activities to the residents of the center.Procedure: 7. After reviewing the Activities Assessment & Preferences for Customary Routine & Activities in the EHR, the IDT designates specific activities for individual residents in the resident's care plan based on their likes/dislikes, preferences, and impairments. 8. The Activity Participation will be recorded by the Activities Director/Assistant or designee in the EHR. Participation will be completed for each resident per each activity. R2 was admitted to the facility on [DATE] with diagnoses including but not limited to; diabetes, hypertension, and dysarthria. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/25 indicated she has a Brief Interview of Mental Status (BIMS) score of 15, indicating she is cognitively intact. Review of Section F: Preference for Customary Routine and Activities indicated the response of Somewhat important for the following questions:A. how important is it to you to have books, newspapers, and magazines to read? B. how important is it to you to listen to music you like? C. how important is it to you to be around animals such as pets? D. how important is it to you to keep up with the news? E. how important is it to you to do things with groups of people? F. how important is it to you to do your favorite activities? G. how important is it to you to do things with groups of people? H. how important is it to you to participate in religious services of practices? During an interview on 02/17/26 at 11:43 AM, R2 stated she was unaware of what activities the facility provided. She states that no one has ever came and offered her to attend activities. She stated, I hear things going on out there, but no one has invited me yet. Review of R2's Assessments, located in the EMR revealed no Activities assessment was completed. Review of R2's care plan did not indicate activities, or the need for activities as a problem. During continuous observations of R2 on 02/17/26, 02/18/26, and 02/19/26, R2 remained in her room, in bed with no activities in place, other than her television. During an interview with the Activities Director on 02/19/26 at 8:53 AM, she stated on admission, she typically does an assessment and then visits daily throughout the facility. She stated she is the only one in the Activities department, so often time she utilizes volunteers. When asked to provide documentation related to R2's assessments and R2's activity attendance, the AD was unable to locate the documents. Upon reviewing the EMR, the AD stated she must've missed this resident and acknowledged R2 did not have any assessments or care plans relative to activities. During an interview with the Administrator on 02/19/26 at 9:10 AM, she stated it is her expectation for all residents to have activities assessments completed within 48 hours of admission and care plans as required, so that their likes and dislikes can be honored.

Based on observation, interview, and record review, the facility failed to provide snacks for 2 residents, reviewed R 8 and R22.Findings include:Review of facility policy titled Nourishments, revision date 10/18/2017.Procedures: 2. Dietary will stock each nourishment kitchen with a variety of food and beverage items. (i.e., peanut butter, crackers, soup, ice cream, cereal, milk, or other beverages).Review of facility policy titled, Bedtime (HS) Snacks, revision date 06/20/2022. Procedures:2. Nursing staff will offer the HS snacks to all patients/residents (with the exception of patients/residents not receiving oral nutrition) at bedtime. An observation on 2/18/26 at approximately 4:19 P.M., observation revealed a family friend providing a snack to R 13, the resident was seated in the common area in front of the nurses' station. The family friend was observed holding a cup containing what appeared to be Chex Mix and pretzels.An observation on 02/19/2026 of 3 of 3 nourishment rooms revealed the following:Unit 1 cupboard at approximately 8:50 AM 1 12 boxes of Fieldstone Fudge Rounds, 5-Fieldstone Oatmeal Creme Pies in the cupboard. Refrigerator contained 9- Shasta [NAME], 6 8ozShasta Diet Ginger [NAME].Unit 2 cupboard at approximately 8:56 AM - 2 six pack 4-ounce apple sauce in the cupboard. Refrigerator contained 1 Glucerna.Unit 3 cupboard at approximately 9:03 AM - 5 Fieldstone Fudge Rounds in cupboards. Refrigerator contained 3 8oz Shasta Diet Ginger [NAME], 3 8. oz Shasta [NAME].An observation on 02/19/2026 of 3 of 3 nourishment rooms revealed the following:Unit 1 cupboard at approximately 5:04PM1 12 count Fieldstone Oatmeal Creme Pies, 1 -12 count Fudge Round, 2 loose Fieldstone Oatmeal Creme Pies, 2 loose Fieldstone Fudge Rounds, 1 60 count 2 pk Oreos in cupboard. Refrigerator contained 11- 8oz Shasta [NAME], 7 8oz Shasta Diet [NAME], 7 8oz Shasta Ginger [NAME], and a variety of supplements (i.e., Glucerna).Unit 2 cupboard at approximately 5:19 PM 60/2count Oreos, 2 12 pack Fieldstone Fudge Rounds, 5 loose Fieldstone Fudge Rounds, 12 6 count Toasty Peanut butter Crackers, 9 4 oz [NAME] Apple Sauce.Refrigerator contained 7 8oz Zero sugar Shasta ginger [NAME], 4 8oz Shasta Zero sugar [NAME], 2 8 oz Shasta ColasUnit 3- cupboard at approximately 5:24 PM: 14 Lance Toasty Peanut butter crackers, 16 Fieldstone Oatmeal Creme Pies, 5 Fieldstone Fudge Rounds.Refrigerator contained 24 8oz Shasta Ginger [NAME], 3 8oz Shasta Diet ginger [NAME].Review of R 8 Minimum Data Set, MDS-section C reveals Brief Interview for Mental Status, BIM score of 15. Review of MDS section F Preferences for Customary Routine and Activities; Section 0400 reveals very important to have snacks available between meals.Review of R 22 Minimum Data Set, MDS-section C reveals Brief Interview for Mental Status, BIM score of 13. Review of section F Preferences for Customary Routine and Activities; Section 0400 reveals very important to have snacks available between meals.Review of facility mealtimes reveals the following:Unit 1 Breakfast 7:00 AM, Lunch 11:30 AM, Dinner 5:00 PMUnit 2 (early small cart) Breakfast 7:10 AM, Lunch 11:40 AM, Dinner 5:10 PMUnit 2 (large cart) Breakfast 7:30 AM, Lunch 12:00 PM, Dinner 5:30 PMUnit 3 (early small cart) Breakfast 7:20 AM, Lunch 11:50 AM, Dinner 5:20 PMUnit 3 (large cart) Breakfast 7:40 AM, Lunch 12:10 PM, Dinner 5:40 PM Based on an interview on 02/18/2026 at 4:17 PM with Certified Nursing Assistant (CNA) [NAME] stated