Every finding on record at River City Center

Based on record review, interviews, and review of a facility investigative summary, the facility failed to ensure the residents' environment remained free of accident hazards by failing to ensure staff's personal medications were stored in a secure location that was not accessible to residents. Specifically, on 11/08/2021, Resident Identifier (RI) #5, who had a diagnosis of Alzheimer's Disease and resided on the facility's Memory Care Unit, accessed and ingested up to twenty [MEDICATION(S)] (an antihistamine medication) tablets from a bottle belonging to Employee Identifier (EI) #19, a Certified Nursing Assistant (CNA). RI #5 was able to obtain the medication because EI #19 placed her purse, which contained the medication, in a resident closet on the Memory Care Unit and left it unsupervised. RI #5 was transported to the emergency room and received treatment for ingestion of this medication. This deficient practice placed RI #5, one of one resident reviewed for accidental ingestion of medications, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 11/07/2022 at 9:07 AM, Employee Identifier (EI) #1, the facility Administrator/Center Executive Director, was provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accidents Hazards/Supervision/Devices. The immediate jeopardy began on 11/08/2021 and continued until 11/11/2021 when the facility implemented corrective actions to address the identified deficient practice, including ongoing monitoring; thus, immediate jeopardy past noncompliance was cited. Findings include: On 11/09/2021 at 10:26 AM, the State Survey Agency received an initial report from the facility regarding RI #5 ingesting Employee Identifier (EI) #19's, a Certified Nursing Assistant's (CNA's), personal [MEDICATION(S)] prescription, which the staff member had stored on the shelf of a closet in a resident room on the Memory Care Unit. Review of an Admission Record revealed RI #5 was originally admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Cognitive Communication Deficit, Need for Assistance with Personal Care, Major Depressive Disorder, and Dementia with Behavioral Disturbance. Review of RI #5's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/30/2021, revealed RI #5 scored a 2 on the Brief Interview for Mental Status, indicating severe cognitive impairment. Review of the facility's investigative file, dated 11/15/2021, revealed RI #5 ingested twenty tablets of [MEDICATION(S)] from a bottle belonging to EI #19, a CNA. The investigation indicated the resident was able to obtain the medication because EI #19 placed her purse, which contained the medication, in a resident's closet on the Memory Care Unit and left it unsupervised. EI #10, another CNA, found RI #5 with the purse and medication bottle. There was a green residue on the resident's lips and tongue, matching the color of the pills. The investigation revealed RI #5 was assessed by the nurse, poison control was called, and the resident was transported to the local hospital by Emergency Medical Services (EMS). The investigation report indicated the resident denied eating or taking any medications. EI #19 admitted to placing her purse on the top shelf of another resident's room and covering it with her jacket. EI #19 stated she had the prescription filled prior to coming to work that day. Review of RI #5's hospital History and Physical, dated 11/08/2021, revealed RI #5 was admitted to the hospital on 11/08/2021 with diagnoses of Toxic Ingestion of Anticholinergic Drugs, Probable Early Onset Toxic [CONDITION(S)] ([CONDITION(S)] caused by exposure to a toxic substance), Dementia, Macrocytic [CONDITION(S)] (a condition in which the blood contains overly large red blood cells and not enough normal red blood cells), and Chronic Kidney Disease. The hospital record indicated the plan was to aggressively rehydrate the resident to enhance the excretion of the [MEDICATION(S)]. The Discharge Summary, dictated on 11/22/2021, documented RI #5 initially had .quite a bit of lethargy, and then woke up and was eating and remained hemodynamically stable . During an interview on 09/16/2022 at 12:45 PM, EI #10, CNA, stated she had given another resident a shower and was returning the resident to his/her room. EI #10 stated she had trouble getting into the room because the door was closed, and when she tried to open it, the door was hitting the open closet door. EI #10 stated when she got the door open, she saw RI #5 lying on the empty bed in the room with a green substance on his/her hands and lips. EI #10 also noted a purse and pharmacy bag on the floor of the closet. EI #10 stated she notified the nurse, who went to the room to take care of RI #5. EI #10 stated she went to the shower room and asked EI #19 if she had any medication in her purse. EI #10 stated EI #19 confirmed she did. EI #10 stated she had never seen staff personal belongings in any resident room before this incident. She stated EI #19 brought belongings to work but EI #10 did not know where she kept them. EI #10 stated the facility had lockers in the breakroom, and that was where staff should keep their belongings. Review of a witness statement, dated 11/08/2021 and written by EI #11, Licensed Practical Nurse (LPN), revealed she was notified by EI #10 that RI #5 had gotten .into employee personal bag and took a bottle of prescription medications . During an interview on 09/16/2022 at 12:56 PM, EI #11 stated she was working and was notified by EI #10 that RI #5 got into some medications. EI #11 stated she went down the hall and saw RI #5 walking in the hall. EI #11 stated RI #5 had a green substance around his/her mouth. EI #11 called EI #2, Center Nurse Executive, who was in the building. EI #2 instructed EI #11 to contact poison control. EI #11 stated she stayed with RI #5 until EMS arrived. EI #11 stated she and other staff kept personal belongings locked in the medication room or in the lockers in the break room. EI #11 stated she had never seen any staff belongings in resident rooms before this incident. Review of a witness statement dated 11/08/2021 and written by EI #19, CNA, revealed EI #19 was giving another resident a shower when another CNA came and told her RI #5 had EI #19's purse with pills in it. EI #19 stated she went to the room and only found nine tablets. EI #19's statement indicated she left her purse high on a shelf with a sweater on top of it, and when she was notified, she went to the room and found the purse on the bed. During an interview on 09/16/2022 at 1:32 PM, EI #19 stated she had a doctor's appointment on 11/08/2021 and stopped to get the prescription filled before work. EI #19 stated she was running late to work, so she went straight to the unit and put her belongings on the closet's top shelf in a resident's room, which was not RI #5's room. EI #19 stated she could not recall which room it was. During the interview, EI #19 acknowledged that RI #5 would frequently wander into other residents' rooms and open drawers and put on clothing. EI #19 said she did not know why she put her purse in the closet that day, that she had never done that before. EI #19 stated she then went to the shower room to give another resident a shower. EI #19 said while she was in the shower room, EI #10 entered the room and stated RI #5 had gotten into EI #19's purse. EI #19 stated she left the shower room as quickly as she could and went to the room and saw the purse on the bed. EI #19 stated the [MEDICATION(S)] prescription was full, with 30 tablets, and had a child-proof cap on the bottle. EI #19 stated she did not know how RI #5 was able to get the lid off. EI #19 stated she did not know how many tablets were missing and did not count the tablets herself. EI #19 stated she did not know why she put her purse on the closet shelf, except that she was in a hurry. Review of a witness statement, dated 11/08/2021 and written by EI #2, revealed she was notified by EI #11 that there was a problem on the hall. EI #2 went directly to the unit and was told EI #19 left her purse in a resident's closet and that the purse contained medications. EI #2's statement indicated she was told RI #5 had taken the medication and swallowed a good amount. EI #2 saw RI #5 walking in the hallway, accompanied by two staff members and noted a green color to RI #5's lips. EI #2's statement indicated she determined what the medication was and that there were nine tablets remaining. EI #2 stated staff contacted poison control and were advised to take the resident to the emergency room . The statement indicated EI #2 attempted to notify the Administrator without success, then notified the Corporate Administrator. Continued review of EI #2's statement revealed EI #2 was instructed to suspend EI #19, conduct a room sweep for loose pills and staff belongings, and conduct an in-service with staff. During an interview on 09/16/2022 at 11:21 AM, EI #2 stated she received a call from EI #11 stating that RI #5 had ingested an unknown medication. EI #2 stated she immediately went to the unit and instructed EI #11 to contact poison control. EI #2 stated EMS was contacted, and she waited with RI #5 until EMS arrived. EI #2 stated EI #19 reported she had been to a doctor's appointment earlier in the day and had picked up the prescription prior to coming to work. EI #2 stated EI #19 put the purse on the top shelf of a resident's closet. EI #2 stated she felt RI #5 would have been able to reach it, as the resident was tall. During an interview on 09/16/2022 at 3:00 PM, EI #1, Center Executive Director, stated he was not working at the facility when this incident occurred but reviewed the investigation. EI #1 stated the facility had investigated the occurrence, provided training to staff, as well as monitored to ensure it did not happen again. During an interview on 09/16/2022 at 4:36 PM, EI #13, Medical Director, stated he had been notified of RI #5's accidental ingestion of the [MEDICATION(S)]. EI #13 stated RI #5 was a little sleepy but had recovered from the ingestion. Once the facility became aware of the incident involving RI #5 ingesting a staff member's medication, the following corrective action plan was developed and implemented: ADHOC QAPI (Quality Assurance and Performance Improvement) Plan for Ingestion Event 11/9/21 1. Resident on Memory Support Unit found a staff members purse on the unit and ingested medication that (he/she) found inside the purse. Poison control notified and resident sent to ER for evaluation. Staff member was sent home under administrative leave. 2. All residents have potential to be affected. Full search of Memory Support Unit completed to ensure no other staff personal items or any other potential hazardous items were on the unit. This was completed on 11/8/21. Full center search for potential hazardous items was completed on 11/9/21. 3. Education initiated for Memory Support staff on 11/8/21 regarding safe guarding personal items and potentially hazardous items from residents. Education included keeping personal items off resident care areas. This education was continued for all staff. 4. Nursing Management will inspect resident rooms on Memory Support Unit Daily x (times) 2 weeks, including off shifts and weekends to ensure that there are no staff personal items and/or other potentially hazardous items in resident care areas. Audits will continue 2 x weekly thereafter. Department Heads will audit non Memory Support unit care areas during their Partner Rounds to ensure no staff items and/or other potentially hazardous items are in resident care areas. Any deviations noted will result in further education and/or disciplinary action. Results of these audits will be brought before the Quality Assurance and Performance Improvement Committee monthly with QAPI Committee responsible for ongoing compliance. 5. Date of compliance: 11/11/21. After review and verification of the information provided in the facility's corrective action plan, in-service/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 11/08/2021 through 11/11/2021, with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 639.