that snacks are usually distributed at approximately 2:00 P.M. and 7:00 PM, and snacks are labeled with residents whose names have been identified as wanting snacks.When asked what occurs between scheduled snack times, the CNA stated that staff may go to the kitchen if nothing is available in the nourishment room and that leftover snacks are sometimes available.The CNA stated there are designated residents who receive snacks and that staff utilize a list of resident names for snack distribution.When asked whether residents who are not on the designated list are offered snacks, the CNA did not state that snacks are routinely offered to those residents and reiterated that there are specific residents identified on the snack list.Based on an interview on 02/18/2026 at approximately 2:17 PM during the Resident Council Meeting, R 8 reports that residents do not get offered snacks at night.Based on an interview on 02/18/2026 at approximately 2:21 PM during Resident Council Meeting R 22 reports she asks for snacks at night and is told there are no snacks, or asks and does receive snacks. R 22 stated she has stopped asking for snacks because she does not receive them and has started purchasing from the canteen up front. Based on an interview on 02/18/2026 at approximately 4:19 PM with a family friend of R13, stated that if she does not bring snacks, the resident would not receive one. She further revealed that R13 does not eat large meals and relies on snacks, and that without snacks, R13 typically does not eat well.Based on an interview on 02/18/2026 at 4:25 PM with the Dietitian, the kitchen closes at 8:00 PM, and residents do not receive additional snacks until the kitchen reopens the following day. The Dietitian stated that if snacks are not available in the nourishment room after the kitchen closes, residents would have to wait until the next day.Based on an interview on 02/19/2026 at 8:45 AM with the DON stated that resident snacks come out twice a day, between meals. DON reports that snacks are offered to residents and that snacks should always be available day and night. DON stated her expectations for resident snacks: Snacks should be available for residents when and as they want them, even when I want a snack at home, it does not matter what time it is. This is their home.The facility failed to meet the nutritional needs and snack preferences of the residents

Based on observation, record review and interviews, the facility failed to ensure appropriate infection control practices were followed related to urinary catheter care for one of two Residents (R) 120 reviewed for catheter care. Specifically, the facility failed to prevent a resident's urinary drainage bag from being placed directly on the floor, creating a potential risk for contamination and infection. Findings include:Review of R120's Face Sheet revealed, the facility admitted R120 on 02/16/26 with diagnoses including but not limited to; urinary tract infection, type 2 diabetes mellitus and Alzheimer's disease. Review of R120's orders reveal Catheter Dx: Chronic Urinary Retention. Indwelling urinary catheter #16 FR 10cc bulb.An observation on 02/17/26 at 01:40 PM of R120 revealed resident lying in bed watching television. Bed was in low position. Catheter bag noted resting on floor.During an observation on 02/17/26 at 04:50 PM revealed resident lying in bed watching television. Bed was in low position. Catheter bag noted resting on floor.During an interview on 02/17/26 at 04:55 PM with Licensed Practical Nurse (LPN) 2 confirmed that resident's catheter bag was resting on the floor.During an observation on 02/18/26 at 11:00 AM revealed resident lying on floor beside her bed. Catheter bag noted resting on floor.During an interview with the unit manager on 02/18/26 at 12:00 PM it was revealed that R120 broke the hook that hangs the bag on the floor when she fell and that is why the catheter bag was on the floor on 02/17/26. The unit manager revealed that she could not explain why the catheter bag was observed on the floor on 02/18/26. The unit manager revealed that she was replacing the privacy bag for R120 and the new privacy bag would keep R120's catheter bag off of the floor.During an interview on 02/18/26 at 01:15 PM with the Director of Nursing revealed, it is common sense. The nurses and the Certified Nursing Assistants (CNA)s know that the catheter bag should always remain off of the floor.During an interview on 02/19/26 at 06:15 PM with the administrator revealed that there is no policy related to catheter care or infection control in regard to a catheter.

Based on observations, interviews and record review, the facility failed to prevent accidents and hazards for one (1) out of three (3) sampled residents (Resident (R)7). Findings include: Review of R7's electronic medical record revealed a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/16/25, that showed the resident was admitted from the community on 1/27/25. The Brief Interview Mental Status (BIMS) revealed a score of 99, which indicated he/she had been unable to complete the cognitive test. R7 requires partial assistance with ADLs (activities of daily living) when going from sitting to lying, from a chair/bed to another chair, with toileting and sitting to standing transfer. During an observation on 06/10/25 at 9:35 AM, of R7's room, there appeared to be a spill under the bed. The spill under bed was covered with a sheet and there was an extension cord plugged into the wall lying on the floor next to R7's bed. R7 was unable to communicate verbally. In an interview on 06/10/25 at 9:36 AM, the Registered Nurse (RN)/Unit Manager stated they would have housekeeping come into the room to clean up the spill. The RN/Unit Manager stated they did not know why an extension cord was in the resident's room. The RN/Unit Manager stated they assumed it was for the portable DVD player the resident had in bed. The RN/Unit Manager stated extension cords should not be in the resident's room. In an interview on 6/11/25 at 9:30 AM, the Maintenance Director stated they had just pulled the extension cord out of the room two (2) weeks earlier. He/she educated staff on keeping an eye on rooms, making sure no extension cords were used. They followed the National Fire Protection Association (NFPA) guidelines and extension cords were not allowed due to fire and safety hazards.

Based on interview, record review, and review of facility policy, the facility failed to report an allegation of resident-to-resident verbal abuse that occurred between Resident (R)16 and R17, for 2 of 8 residents reviewed for resident-to-resident altercations. Findings include: A review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last revised 07/29/19 revealed, It is the policy of the facility and its affiliated entities to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, and misappropriation of property. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, should be immediately reported to the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency, the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state agency should be notified of any allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events involve serious bodily injury, and not later than 24 hours after the allegation if the events do not involve or result in serious bodily injury. Review of R16's Face Sheet revealed, R16 was admitted to the facility on [DATE] with the diagnoses including but not limited to hypertension, dementia without behaviors, schizoaffective disorder, major depressive disorder, and anxiety disorder. Review of R16's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 08/01/23, revealed R16 has the Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicates that R16 is cognitively intact. Review of R16's Progress Note dated 06/15/23 at 5:02 PM revealed, Patient had a verbal exchange with roommate that involved yelling and screaming, roommate waved her grabber stick at the patient (R16). [R16] moved to another room, since room change patient has been calm and pleasant with no verbal exchanges with new roommate. Review of R16's Progress Note dated 09/04/23 at 5:28 PM revealed, Patient spoke to Social Worker about her previous roommate. Both ladies are no longer roommates, but they are on the same unit. Patient has spoken to Social Worker about being moved further apart if possible. Patient states she and previous roommate had some heated words over the weekend. Social Worker has assessed situation and is trying to come up with possible room changes. Patient states she can get along with other resident until something is figured out. Review of R16's Care Plan last revised 08/09/22 revealed, Resident had a verbal exchange with roommate and was yelling loud enough to be heard in the hallway. Interventions include encouraging continued visits with psychiatric services to help with anger management; encouraging resident to remain calm and calling for staff to mediate between her and other residents. Review of R17's Face Sheet revealed R17 was admitted to the facility on [DATE] with the diagnoses including but not limited to end-stage renal disease, schizophrenia, bipolar disorder, and altered mental status. Review of R17's Quarterly MDS with an ARD of 07/12/23 revealed R17 has a BIMS score of 15 out of 15 which indicates R17 is cognitively intact. Review of R17's Progress Note dated 06/13/23 at 6:56 PM revealed, Resident and roommate had verbal exchange at each other. Resident swung her grabber stick at her roommate but did not hit her. Due to a verbal altercation resident is in agreement to be moved and family was notified. Review of R17's Care Plan last revised 07/17/23 revealed, Resident had a verbal exchange with roommate and was waving grabber stick at roommate. Interventions include, continued visits with psychiatric services to help with anger management; encouraging the resident to remain calm and calling for staff to mediate between her and other residents. Review of R17's Social Services Progress Note dated 09/04/23 at 5:20 PM revealed, patient spoke to Social Worker about past roommate. Both ladies are no longer roommates but remain on the same hall. Patient is requesting that they be moved further apart. Patient states she and this other resident had some heated words over the weekend, and she did not like it. Social Worker assessed the situation and spoke to patient about possible room changes. Patient states she can get along with this resident while a plan is put into place. During an interview on 09/12/23 at 1:50 PM, Licensed Practical Nurse (LPN)2 revealed, [R16] and [R17] had recently gotten into a verbal and slightly physical resident-to-resident altercation. [R16] and [R17] were previously roommates who had to be separated due to verbal altercations and disagreements. The most recent argument took place because they live on the same unit but in different rooms due to the remodeling of the facility. During the verbal altercation, [R16] and [R17] threatened to hit each other, [R16] was noted to have attempted to hit [R17] with their grabber device and had to be separated by nursing staff. Afterward, we (nursing staff) were able to move their rooms further apart but because of the remodel, we were unable to place them on different units. This incident was not reported to the state agency because staff did not want this incident to be investigated. During an interview on 09/12/23 at 2:10 PM, R17 revealed that they feel safe at the facility now but recently had issues with another resident (R16). R17 stated that R16 and her used to be roommates but had to be separated due to disagreements. R17 further stated that they still see R16 at times because they reside in the same unit and recently got into another argument where R16 threatened to hit her with their grabber stick and they had to be separated by nursing staff. R17 stated, I try to ignore her, but I am not about to let her threaten me without fighting back. During an interview on 09/12/23 at 2:20 PM, the Social Worker revealed that they did not know the extent of the verbal altercation between R16 and R17 that took place recently (09/04/23) because it took place over the weekend when they were off but spoke to both residents when they returned to work. R16 and R17 have previously had verbal disagreements and were separated as roommates however, due to the remodeling of the facility are still on the same unit. At the time of the argument on 09/04/23, they were living as next-door neighbors but R16 has since been moved further down the unit. The Social Worker further stated that they were unsure if this incident was reported to the state agency. During an interview on 09/12/23 at 3:47 PM, R16 revealed that they do not fully feel safe at the facility because of R17. R16 stated that during their verbal altercation with R17 on 09/04/23 they had to be separated by nursing staff and accidentally dislocated a nurse's arm during the separation. We didn't physically hit each other but R17 threatened to hurt me which made me scared and is why I now keep my own grabber stick with me at all times in case R17 tries to threaten me again. Observation during the interview revealed R16 had a grabber stick in their bag that is on the back of their wheelchair, R16 also demonstrated how they were swinging their grabber stick during the verbal altercation on 09/04/23. During an interview with the Director of Health Services and Administrator on 09/12/23 at an unspecified time, revealed that the verbal resident-to-resident altercations with R16 and R17 had not been reported to the state agency.

Based on interview, record review, and review of facility policy, the facility failed to ensure a resident with a history of falls had Care Plan interventions implemented for 1 (Resident (R)9) of 3 residents reviewed for falls. This had the potential for R9 to sustain a fall with injury. Findings include: Review of the facility policy titled Care Plans with a revised date of 07/27/23 revealed, the comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident; s highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of R9's Face Sheet revealed R9 was admitted to the facility on [DATE] with diagnoses including but not limited to vascular dementia, muscle weakness, difficulty in walking, and disorientation. Review of R9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/23 revealed, R9's Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating R9 was severely cognitively impaired. Review of R9's Physician Orders dated 05/09/23 revealed, Fall mat x1 side of bed to prevent serious injury from falls every shift. Review of R9's Care Plan with a start date of 03/09/22 revealed, Resident has history of falling R/T cognitive loss, comorbidities, ect. Fall 5/8/23 no injuries., with a goal that R9 will remain free from significant injury due to falls through next review date. Approaches for R9's Care Plan included: Fall mat to side of bed to prevent serious injury due to fall on 5/8/23, Keep bed in lowest position with brakes locked, Keep call light in reach at all times, Provide resident an environment free of clutter, Give resident verbal reminder not to ambulate/transfer without assistance. During an observation on 09/12/23 at 3:24 PM, R9 was in his room, laying his bed. There was no fall mat in place and the bed was not in the lowest position. During an interview on 09/12/23 at 3:10 PM, Certified Nursing Assistant (CNA) verified there was no fall mat on R9's floor and his bed was not in the lowest position as the Care Plan indicated. During an interview on 09/12/23 at 3:58 PM, the Director of Health Services (DHS) confirmed that R9 was care planned for a fall mat and for his bed to remain in the lowest position. The DHS further stated that every shift staff should be ensuring and documenting that the components of R9's care plan are in place, and it is the responsibility of both nurses and CNAs to ensure interventions in the care plan are in place.