Based on interviews, medical record review, and review of a facility policy titled, OPS111 Elopement of Patient, this facility failed to ensure Resident Identifier (RI) #6 was supervised in a manner that staff knew of his/her whereabouts and that he/she did not leave the facility without staff knowledge. On 9/14/2021 at approximately 12:05 PM, RI #6, a cognitively impaired resident, was witnessed by a staff member to unlock and open an exit door. As the resident was exiting, two facility staff members went outside to get the resident. As the staff members approached RI #6, he/she began to run, getting approximately 85 feet from the facility near the street. The staff members were able to retrieve RI #6 and bring him/her back into the facility and into his/her room. However, the staff members left RI #6 in the room with no additional supervision to ensure the resident would not leave the facility again as they performed other duties. At approximately 12:40 PM, RI #6 could not be located inside the facility or on the facility grounds. As the facility was searching for RI #6, a call was received from the resident's sister who indicated RI #6 was at her home, approximately 2.9 miles from the facility. This deficient practice placed RI #6, one of seven sampled residents reviewed for elopement risk, in immediate jeopardy, as it posed a situation that may have resulted in serious injury, serious harm, impairment or death. On 9/25/2021 at 6:43 PM, the facility's Administrator and the Nurse Practice Educator (Registered Nurse) were provided the Immediate Jeopardy template and notified of the findings of substandard quality of care at the Immediate Jeopardy level in the area of Quality of Care/Free of Accident Hazards/Supervision/Devices, F689. This deficient practice affected RI #6, one of seven residents sampled for elopement risk. Findings include: Review of a facility policy titled, OPS111 Elopement of Patient, with a revision date 2/28/2021, documented: POLICY . Elopement occurs when a patient leaves the premises without authorization (i.e., an order for discharge or leave of absence (LOA) and/or any necessary supervision to do so. 2. Witnessed Attempted or Actual Elopement: 2.1 Staff witnessing a confused patient or an identified elopement risk patient attempting to leave the Unit and/or Center unaccompanied will intervene as appropriate to redirect the patient to a safe area and prevent elopement . RI #6 was admitted to the facility on [DATE], with diagnoses including Unspecified Alzheimer's Disease, Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbance, [CONDITION(S)] with Hallucinations due to Known Physiological Condition, Delusional Disorders, and Generalized Anxiety Disorder. RI #6's medical history also included a diagnosis of Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. Review of RI #6's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/7/2021 revealed RI #6 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. On 9/16/2021 at 12:54 PM, the facility self-reported to the Alabama State Survey Agency an incident of neglect. According to the initial report, RI #6 was able to unlock the rehab unit door to exit the center while staff noticed him/her exiting he/she able to be directed back into the center to his/her room by Employee Identifier (EI) #3, Social Services Director (SSD) and EI #4, Certified Nursing Assistant (CNA). The SSD emailed to alert the IDT (Interdisciplinary Team) that RI #6 was more appropriate for the secured unit. Rehab staff then reported the resident was no longer in his/her room. A facility and exterior search was initiated. RI #6's family called the facility at 1:10 PM and stated that RI #6 was picked up by a family friend and taken to the home, but she did not state where RI #6 was picked up from. On 9/17/2021, an Updated Summary related to (RI #6's) elopement, documented: After reviewing statements from staff here is an estimated timeline of events and additional details. At approximately 12:13 PM, the SSD sent an email stating resident was out of the center on the street and was able to be brought back in the center but would need to be moved to secure unit. SSD also stated that the resident was dressed in a two piece outfit and exited the center by unlocking a manual lock on the rehab unit. At approximately 12:40 PM, EI #1, Administrator (ADM), was alerted that resident was not located in the center and was believed to have left the center a second time. Facility interior and exterior searches were initiated. At approximately 1:10 PM, the family called the center and stated RI #6 was at their home and asked the facility to come pick the resident up. They stated a family friend picked RI #6 up about a block and a half from the facility near a two lane road. On 9/24/2021 at 4:12 PM, an interview was conducted with EI #3, SSD. EI #3 was asked who found RI #6 outside the facility on 9/14/2021. EI #3 said there were two incidents. EI #3 said that EI #4, a CNA, had yelled she needed her help, so she ran out of her office and saw RI #6 outside, on the street and brought him/her back inside and to his/her room. EI #3 stated she went back into her office and sent an email to EI #1, the Administrator, telling her that RI #6 had been outside the building and should be moved to the secure unit. EI #3 stated when EI #5, the Registered Nurse (RN) came back on the unit, she told her what happened and that she had notified administration. EI #3 stated when EI #5 went in RI #6's room to administer medication, RI #6 was not in room and the elopement protocol was initiated. EI #3 was asked where RI #6 was located. EI #3 said a family friend recognized RI #6 and took him/her to a family member's home and the family called and told the facility that he/she was there. EI #3 was asked how the second incident could have been prevented. EI #3 said in hindsight, she should not have left RI #6, and someone should have sat with him/her until he/she was moved to the dementia unit. On 9/24/2021 at 5:03 PM, an interview was conducted with EI #4, a CNA. EI #4 was asked how she became aware that RI #6 had left the faciity on [DATE]. EI #4 said she heard the door unlock and when she looked, RI #6 was closing the door back and she yelled for EI #3, the SSD, to help. She further stated RI #6 was about to cross the street and she and EI #3 ran to him/her and brought him/her back in the facility. EI #4 was asked what happened after RI #6 was returned to the facility. EI #4 said EI #3 walked him/her back down to his/her room while she went to feed another resident on the unit. EI #4 further stated that she did not see RI #6 again until after he/she was brought back and taken to the secure unit. EI #4 was asked what she meant by brought back. EI #4 said when she came back from feeding, EI #5, the RN, asked her if she had seen RI #6. She further stated she and EI #5 looked room to room and could not find RI #6, so they let all the other stations know that the resident was missing. EI #4 was asked how the second elopement could have been prevented. EI #4 said they should have had RI #6 one on one after the first elopement. On 9/24/2021 at 6:10 PM, an interview was conducted with EI #1, the ADM. EI #1 was asked about the incident with RI #6 was. EI #1 said RI #6 got out of the facility and made it back home on 9/14/2021. EI #1 was asked if RI #6 had another incident. EI #1 said yes, he/she made it to the parking lot and was redirected back inside earlier the same day, on 9/14/2021. EI #1 was asked when she became aware of the incident. EI #1 said she became aware of the second incident while reading an email about the first incident. She further stated she received the email at 12:34 PM and while reading it, EI #2, the Interim Director of Nursing came in and said they could not locate RI #6. EI #1 further stated they did not know where RI #6 was from 12:40 PM to 1:10 PM when the family called and notified the facility that he/she was at their home. On 9/25/2021 at 9:57 AM, a telephone interview was conducted with EI #2, the Interim Director of Nursing (DON). EI #2 was asked how she was notified that RI #6 had gotten out of the facility and was brought back in by staff on 9/14/21. EI #2 said her notification was sent by email and she did not see it right away. EI #2 explained that since they were in the building, EI #3 should have directly told her about the incident instead of sending the email. EI #2 was asked if the second elopement could have been prevented. EI #2 said absolutely. EI #2 was asked how it could have been prevented. EI #2 said they should have initiated one on one with him/her until they could expedite him/her being moved to their secured unit. On 9/25/21 at 4:01 p.m., a telephone interview was conducted with EI #5, an RN. EI #5 was asked who reported to her that RI #6 had gotten out of the building and was brought back in on 9/14/2021. EI #5 said EI #4, a CNA, and EI #3, the SSD. EI #5 was asked where EI #3 and EI #4 told her that they found RI #6 and what time. EI #5 said they told her RI #6 was seen unlocking the side door and going to the street and they brought him/her back in and placed him/her in his/her room. She further stated when she went to RI #6's room to administer medication he/she was not in the room and she called the DON and implemented the elopement protocol. EI #5 was asked how the second elopement could have been prevented. EI #5 said if someone had been with him/her. ************************************************ On 9/26/2021, the facility submitted the following as their removal plan for the identified Immediate Jeopardy: *Licensed Nurse completed an assessment on RI #6 on September 14, 2021 and no injuries were identified. The Physician was notified of the findings and wander guard bracelet ordered and applied on September 14, 2021. *RI #6 was placed on a secure unit on September 14, 2021. *The Center Nurse Executive and/or designee placed RI #6 on 1:1 supervision for 12 hours due to exit seeking behaviors on September 14, 2021. *Nurse Manager and/or designee completed an Elopement Assessment and updated RI #6's care plan on September 14, 2021. *Maintenance Director and/or designee inspected all exit doors and gates on September 14-17, 2021 to validate doors were functioning and fully secured. *Center Executive Director and/or designee placed a door/monitor at the TCU sliding door on September 26, 2021 at approximately 6 pm to provide 24 hour surveillance until an alarm can be placed on the exit door. (This action was actually verified as implemented as of 9/25/2021 by the survey team.) . *Licensed Nurses completed an Elopement Assessment on all residents by September 24, 2021 to identify all other residents at risk for Elopement. The care plan was reviewed and updated as needed. *Nurse Managers and/or designee reviewed and updated the Elopement Binders by September 24, 2021 to validate photographs of residents at risk for Elopement are located in the binders and the binders are easily accessible to staff. *Nurse Practice Educator and/or designee performed an Elopement Drill on September 13, 2021. *Center Executive Director and/or designee completed one on one education with the Maintenance Director on September 26, 2021 related to ensuring TCU sliding door has a functioning alarm. *The Nurse Practice Educator and/or designee initiated re-education with all active employees on September 14, 2021 and completed by September 24, 2021 on the Elopement Policy. Active employees and employees on leave of absence (FMLA), vacation, or PRN staff who have not been re-educated, will be trained prior to returning to duty. *Center Executive Director hosted a Quality Assurance Performance Improvement (QAPI) meeting via phone on September 14, 2021 and in person on September 15, 2021 with Interdisciplinary Team members to include: Interim Center Nurse Executive, Admissions Director, Recreation Director, Director of Rehab., Social Services Director, Housekeeping Manager, Nurse Managers, Clinical Reimbursement Manager, Maintenance Director, Medical Records, Staffing Coordinator, Business Office Manager and reviewed with the Medical Director (via phone) on the center's Elopement Policy. Completed on 9/25/2021. ************************************************ After reviewing the facility's information provided in their Removal Plan and verifying the immediate corrective actions had been implemented, the scope/severity level of F689 was lowered to a D level as of 9/25/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 553.