Based on observation, interviews, record review, document review, facility policy review, and review of manufacturer's information for the facility's wheelchair securement system, the facility failed to properly secure Resident (R)225 in the facility's transportation van while transporting the resident back to the facility following an appointment. On 10/14/2022, at approximately 2:30 PM, the Van Driver placed R225 in the facility van, securing the wheelchair in the back, locking the wheelchair brakes, and placing the lap belt on the resident, but did not secure the front of the wheelchair. Upon leaving the parking lot, the van stopped at a red light that was on an incline, and when the van started to move, the resident's wheelchair flipped backwards, causing a skin tear to the resident's right hand, abrasion to the forearm, and a knot to the back of the resident's head. R225 was then provided first aid by the Minimum Data Set (MDS) Nurse, who was also on the van for the transport, and then the wheelchair was secured in the van for transport back to the facility. On 04/19/2023 at 6:08 PM, the interim Administrator was presented with an Immediate Jeopardy (IJ) template that indicated IJ existed at F689 with a start date of 10/14/2022 and an end date of 10/17/2022. Implementation of the facility's corrective action plan was verified through observation, staff interviews, and record reviews. Observation and interviews with the Van Driver and MDS Nurse revealed they had received training on how to properly secure residents in the facility van. Additional review revealed the facility failed to complete a thorough investigation of falls to determine the root cause and develop interventions for 1 (R70) of 7 residents sampled for accidents. Furthermore, the facility failed to ensure the environment remained free of accident hazards for 1 (R19) of 4 residents reviewed for medication self-administration. Specifically, staff allowed R19, who was cognitively impaired and assessed to be unable to self-administer medications, to store medication at the bedside. Findings include: 1. A review of the facility's policy titled, Transportation Guidelines, revised 01/25/2016, revealed guidance on how to provide safe transportation for patients/residents. The section for Requirements for Transporting included the following: 1. The partner shall have completed all training outlines [sic] in the Van Transportation Certification Program. A review of the facility's policy titled, Driver Authorizations, issued November 2012, revealed, Healthcare Center will maintain a system for making certain that all partners who operate or occupy a motor vehicle for transportation have been authorized by the Administrator and have met required training and qualifications. The policy also indicated, The Administrator is responsible for monitoring the compliance to this policy. A review of a facility policy titled, Wheelchair Transports, issued November 2012, revealed, The transportation partners are responsible for the implementation of this policy. The policy directed staff on the steps to take for Safe use of Wheelchairs, including the following instructions regarding strapping the wheelchair down in the transportation van: When securing a wheelchair, attach the four tie down straps to the securement points provided on the wheelchair. Tighten the straps to remove all slack. A review of a facility policy titled, Competency Requirements for Van Drivers, issued November 2012, revealed, Healthcare Centers recognize the importance of having competent partners that have received training and education related to providing transportation services. Responsible Parties: The Administrator is responsible for monitoring compliance to this policy. Education Requirements: Wheelchairs: Transportation Aide has completed the wheelchair training by the approved trainer. The policy indicated this training would be completed upon hire and annually. A review of the undated manufacturer's information from the facility's wheelchair securement system revealed the product was designed to make transportation safer for passengers with special needs. The manufacturer's information also indicated, As transportation professionals, you are responsible for the safety and welfare of your passengers. That's why it's extremely important to learn the correct way to secure passengers and their wheelchairs and comply with the regulations that apply to you. Section 4: Securing the Wheelchair revealed, Correctly securing a wheelchair is extremely important for the safety and comfort of the passenger as well as your own peace of mind. Injury or death may result from improper securement. A review of R225's Resident Face Sheet revealed the resident was admitted to the facility with diagnoses including vitamin D deficiency, muscle weakness, and difficulty walking. A review of R225's admission MDS, dated [DATE], revealed R225 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. The MDS also indicated R225 used a wheelchair for mobility. A review of R225's Resident Progress Notes, dated 10/14/2022, revealed that during the transport back to the facility from their dialysis appointment, R225's wheelchair flipped backwards, and R225 sustained a golf-ball size area to the back of the head, an abrasion to the right elbow, and a skin tear on the left hand. During an interview on 04/19/2023 at 8:42 AM with the Van Driver, he stated that prior to 10/14/2022 he had only driven the facility's van four or five times and had always had a certified nursing assistant (CNA) present with him to secure the residents in the van. The Van Driver said on 10/14/2022 he picked up R225 from an appointment, and when he was securing R225's wheelchair into the van, the resident asked him not to secure the front of the wheelchair. He said once they were in route to the facility, they had to stop at a red light, which was on an incline, and when he put the van into motion, the resident's wheelchair flipped backwards. He said he then pulled the van over and the MDS Nurse, who was also present on the van, checked on the resident and provided first aid. The Van Driver said they then set up the wheelchair and he fully secured the resident's wheelchair in the van and transported the resident back to the facility. He said the reason R225's wheelchair flipped backwards was because he failed to fully secure the resident's wheelchair when he did not secure the front of the wheelchair. He said that he did not recall ever being checked off on how to transport or secure residents prior to the incident on 10/14/2022. During an interview on 04/19/2023 at 9:45 AM with the MDS Nurse, she stated 10/14/2022 was the first time she ever transported a resident. She indicated the administrator at that time asked her to go along for the transport because they did not have any other staff available to go with the Van Driver. The MDS Nurse said she had not received any training on transporting residents prior to this incident, and she was just along for the ride, and did not provide any assistance to the Van Driver in securing R225's wheelchair. She said she relied on the Van Driver to know how to properly secure the resident. The MDS Nurse said after R225 finished their dialysis appointment, the Van Driver loaded the resident and wheelchair in the facility van and secured the back wheels. She said she overheard R225 tell the driver not to lock down the front of the wheelchair. She said she saw the driver secure the wheelchair, but he did not secure the front of the wheelchair. She said that on the drive back to the facility, they stopped at a red light that was on an incline, and when the Van Driver began moving again after the light changed, the resident's wheelchair flipped backwards. She said they immediately pulled the van over, and she assessed the resident. She said the resident had a skin tear on the right hand, an abrasion to the elbow, and a small knot on the back of the head. She provided first aid to the resident, then they raised the wheelchair back up, and the Van Driver fully secured the wheelchair and they returned to the facility, where she gave a report to the nurse. On 04/19/2023 at 3:15 PM, the Van Driver demonstrated how to secure a wheelchair in the facility van. He said that on 10/14/2022, he secured the back of the wheelchair, locked the brakes, and placed the long seat belt on the resident, but did not secure the front of the wheelchair because the resident requested for him not to. During an interview on 04/21/2023 at 11:52 AM, the MDS Nurse stated she should have reminded the Van Driver and the resident of the importance of properly securing the wheelchair, and she should have reached out to her supervisor when she realized the resident had not been properly secured in the van. During an interview on 04/21/2023 at 12:39 PM, the interim Director of Health Services (DHS) stated she thought they should have provided some more training to the staff regarding transporting residents. She said they did not use the van for transports at this time. During an interview on 04/19/2023 at 11:38 AM with the Administrator, she stated that since the incident on 10/14/2022, they had used an outside transportation company for all transporting needs of the residents. The facility van had not been used since the incident on 10/14/2022. The facility's undated Plan of Correction developed following the 10/14/2022 incident included the following corrective actions: 1. [Van Driver] is not to transport any longer. 