Based on interview, review of the facility's online incident reports to the state agency, and review of the facility's policy titled, OPS300 Abuse Prohibition, the facility failed to ensure allegations of abuse were reported to the state agency within two hours or within the required time frames. This deficient practice occurred with two of eight facility reported allegations of abuse or neglect involving Resident Identifier (RI) #s 2, 3, and 4, three of seven sampled residents. Findings Include: Review of the facility's policy titled OPS300 Abuse Prohibition with a revision date of 4/09/2021 documented: .7.2 Report allegations involving abuse .not later than two (2) hours after the allegation is made . 7.4 Report allegations involving neglect, .within 24 hours if the event does not result in serious bodily injury . 1) This facility reported to the state agency via the online reporting system on 9/13/2021 at 5:39 PM, an allegation of physical abuse involving RI #s 2 and 3. The report states that on 9/11/2021 at 4:02 PM (RI #2) hit (RI #3) unprovoked when (RI #3) was rolling past (RI #2). According to a document contained within the investigative file prepared by Employee Identifier (EI) #1, Administrator/Abuse Coordinator, this incident was witnessed by facility saff member; however, it was not reported within the two hour time frame in accordance with the regulatory requirement and as stated in the facility's policy. An interview was conducted with EI #1, Administrator/Abuse Coordinator on 9/24/2021 at 1:00 PM. EI #1 stated the incident of physical abuse involving RI #s 2 and 3 was reported to the facility on [DATE]. EI #1 stated it was reported to the state agency on 9/13/2021 at 5:39 PM. EI # 3 further stated the incident should have been reported to the State Agency within two hours on 9/11/2021. 2) This facility's former Director of Nursing (DON) reported to the state agency via the online reporting system on 8/25/2021 at 5:55 PM an allegation of verbal abuse. The former DON included in the online report the following narrative summary of the incident: It was reported to myself around 10am on 8-25-2021 that resident (RI #4) stated that staff wanted to fight (him/her). An interview was conducted with EI # 1 on 9/25/21 at 3:15 PM. EI #1 stated the incident of verbal abuse involving RI # 4 occurred on 8/23/21 at 7:30 PM. EI #1 stated the incident was reported to the State Agency on 8/25/21 at 5:55 PM. EI #1 stated it should have been reported within two hours of the incident occurring. EI #1 stated a former employee took the report. EI #1 was unsure why it was not reported within two hours. This deficiency was cited as a result of the investigation of complaint/report number AL 554.