2. All transport personnel are not to drive van until full completion of required education/competency and DMV [Department of Motor Vehicle] checks are completed. 3. Scenario education to be provide when a resident refuses safety devices-Van is NOT to transport under any circumstances. 4. Scenario education on what to do when an event occurs; - Immediately stop the van in a safe location- - Call Administrator and 911 - Have EMS [emergency medical services] to evaluate-if resident refuses to seek medical attention have resident transported back to facility by EMS. - Immediate inspection and re-enactment need to occur to determine root cause related to any accidents/incidents. 2. Review of the facility's policy titled, Occurrences, revised 11/29/2022, revealed, Investigation and Follow-up: 1. Occurrence investigation and follow-up is a joint responsibility within the healthcare center. 2. Communication between all parties is essential for identifying the events and circumstances that resulted in the occurrence and for identifying interventions that limit the risk of occurrence being repeated. The policy further indicated, 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation on the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. 7. The Administrator or designee will complete the supervisor investigation on all occurrences. A review of R70's Resident Face Sheet revealed the facility admitted the resident with diagnoses that included difficulty in walking, dizziness and giddiness, repeated falls, and muscle weakness. A review of R70's admission MDS, dated [DATE], revealed R70 had a BIMS score of 15 out of 15, indicating the resident was cognitively intact. R70 had no history of falls on admission. R70 required limited assistance of one person for transfers. R70 was unsteady during transitions and walking and was only able to stabilize with staff assistance. A review of R70's comprehensive Care Plan, revealed a care plan addressing Falls, dated 11/14/2022. The falls care plan indicated R70 was at risk for falling R/T [related to] requiring assistance with ADLs [activities of daily living], incontinence of bowel and bladder, seizure disorder. A review of a Progress Note, dated 11/11/2022 at 7:17 PM, indicated R70 slid to the floor from the bed during an attempt to toilet without assistance. A review of a Progress Note, dated 11/21/2022 at 5:20 PM, revealed R70 was observed sitting on the bathroom floor at 4:15 PM. R70 reported to staff they were attempting to self-toilet and slipped and fell . A review of a Progress Note, dated 12/03/2022 at 6:49 PM, indicated the CNA assigned to R70 notified staff the resident slid out of their wheelchair while attempting to self-transfer. A review of a Progress Note, dated 12/14/2022 at 8:16 AM, indicated R70 had gotten out of the bed, walked to the bathroom without assistance, and fell . A review of a Progress Note, dated 01/18/2023 at 2:25 PM, revealed R70 was observed sitting on the floor beside the bed. R70 reported to staff they were trying to reach an item on top of their bedside table and slid to the floor. R70 verbalized they landed on their buttocks and denied hitting their head. On 04/18/2023 at 12:50 PM, the Administrator said they had provided all investigations or incident reports for R70 for November 2022 through the current date. She confirmed there were no fall investigations for R70's falls on 11/11/2022, 11/21/2022, 12/03/2022, 12/14/2022, and 01/18/2023. During an interview on 04/18/2023 at 2:18 PM with the Administrator, she stated she expected the staff to start an investigation when a resident had a fall. During an interview on 04/19/2023 at 2:03 PM with Licensed Practical Nurse (LPN)1, she stated R70 liked to be independent and would try to go to the bathroom without assistance. She said they tried to re-direct the resident and remind the resident to ask for assistance. She said for falls, a root cause should be identified, and interventions would be put in place to keep the resident safe. During an interview on 04/21/2023 at 12:39 PM with the interim DHS, she stated she needed to know immediately if a resident had a fall so she could conduct an investigation. During an interview on 04/21/2023 at 1:07 PM with the Area [NAME] President (VP), he stated he expected the staff to follow the facility's fall policy, conduct investigations, and implement interventions to keep the residents safe. 22445 3. A review of a facility policy titled, Self-Administration of Medications by Patients/Residents, revised on 01/24/2020, revealed, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. A review of the Resident Face Sheet revealed the facility had admitted R19 with Parkinson's disease, muscle weakness, dementia, generalized anxiety, intercostal pain, and collapsed vertebrae. A review of the quarterly MDS, dated [DATE], indicated R19 had a BIMS score of 3 out of 15, which indicated the resident had severely impaired cognition. The MDS revealed the resident had impaired vision and was only able to see large print. R19 required extensive assistance of staff for bed mobility, dressing, and personal hygiene and required supervision for eating. Further review of the MDS revealed a staff assessment for pain was not conducted for the resident. The resident's care plan, dated 02/28/2023, indicated R19 had self-care deficits related to poor cognition and the resident's physical status. The facility developed an intervention that directed staff to observe the resident for signs and symptoms of discomfort during care. A review of R19's Self-Administration of Medication assessment, dated 11/17/2022, indicated based on the assessment, it was not appropriate for the resident to self-administer medications; subsequently, the resident would not be storing medications. Observations made on 04/17/2023 at 10:05 AM, 04/18/2023 at 1:57 PM, and 04/19/2023 at 8:30 AM revealed a tube of generic arthritis pain gel was seen in the resident's room. A review of R19's Physician Order Report revealed the resident had an order for a Lidocaine self-adhesive patch applied to the skin for pain and for Voltaren arthritis pain gel to be applied twice a day for pain. There was no documented evidence the resident had an order to self-administer medications, to keep medications at the bedside, or for R19 to have a generic arthritis pain gel. CNA17 was interviewed on 04/19/2023 at 9:10 AM and stated if she saw medication at a resident's bedside, she would remove the medication and give the medication to the nurse. The CNA stated she would be scared a wandering resident may get the medication. She stated there was one resident who wandered on the unit where R19 resided who had been seen going in and out of other residents' rooms. Registered Nurse (RN)19 was interviewed on 04/20/2023 at 1:45 PM. The nurse was aware of the pain cream at R19's bedside. RN19 stated a family member gave the resident the pain cream. RN19 stated she had tried to educate the family, but the family continued to bring the medication to the resident. The DHS was interviewed on 04/21/2023 at 11:57 AM. The DHS stated a resident with a BIMS score of 3, such as R19, would not be competent to self-administer medications. She stated she expected staff to immediately remove any over-the-counter medications from the room. The DHS further stated if the family continued to bring medication and leave it at the resident's bedside, she expected the nurse to educate the family. If the family continued to bring in medication, she expected the nurse to report the situation to the DHS. According to the DHS, she had received no reports regarding the over-the-counter medication in R19's room.

Based on observations, interviews, record review, and review of facility policy,the facility failed to assess 1 (Resident (R)25) of 4 residents to determine their capability to self-administer medications. Findings include: A review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, revised on 01/28/2020, indicated, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patient/residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. 2. If the patient/resident or family member desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. Also, the resident or family member should, in conjunction with the facility nurse, utilize the Electronic Medical Record Observation tool, Medication Self-Administration Observation to complete the administration of the medication. 3. If the Licensed nurse determines the patient/resident or family member are capable of self-administration of medications, the attending physician must write an order to that effect that includes the specific medications based off of the Self-Administration Medication Observation. A review of the Resident Face Sheet for R25 revealed the facility admitted the resident with diagnoses that included Parkinson's disease, depression, muscle spasms, seizures, major depressive disorder, anxiety disorder, and diabetes with diabetic neuropathy. A review of the significant change in status Minimum Data Set (MDS), dated [DATE], revealed R25 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately cognitively impaired. The MDS indicated R25 had verbal behaviors that occurred daily. The resident required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident required supervision for locomotion on and off the unit and with eating. The resident was identified as having a functional limitation in range of motion on one side of the upper extremities and lower extremities. A review of R25's care plan, dated 05/09/2019, revealed the resident had alterations in thought process related to a diagnosis of traumatic brain injury. The care plan also indicated the resident had self-care deficits due to a traumatic brain injury, generalized weakness, muscle spasms, impaired mobility, and tremors. The facility developed an intervention that directed staff to administer the resident's medications as ordered. A review of R25's Physician Order Report revealed an order started on 09/08/2022 to administer Miralax 17 grams of powder mixed with eight ounces of water once per day at 9:00 AM for constipation. There was no documented evidence that R25 had an order to self-administer the medication On 04/18/2023 at 8:02 AM, Registered Nurse (RN)19 was observed giving R25 morning medications. The nurse gave R25 pills, which the resident took without any problems. RN19 then gave R25 a cup that contained Miralax and water. R25 drank approximately 25% of the Miralax and set the cup on the over-bed table. The RN stated she would leave the Miralax at the bedside for the resident to drink later. The RN left the room and R25 left the room also, accompanied by another staff member. An interview was held with RN19 on 04/18/2023 at 1:45 PM. She stated medications were not left in the room because the nurse needed to make sure all the medications were taken. The nurse acknowledged she had left the cup of Miralax in R25's room because she wanted the resident to take time and drink all the medication. RN19 stated Miralax was a medication, and she should not have left the medication in the resident's room. The nurse stated the resident had not been assessed for self-administration of medication. The Director of Health Services (DHS) was interviewed on 04/21/2023 at 11:57 AM. The DHS stated before a resident was able to self-administer medications, an order from the physician was required. Additionally, the resident received education, and staff needed to make sure the resident was competent to self-administer medication. The Area [NAME] President was interviewed on 04/21/2023 at 12:59 PM. He stated he expected the staff to follow the facility policy on self-administration of medications and make sure self-administration was possible for the individual resident.

Based on interviews, record review, and facility policy review, the facility failed to provide written notice to the resident and/or the resident's representative prior to a room change for 1 (Resident (R)223) of 1 sampled resident reviewed for a room change. Findings include: Review of a facility policy titled, Room or Roommate Changes, revised on 12/06/2022, indicated, It is our policy to inform patients/residents in advance of any change in room or roommate and allow patients/residents the opportunity to have input in the decision. A review of R223's Face Sheet indicated the facility admitted the resident with diagnoses that included endocarditis (an infection of a heart valve), supraventricular tachycardia (an abnormally fast heartbeat), and an abscess of the abdominal wall. An admission Minimum Data Set (MDS), dated [DATE], revealed R223 had a Brief Interview for Mental Status score of 3, which indicated severe cognitive impairment. The MDS indicated the resident required extensive to total assistance from staff for all activities of daily living. Review of R223's Care Plan, revised on 05/10/2022, indicated the resident had dementia, difficulty understanding others, and impaired cognitive skills for decision making. A review of a Resident Census sheet indicated that on 05/16/2022 at 4:33 PM, R223 was moved from room [ROOM NUMBER]-A to room [ROOM NUMBER], which was designated as a private room. A review of R223's Resident Progress Notes indicated that on 05/16/2022 at 4:39 PM, Social Worker (SW) 6 met with R223's Resident Representative (RR)40 and discussed the resident's discharge plans and answered questions RR40 may have had. There was no documentation in the progress notes that indicated the room change was discussed. A telephone interview was held with RR39 on 04/17/2023 at 3:42 PM. RR39 stated that while R223 lived at the facility there had been a room change, and she had not been notified prior to the room change. SW14 was interviewed on 04/20/2023 at 9:03 AM. The SW stated that when a room change was planned, the resident and resident representatives were given as much notice as possible. SW14 stated that generally the discussion about a room change was documented in the progress notes. SW14 did not state that written notification was provided prior to a room change. SW14 stated she was unable to remember why R223's room had been changed. Registered Nurse (RN)16 and SW6 were interviewed on 04/20/2023 at 9:30 AM. RN16 stated that on 05/16/2022, when SW6 spoke to the family about discharge plans, SW6 also spoke to the resident representative about the room change and just had not documented that part of the conversation. SW6 neither denied nor agreed with the RN's statement, but acknowledged there was no documentation the room change was discussed with RR40. The Area [NAME] President was interviewed on 04/21/2023 at 12:59 PM, in the absence of the Administrator, and stated he expected staff to follow facility policy regarding room change notifications.