Based on interviews and medical record review, this facility failed to ensure Resident Identifier (RI) #7's left plantar foot dressing was changed on 9/17/2021, 9/18/2021 and 9/19/2021. On 9/20/2021, when the wound physician removed RI #7's dressing, it was dated 9/16/2021. This deficient practice affected RI #7, one of two sampled residents reviewed for wounds. Findings include: RI #7 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #7's Order Recap Report, dated September 24, 2021, revealed: Clean L (left) foot plantar with Dakin solution, lightly fill wound bed with Dakins soaked4x4 and secure with roll gauze as needed for soilage/displacement AND every day shift. The start date for this order was on 8/25/2021. On 9/24/2021 at 3:23 PM, an interview was conducted with EI #10, Licensed Practical Nurse (LPN)/Wound Nurse. EI #10 was asked how she became aware of the concern with RI #7's left foot wound. EI #10 said RI #7 was being followed by the wound physician. When the wound physician removed RI #7's dressing on 9/20/2021 it was dated 9/16/2021. EI #10 was asked what she did. EI #10 stated they brought EI #2, the Interim Director of Nursing (DON) down to see the dressing and wound. EI #10 was asked how often the dressing changes were ordered. EI #10 said they were a daily dressing change at that time. On 9/24/2021 at 5:51 PM, a telephone interview was conducted with the wound physician. The wound physician was asked what the concern was with RI #7's dressing not being changed from 9/16/2021 until 9/20/2021. The wound physician said that RI #7's wound care had not been done and it was supposed to be changed daily. EI #8 was asked what was the concern with RI #7's dressing not being changed as ordered. EI #8 said it would not heal and the dressing needs to be changed daily. On 9/25/2021 at 9:45 AM, an interview was conducted with EI #1, the Administrator (ADM). EI #1 said that RI #7's dressing had not been changed since 9/16/2021. On 9/25/2021 at 2:04 PM, a telephone interview was conducted with EI #9, Registered Nurse (RN). EI #9 was asked how she became aware of the wound physician having a concern with RI #7's dressing changes. EI #9 said EI #1, the ADM and EI #2, the DON, asked her about it. EI #9 was asked what the concern was. EI #9 said the dressing had not been changed since 9/16/2021.

Based on record review, interviews, and review of a facility policy titled, NSG113 Nursing Documentation, the facility failed to ensure Employee Identifier (EI) #9, a Registered Nurse (RN), did not document that she performed dressing changes she did not do for Resident Identifier (RI) #7 on 9/18/2021, 9/19/2021 and 9/20/2021. This deficient practice affected RI #7, one of two sampled residents reviewed for wound documentation. Findings include: A review of a facility policy titled, NSG113 Nursing Documentation, with a revision date of 6/1/2021, revealed: . POLICY Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate . Nursing staff will not falsify . nursing documentation. PRACTICE STANDARDS 1. Nurses will not: 1.1 Document services that were not performed; 1.2 Document services before they are performed; . RI #7 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #7's Treatment Administration Record (TAR) dated 9/1/2021 - 9/30/2021, revealed that EI #9, RN, signed off that she had completed RI #7's ordered dressing changes to the left foot on 9/18/2021, 9/19/2021 and 9/20/2021. During an interview on 9/24/2021 at 3:23 PM, EI #10, Licensed Practical Nurse (LPN)/Wound Nurse, stated on 9/20/2021 it was identified RI #7's dressings had not been changed as ordered. EI #10 explained that the wound physician was in on 9/20/2021 to assess RI #7's wound, and found the dressing was dated 9/16/2021. On 9/24/2021 at 5:51 PM, a telephone interview was conducted with the wound physician. The wound physician said RI #7's wound care was supposed to be changed daily and it was not. On 9/25/2021 at 9:45 AM, an interview was conducted with EI #1, ADM. EI #1 was asked what her investigation had determined about RI #7's dressing changes. EI #1 said that the dressing had not been changed since 9/16/2021, when the wound doctor removed the dressing on 9/20/2021. EI #1 was asked who signed that the dressings had been changed. EI #1 said EI #9, RN. According to EI #1, EI #9 said she thought hospice was supposed to change the dressing, so she signed off on it and that she also signed off on it when she thought the wound nurse had changed it. EI #1 was asked why a nurse should not document what she thought another nurse had done. EI #1 said because the nurse might not have done it and then the other nurse's initials say it was done. EI #1 was asked what the concern was with treatments being documented as completed but were not actually done. EI #1 said false documentation. EI #1 was asked what the concern with false documentation was. EI #1 said the patient's record would not be accurate. On 9/25/21 at 2:04 PM, a telephone interview was conducted with EI #9, RN. EI #9 was asked why she had documented that she had changed RI #7's left foot dressing. EI #9 said because she went ahead and signed off and made a list of what she had to do, and it must have fallen through the cracks and she did not do it. EI #9 was asked what the concern was with charting something had been completed before she had done it. EI #9 said it would not get done. EI #9 was asked what the concern was with medical record documentation not being accurate. EI #9 said it would be false documentation. EI #9 was asked when she should document that a treatment had been done. EI #9 said after she did it herself. EI #9 was asked if she completed RI #7's dressing changes on 9/18, 9/19 and 9/20/2021 as was documented in the medical record. EI #9 said no, she did not. EI #9 was asked what that documentation would be for those dressing changes. EI #9 said false documentation.

Based on observations, interviews, and record review, the facility failed to follow the posted menu for the lunch meal on 04/26/21. This failure has the potential to affect 133 of 134 residents living at the facility, there was one resident requiring tube feedings. Findings include: During the lunch meal observation on the East Short Hallway and the Solona Unit, on 04/26/21 at 12:20 PM, nine residents were served chicken alfredo and green peas. Observation on 04/26/21 at 1:20 PM revealed Resident Identifier (RI) #80 was served a plain hot dog on a bun and mashed potatoes. On 04/26/21 at 1:20 PM, RI #48 was served a plain hot dog on a bun and mashed potatoes. On 04/26/21 at 01:20 PM an interview with Employee Identifier (EI) #10, Assistant Director of Nursing (ADON) confirmed RI #80 and RI #48 were served hot dogs for lunch. On 04/26/21 at 1:40 PM, EI #17, a dietary staff member acknowledged that chicken alfredo was served for lunch today and the change was not updated and posted on the menu. On 04/26/21 at 2:00 PM, RI #8 stated he/she was served a hotdog with mashed potatoes for lunch today. A review of the posted lunch menu for 04/26/21 revealed: Ham and Pinto Beans Pan Fried Potatoes Homestyle Cornbread Alternate: Sloppy [NAME] on a Roll Fiesta Corn Chocolate Ice Cream A review of the facility's policy titled, Menus, dated 09/2017 revealed, . 6. Menus will be served as written, .