Based on interviews, record review, and facility policy review, the facility failed to assist a resident in filing a grievance related to missing personal property and failed to ensure prompt efforts were made to resolve the issue for 1 (Resident (R)42) of 6 sampled residents reviewed for missappropriation of property. Findings include: Review of a facility policy titled, Grievances: Healthcare Centers, revised 11/21/2022, indicated, In the event a patient expresses a grievance or complaint to a staff member, one or more of the following actions will be taken: If the patient or family member requires assistance with writing the grievance, the staff person receiving the information will assist with completing the appropriate section of the Grievance/Complaint Form: Healthcare Centers. The policy indicated, The Administrator or designee will then refer the grievance to the appropriate department for investigation if it has not already been referred. Further review of the policy indicated, The Grievance/Complaint should be resolved within three business days. A review of R42's Resident Face Sheet indicated the facility admitted the resident with diagnoses that included transient cerebral ischemic attack (a temporary episode that causes symptoms similar to those of a stroke) and depression. A quarterly Minimum Data Set (MDS), dated [DATE], revealed R42 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. According to the MDS, R42 required extensive assistance with personal hygiene, bed mobility, dressing, and toilet use and required supervision with eating. Review of R42's Care Plan, revised on 04/04/2023, indicated the resident had a self-care deficit and required staff assistance for completion of activities of daily living. R42 was interviewed on 04/17/2023 at 9:39 AM. R42 stated they had missing clothes and a missing tube of specialty toothpaste for tooth sensitivity. The resident stated staff were informed of the missing items but did not seem to take the resident's concerns seriously. The resident stated that since the toothpaste was missing, staff suggested the resident use facility-supplied toothpaste; however, the resident could not, due to sensitivity. R42 was unable to identify the staff member to whom they reported the missing clothes and toothpaste. During an interview on 04/20/2023 at 7:59 AM, Social Worker (SW)6 stated that when residents reported missing items to staff, the staff were expected to notify their supervisor, and the supervisor was expected to notify the SW, so a search for the items could be initiated. SW6 stated if the missing items were not found, the facility replaced the items. The SW stated missing items were written up as a grievance. SW6 stated no one had reported missing items for R42. During an interview on 04/20/2023 at 9:08 AM, SW14 stated that staff usually reported when a resident was missing items. She added an email was then sent to other staff, and staff would look for the items. SW14 stated if lost items were not found, the facility replaced the lost items. SW14 stated she would check the grievance log to see if anything had been reported missing for R42, and she would speak with the resident. The grievance log did not contain documentation regarding R42's missing items. Registered Nurse (RN)19 was interviewed on 04/20/2023 at 2:03 PM. RN19 stated that on Friday, 04/14/2023, R42 told her a large tube of toothpaste brought in by the resident's family had disappeared. RN19 stated the resident had not told her about missing clothes. The RN stated she told the certified nursing assistant (CNA) who worked on the resident's hall about the missing toothpaste so the CNA could look for the toothpaste. The RN stated she had not told anyone else about the missing toothpaste, but added the SW (the RN did not specify which SW) knew about R42's missing items. The Interim Director of Health Services (DHS) was interviewed on 04/21/2023 at 12:12 PM. The Interim DHS stated that when residents reported missing items, the staff were expected to report the incident to the SW and the Interim DHS, then staff were expected to look for the items. The Interim DHS stated if the items were not found, the facility would replace the lost items. The expectation was that the staff notify the Interim DHS and SW immediately. The Area [NAME] President was interviewed on 04/21/2023 at 12:59 AM. He stated the expectation was for the staff to report the missing items to the grievance coordinator so the staff could look for the items.

Based on record review, interviews, facility document review, and facility policy review, it was determined that the facility failed to thoroughly investigate an incident of injury of unknown origin for 1 (Resident (R)173) of 11 residents reviewed for abuse and/or neglect. Findings include: A review of a facility policy titled, Investigation of Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 10/09/2020, revealed, The administrator of the provider is responsible for assuring that an accurate and timely investigation is completed. If there is an occurrence of or allegation involving patient abuse (including injuries of unknown source), neglect, exploitation, mistreatment or misappropriation of patient property, the following investigation and reporting procedures will be followed. The policy further indicated, If it appears to a reasonable person that injury of unknown cause has occurred, interviews should be conducted. Signed statements should be gathered from: staff who cared for patient just prior to and after injury; other reliable patients in the vicinity nearby area; and family or visitors who may have noticed anything. A review R173's Face Sheet revealed the resident was admitted to the facility with diagnoses that included Alzheimer's disease, generalized muscle weakness, difficulty walking and hypertension. On readmission, the Face Sheet indicated R173 had sustained a fracture of the right femur (large bone in the upper leg-thigh). A review of R173's Progress Note, documented by the Nurse Practitioner (NP) on 08/23/2022 at 7:30 AM, revealed the NP received a call from a facility nurse, who told her R173 was lying in bed and complaining of right hip and knee pain. The note also indicated the resident's right leg was rotated outward, the resident would not let staff move the leg, and the resident refused to attempt to bear weight. The NP ordered x-rays of the hip and knee. A review of R173's Progress Note, documented by Registered Nurse (RN)29 on 08/23/2022 at 7:40 AM, revealed a Certified Nursing Assistant (CNA) reported R173 was complaining of pain during incontinence care. The RN documented the resident was guarding their right thigh. No redness or discoloration was noted. RN29 indicated she called the NP and was waiting for an order. A review of R173's Progress Note, documented by Licensed Practical Nurse (LPN)33 on 08/23/2022 at 8:03 AM, revealed LPN33 assessed R173 due to receiving a report from the night nurse. LPN33 documented R173 was lying in bed with their legs stretched out, and the resident's right hip and leg were rotated outward. The nurse also indicated the resident was touching their hip and complaining of pain, and limited range of motion was observed. LPN33 also documented, No known injury. A review of R173's Progress Note, documented by the NP on 08/23/2022 at 6:18 PM, revealed, Outreach Notes: Received notification from facility: X-ray results: acute mildly displaced intertrochanteric fracture in the right femur. Plan: Send to [emergency department] for evaluation and treatment. A review of R173's hospital records revealed the resident was brought in from [resident's] facility after obtaining x-ray showing right sided intratrochanteric [sic] fracture on x-ray pelvis at outside facility. Facility by report denies any falls or known injuries. A review of the 24-hour initial report sent to the state agency, dated 08/23/2022 at 8:10 PM, indicated, Resident complained of right hip pain, no known cause of hip fracture, no reported falls. X-ray was