Based on observation, interview and record review, the facility failed to ensure the proper handling of clean dishes and silverware. This failure has the potential to affect 133 of 134 residents living at the facility, there was one resident requiring tube feedings. Findings include: 1. On 04/26/21 at 9:38 AM an observation of Employee Identifier #18, Dietary Aide (DA) revealed EI #18 was cleaning off dishes, pots, pans, and glasses from breakfast preparing them for the dishwasher wearing gloves. EI #18 was observed spraying/rinsing off dirty dishes and placing them on trays and into the dishwasher and then moving to the clean side of the dishwasher and handling the clean trays of dishes wearing the same gloves. EI #18 never removed the gloves or performed hand hygiene. On 04/26/21 at 09:40 AM an interview with EI #18 was conducted. When questioned what actions she had just performed she stated, I went from handling dirty dishes to handling clean dishes and did not change gloves and perform hand hygiene. A review of the facility's policy titled, Warewashing (sic), dated 09/2017, indicated, Policy Statement All dishware, serviceware (sic), and utensils will be cleaned and sanitized after each use. Procedures 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.

Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of and contained. This failure has the potential to affect all 134 residents who resided at the facility. Findings include: On 04/26/21 at 9:43 AM an observation of the area behind the building with Employee Identifier #17, a dietary staff member, revealed four dumpsters used for collecting garbage at the facility. One of four dumpsters was left open; multiple bags of garbage and boxes were noted inside. During an interview on 04/26/21 at 9:43 AM an interview with EI #17, EI #17 stated, the door should be closed. She confirmed one of four trash dumpsters had a door open and the dumpster contained a mixture of cardboard boxes and miscellaneous trash. A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 08/2017, indicated, Policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris.

Based on observations, interviews, review of the facility's document, and facility policy review, it was determined the facility failed to ensure a clean and comfortable environment free of the growth of a black substance on three air conditioning units: six overbed tables missing vinyl covering. All located in nine of 39 rooms located on the Solona unit and the East hallway (short hall). Findings include: On 04/29/21 at 09:00 AM a tour was performed, with Employee Identifier (EI) #21, the Maintenance Supervisor (MS). Observations of the East Hall and the Solana Unit revealed the following: 1. Room 55, the overhead air conditioning (AC) unit was found to have dirt, dust, and a black substance covering the air vent. 2. Room 54, the overhead AC unit was found to have dirt, dust, and a black substance covering the air vent. 3. Room 57, the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. 4. Room 60, the overhead AC unit was found to have dirt, dust, and a black substance covering the air vent. 5. Room 63, the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. 6. Room 67, the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. 7. Room 68, the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. 8. Room 71, the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. 9. Room 80, the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. In an interview on 04/29/21 at 09:25 AM, EI #21 confirmed the AC units had a black substance, and dirt covering the air vent and need to be cleaned. EI #21 stated, the overbed tables cannot be properly cleaned due to the vinyl tears and missing vinyl. A review of the facility un-named and undated maintenance monthly check list indicated, HVAC (Heating, Ventilation, Air Conditioning) RTU (Roof Top Unit), Clean / change air filter and verify unit operation. A review of the undated facility's policy titled, 5-Step Daily Room Cleaning indicated, .2. Horizontal Surfaces - disinfected.Using a solution of properly diluted germicide, sanitize all horizontal surfaces.Table tops, headboards, window sills, chairs - should all be done.

Based on observation, record review and interview, the facility failed to provide breakfast or a nourishing snack to residents who dialyze on the first/early shift three times a week. This failure affected two of nine residents identified by the facility as receiving [CONDITION(S)]. Findings include: During an interview with Resident (RI) #62 on 04/27/21 at 2:00 PM, during a Resident Council Meeting, stated I don't get no breakfast before [CONDITION(S)] and I am a diabetic. RI #62 said that he/she undergoes [CONDITION(S)] three times a week on the first shift (6:30 AM to 10:30 AM). During an interview with RI #120 on 04/27/21 at 11:05 AM, he/she stated he/she was not provided anything to eat prior to going to [CONDITION(S)]. During an interview with RI #120 on 04/28/21 at 5:46 AM, in his/her room just prior to his/her being placed on the transport gurney, RI#120 stated he/she had not received anything to eat this morning. During an interview with EI #25, Registered Nurse (RN), on 04/28/21 at 6:56 AM, at the medication cart in the TCU hallway, when questioned about RI #120 not receiving breakfast this morning, stated the kitchen has a list of residents on [CONDITION(S)] and the kitchen staff is supposed to bring those residents something to eat prior to that resident leaving for [CONDITION(S)]. During an interview on 04/28/21 at 6:40 AM, with the EI #10, Assistant Director of Nursing (ADON), at the nurses' station of TCU, said he/she thought the kitchen staff brought a snack or breakfast for the residents going to their early (prior to the facility's usual breakfast time) [CONDITION(S)] appointments. EI #10 reviewed RI #120's Electronic Medical Record (EMR) for an order regarding an early breakfast for RI#120 on [CONDITION(S)] days, but was unable to locate that order. EI#10 stated he/she would follow up with the kitchen staff regarding the early breakfast process. EI#10 also reviewed the EMR for RI#290 (an additional Resident that goes to an early [CONDITION(S)] appointment) and was unable to locate any information regarding an early breakfast on [CONDITION(S)] days. During an interview with the EI #16, Dietary Account Manager (DAM), on 04/29/21 at 10:30 AM, in the dining room, stated there was a list of [CONDITION(S)] residents posted in the kitchen with their [CONDITION(S)] chair times and when they depart the facility to go to [CONDITION(S)]. EI #16 explained the process in the kitchen was if a resident left for [CONDITION(S)] prior to 5:30 AM the night shift cook prepared a snack that was placed in the nursing unit's pantry for the floor nursing staff to give to the Resident prior to leaving for [CONDITION(S)].

Based on document review and staff interview, the facility failed to notify the Ombudsman of a resident's transfer to the hospital for three of three residents (Resident Identifier (RI) #27,112 and 72) reviewed who were transferred to the hospital. Findings include: Review of RI #27's Electronic Medical Record (EMR) revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR stated RI #27 was transferred and admitted to the hospital on 04/12/21 and returned on 04/14/21. Review of RI #73's EMR revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #112's EMR revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #112 was transferred and admitted to the hospital on 03/26/21 and returned to the facility on [DATE]. Interview with Employee Identifier (EI) #1, Administrator and EI #2, the Director of Nursing on 04/29/21 at 11:27 AM, both confirmed the facility never sent the ombudsman a notice of transfers.