obtained and results were R [right] hip fracture, resident was transferred to hospital. Responsible party and NP made aware. Investigation initiated. A review of the investigation that was included with the facility's final report, dated 08/30/2022, included a timeline that indicated CNA27 and RN29 worked with the resident the night prior to the identification of the fracture. The facility's investigation did not include witness statements from CNA27 or RN29. The summary indicated the facility was unable to validate if a fall had or had not occurred and indicated that prior to the fracture, R173 had been able to transfer independently and was ambulatory. Furthermore, the facility documented within the investigation that the fracture could have been a result of a spontaneous fracture, as it was mildly displaced. Another area of the report indicated RN29 and CNA2 had been on duty at the time of or prior to the incident. CNA2 handwrote a witness statement that indicated she had not been working at the time of the incident. No further statements or investigation were completed to determine the origin of R173's injury. A telephone interview was held on 04/17/2023 at 1:04 PM with R173's resident representative (RR). She stated she had not gotten an answer from the facility on what caused R173's fracture. The RR stated R173 had neither a diagnosis of osteoporosis nor osteopenia. The Administrator was interviewed on 04/18/2023 at 2:10 PM. The Administrator stated she would have preferred to see much more in the investigation related to R173's injury. The Administrator presented the completed investigation for R173's fracture, which consisted of progress notes and included no interviews from staff that worked on the shift when the resident was supposed to have sustained the injury. The NP was interviewed on 04/19/2023 at 10:05 AM and described R173 as independent with transfers, toilet use, and ambulation. The NP added the resident was confused, and while the resident was supposed to use a rollator for ambulation, the resident would forget. The NP reviewed her notes and stated that on 08/23/2022, she received a call that indicated R173 was complaining about hip and knee pain and received a report the leg was rotated outward; the resident would not bear weight and would not let staff touch the leg. The NP stated she had been told by staff later that R173 had fallen. The NP stated she thought the resident had gotten up to go to the bathroom and had slipped. The Physical Therapist (PT) was interviewed on 04/19/2023 at 11:21 AM and stated R173 was physically able to ambulate around the room without a device and toileted independently. The PT stated R173 had profound dementia, and the resident's memory about using a device was impaired, adding the resident carried their walker or cane instead of using the devices. The PT stated he had heard from facility staff that R173 had fallen, while the RR told him the resident had rolled out of bed. He added the consensus of the facility was there was a fall of some kind that resulted in the fracture. Licensed Practical Nurse (LPN)1 was interviewed on 04/19/2023 at 2:33 PM and stated that while R173 had been provided devices for ambulation, the resident was unable to remember to use the devices. LPN 1 stated she had come into work and the day shift nurse reported R173 would not allow the CNA to complete incontinence care and was pushing the staff member away from touching the hip. LPN1 stated she assessed R173 and found the resident's hip externally rotated. The nurse stated she was unable to explain how the resident broke their hip but added there were several stories being told in the facility. LPN1 stated one story indicated R173 fell and then returned to bed independently, while another story was the resident fell out of bed, staff returned the resident to bed, and no one reported fall. LPN1 identified RN29 and CNA27 as the staff that worked with the resident on the night the injury occurred. LPN1 stated the resident walked independently and roamed throughout the building, so the resident could have fallen out of bed or could have slipped while walking. CNA2 was interviewed on 04/19/2023 at 4:42 PM. CNA2 stated she had worked with R173 on the 3:00 PM to 11:00 PM shift on 08/22/2023. CNA2 stated that when she left for home after the end of the shift, R173 was in bed and had no complaints of pain or discomfort during the shift. CNA2 stated that when she returned to work a few days later, CNA27 stated she had answered the resident's call bell, and R173 told CNA27 there had been a fall, but the resident was in bed. CNA2 stated R173 could not have gotten up independently from the floor, even without a broken hip. CNA2 stated she had also heard R173 had been in bed the entire 11:00 PM to 7:00 AM shift, and she had wondered how R173 could have sustained a broken hip. RN29 was interviewed via telephone on 04/19/2023 at 8:45 PM and acknowledged she had been assigned to care for R173 on the night shift on 08/22/2022. RN29 stated that when she arrived to work, R173 was up and ambulating independently but was a bit unsteady. RN29 stated that eventually the resident went to bed. The RN stated that a little after midnight, the resident complained of pain and was given Tylenol and added the resident remained in bed for the remainder of the shift and had slept soundly. The RN stated the next morning, 08/23/2022, R173 complained of more pain, and the NP was called, and x-rays were ordered. RN29 stated she had no knowledge of any falls, and CNA27, who cared for the resident that night, had not reported any falls and, in fact, had told her the resident had not been out of bed. A telephone interview was held with CNA27 on 04/20/2023 at 11:22 AM, and CNA27 acknowledged she had worked with R173 on the 11:00 PM to 7:00 AM shift on 08/22/2022. CNA27 stated that shortly after 11:00 PM, she went to the resident's room, and the resident told her they had fallen and were hurting and stated the resident was holding the stomach/side area. The CNA stated the resident had dementia, so it was hard to understand what they said. After the resident told the CNA about the fall, CNA27 told RN29, who was working on another unit. A telephone interview with CNA35 was held on 04/20/2023 at 12:02 PM. CNA35 stated that when she got to work at approximately 11:00 PM, R173 was already in bed. She added she assisted CNA27 with incontinence care and during care, R173 yelled, Ouch, Ouch, and they both knew something was not right with the resident. CNA35 stated R173 had not mentioned anything about falling. CNA35 stated she and CNA27 reported the resident's pain to RN29. CNA35 stated RN29 responded within a short time. CNA35 stated R173 was in bed during the entire shift starting on 08/22/2023 at 11:00 PM and ending on 08/23/2022 at 7:00 AM. The Administrator was interviewed on 04/21/2023 at 10:30 AM. She stated that in review, the investigation into R173's incident was not thorough. She stated if a thorough investigation had been completed, it would have included witness statements and enough information would be obtained to determine what happened to R173. The Administrator stated if a cause of an accident could not be determined, then the person investigating the accident/incident should drill down enough to determine a reasonable idea of what happened. She stated that with the different stories being told about what caused R173's fracture, there was no way anyone had investigated enough to determine what happened to the resident. The Director of Health Services (DHS) was interviewed on 04/21/2023 at 12:19 PM. The DHS stated a thorough investigation should include witness statements from nurses and nursing assistants working during the shift. She added if the resident had short-term and long-term memory impairment, no weight should be placed on the resident's interview. The DHS stated she had reviewed the submitted state report for R173's incident and stated the former administration had not completed a thorough investigation.