Based on interview, record review and the facility's policy titled NSG241 Treatments, the facility failed to provide evidence of Resident Identifier (RI) #1's wound care treatments being provided, according to physician orders. This deficient practice affected RI # 1, one of two resident whose Physician order [REDACTED]. The facility's policy titled, NSG241 Treatments, revised date 11/28/19, revealed, Policy A licensed nurse or medical technician, per state regulations, will perform ordered treatment. Accepted standard of practice will be followed. 9. Document: 9.1 Administration on Treatment Administration Record. RI #1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of RI #1's physician's orders [REDACTED]. The order was to clean the left toe with Vashe, cover with wet to dry dressing and wrap with Kerlix dressing daily and as needed. A review of RI #1's Treatment Administration Records (TAR), with a start date of 7/25/19, revealed no initials documented for 7/25/19-7/27/19, to indicate that wound treatment was provided to the toe. On 8/22/19 at 3:36 p.m., the surveyor conducted an interview with a Registered Nurse, Employee Identifier (EI) #4. The surveyor asked EI #4 how would the surveyor know RI #1's wound care dressing was done, according to the TAR. EI #4 said she did it and forgot to sign it off. EI #4 was asked when documenting during her shift, where could the surveyor find the evidence the wound care was done. EI #4 said she would have signed the TAR, she just forgot to sign it off. EI #4 was asked when working with RI #1 had the resident refused wound care. EI #4 said no, she had only worked with EI #1 a few times.

Based on review of Resident Identifier (RI) #104's medical record, the facility's policy titled OPS402 Clinical Record: Charting and Documentation and interview, the facility failed to ensure licensed nurse staff documented completion of wound care treatments for RI #104 on 3/20/19 and 3/23/19. This affected one of three sampled residents reviewed for wound care. Findings include: The facility's policy titled OPS402 Clinical Record: Charting and Documentation, revised 1/1/13, documented . PURPOSE To provide a complete account of the patient's total stay from admission through discharge, provide information about the patient that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. PR[NAME]ESS . Document treatments . RI #104 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #104's physician's orders [REDACTED]. RI #104's (MONTH) 2019 Medication Administration Record [REDACTED]. In an interview on 4/25/19 at 5:01 PM, Employee Identifier (EI) #7, a Registered Nurse acknowledged that she completed the treatment for 3/23/19; however, she failed to document it on the MAR.

Based on observation, interview and review of a facility policy titled, NSG305 Medication Administration: General and Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a Licensed Practical Nurse (LPN) did not leave an insulin pen on top the medication cart, out of her sight, when she entered a resident's room during medication administration on 3/12/19. This had the potential to affect one of 27 residents who received medications from cart one on the East wing. Findings Include: A review of a facility policy titled . Medication Administration: General with a Revised date of 7/24/18, revealed the following: POLICY . Accepted standards of practice will be followed . A review of Potter and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, with a Copyright of (YEAR), Chapter 32, page 683, revealed the following: .prepared medications are never left unattended . On 03/12/19 at 11:15 AM, Employee Identifier (EI) #1, a Registered Nurse (RN), was observed preparing medication. EI #1 removed an insulin flex pen from the medication cart. EI #1 placed the insulin flex pen on top of the medication cart and went into a resident's room to get paper towels. While in the resident's room, a staff member passed the medication cart in the hallway with the insulin flex pen lying on top of the cart. EI #1 returned to the medication cart with paper towels, retrieved the insulin flex pen and continued with medication administration. After the medication administration, during an interview with EI #1, the surveyor asked EI #1 did she leave an insulin flex pen on the medication cart and go into a resident's room to get paper towels. EI #1 stated, yes. The surveyor asked what if a resident picked up the medicine (Insulin) or even an employee while she was in the resident's room. EI #1 stated, that would be a problem.

Based on observation, interview and review of a facility policy titled, . Storage and Expiration Dating of Medications ., the facility failed to ensure an opened vial of Influenza Vaccine was marked with the date it was opened and the date to be used by. This deficient practice affected one of two medication rooms observed. Findings include: Review of a facility policy titled, . Storage and Expiration Dating of Medications . with a revision date of 10/31/16, revealed the following: . 5. Once any medication .package is opened .Facility staff should record the date opened on the medication container .5.1 Facility staff may record the calculated expiration date based on date opened on the medication container . On 03/12/19 at 3:07 PM, during the observation of the medication refrigerator on the Rehabilitation Unit, the surveyor observed an open vial of Influenza Vaccine with no open date or expiration date recorded on the medication. On 03/12/19 at 3:20 PM, during an interview with Employee Identifier (EI) #2, (Licensed Practical Nurse) LPN, the surveyor asked was there a date on the vial. EI #2 stated, no. The surveyor asked should there be an open date. EI #2 stated, yes. The surveyor asked, without an open date what were the issues. EI #2 stated, we are not sure how long it has been in the refrigerator so we do not know if it is viable or not.

Based on record review, interviews, review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility's investigation file and a report received by the Alabama State Survey Agency, the facility failed to ensure Resident Identifier (RI) #14 was free from abuse. On 6/22/2018, RI #14 reported a tall girl that worked the previous night grabbed him/her by both arms and threw him/her into the bed. When assessed, it was found RI #14 had bruising to left forearm and swelling and pain was noted to the left hand. The facility's investigation revealed Employee Identifier (EI) #15, a Certified Nursing Assistant (CNA), was responsible for physically abusing the resident. This deficient practice affected RI #14, one of 10 sampled residents reviewed for abuse. Findings include: The facility's policy titled, OPS 300 Abuse Prohibition, with a revision date of 11/28/2017, documented POLICY . will prohibit abuse, mistreatment, . for all residents . The Center will implement an abuse prohibition program through the following: . Prevention of occurrences . Federal Definitions: Abuse is defined as the wilful infliction of injury . with resulting physical harm, injury, or mental anguish . On 6/22/2018,, the facility notified the Alabama State Survey Agency of an allegation of physical abuse. The report indicated RI #14 reported to staff on 6/22/2018 that a tall girl that worked last night (6/21/2018) grabbed the resident by both of his/her arms and threw him/her in the bed. Bruising was noted to RI #14's left forearm and swelling and pain was noted to the left hand, with x-rays pending. The employee identified as EI #15, a CNA was suspended pending investigation and the local police was notified. On 7/2/2018, the facility submitted their full investigation file to the Alabama State Survey Agency. The Investigation Summary documented DESCRIPTION OF INVESTIGATIVE PR[NAME]ESS: Resident (RI #14) reported to nursing staff on 6/22/18 that the night before a very tall black CNA that worked the previous night grabbed (him/her) by both arms of (his/her) arms and threw (him/her) in the bed. By the description of the employee she was identified as (EI #15) who was on shift that night and on that unit. Employee was suspended pending investigation, Event reported to ADHP (ADPH) and (local) Police Dept, Sponsor and Nurse practitioner notified of allegation and investigation initiated . RESULTS/FINDINGS: River City was able to SUBSTANTIATE the allegation of physical abuse based on the evidence of the injury noted to resident. The identification of the employee was not by actual name of employee it was based on the consistant (consistent) description of employee in the initial statements given by (EI #5) and (EI #6) by resident and also to the police officer, CNE (Clinical Nurse Educator) and investigators. This employee was the only one that fit it on the staffing schedule for the facility. Resident was not able to pick out employee due to employee being suspended pending the results of this investigation. RECOMMENDATIONS: . Employee (EI #15) is terminated from employment at River City Center. RI #14 was readmitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED].#14 has a medical history to include a [DIAGNOSES REDACTED]. RI # 14's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/8/2018, indicated RI #14 was moderately impaired in cognitive skills, with a Brief Interview of Mental Status (BIMS) score of 9. The MDS indicated RI #14 is usually understood and usually understands others. During this assessment period, RI #14 had no behaviors. Contained within the facility's investigation file was a handwritten statement signed by EI #6, a CNA dated 6/22/2018, which read I (EI #6) came in to get (RI #14) a bath an (and) dressed for Breakfast I told (RI #14) excatly (exactly) what I was about to do an (and) I pulled the cover back to (RI #14's) feet (RI #14) yelled at me Don't touch me I ask (RI #14) what was wrong that I needed to get her ready for breakfast (RI #14) then said people like you don't need for me to get up I asked why an (and) (RI #14) repeated it again I told (RI #14) again that I needed to bath (him/her) (RI #14) told me no an (and) don't touch (him/her) I ask could I atlest (at least) change (him/her) an (and) (he/she) yelled no I asked (RI #14) what happen an (and) whats wrong (RI #14) said you know I told her who I was again an (and) (RI #14) said no the tall girl was nasty to me she almost broke my arm an (and) (RI #14) showed me (his/her) arm an (and) I told (RI #14) I would get the nurse an (and) that I would be right back So I let the nurse know an (and) ask (asked) the nurse to encourage (RI #14) to let me get (him/her) bath an (and) dressed. In an interview on 7/12/2018 at 10:45 AM, EI #6, the CNA assigned to care for RI #14 during the morning of 6/22/2018 was asked about her statement she made regarding RI #14. EI #6 explained she went into RI #14's room on 6/22/2018 around 7:15 AM/7:30 AM to bathe and dress the resident; however, RI #14 was more quiet than usual and said to leave him/her alone. EI #6 said RI #14 made a comment that people like EI #6 didn't need (him/her) to get up. According to EI #6, RI #14 refused to allow her to change or touch him/her. EI #6 stated RI #14 told her a tall girl was mean to him/her and almost broke his/her arm. When asked to describe the bruises she saw on RI #14, EI #6 described a bruise on RI #14's arm as purple, around two inches in length. EI #6 stated she left the resident's room and went and got EI #5, a Registered Nurse (RN). When asked who identified EI #15 as the person responsible for the bruises on RI #14's arm, EI #6 stated EI #15 was taller than anyone else that worked the night of 6/21/2018 to include CNAs and nurses. EI #6 said EI #15 was over six feet tall. The River City Center Daily Staff Assignment sheet dated 6/21/2018, indicated EI #15, a CNA, was assigned to care for RI #14 on the third shift beginning on 6/21/2018 at 10:00 PM and ending on 6/22/2018 at 6:00 AM. EI #15's time sheet indicated she clocked in to work on 6/21/2018 at 5:29 PM and clocked out on 6/22/2018 at 7:17 AM. RI #14's Activities of Daily Living (ADL) Record for (MONTH) (YEAR), indicated EI #15 provided ADL care to RI #14 during the third shift (10:00 PM to 6:00 AM) on 6/21/2018. Contained within the facility's investigation file was a handwritten statement signed by EI #5, a RN dated 6/22/2108, which read CNA (EI #6) reported to nurse (EI #5), RN that resident (RI #14) staffs (states) that another CNA, (last night) was rough with (him/her) and being mean to (him/her). (RI #14) states to nurse that a tall girl that worked last night picked (him/her) up by both of (his/her) arms and threw (him/her) in (his/her) bed. (RI #14) also states that (he/she) told the CNA that she was an idiot and CNA hit (RI #14) with her fist on (his/her arms). Resident currently complains of pain to (his/her) left forearm. Resident has brusing on the left forearm where (he/she) complaints of pain and swelling in (his/her) right hand. Resident states that (he/she) does not want CNA back in (his/her) room nor does (he/she) want her to work with (him/her) anymore. During an interview with EI #5, a RN, on 7/12/2018 at 12:30 PM, she explained she noticed a bruise on RI #14's arm on 6/22/2018 when she was called into the room by the CNA, EI #6. EI #5 stated RI #14 told her a tall girl grabbed him/her up and threw him/her in the bed. EI #5 stated she completed an assessment and there was only the bruise on her arm. EI #5 described the bruise as being on the resident's left forearm, it was red and dark purple with red around the outer edges. EI #5 stated she felt this was a new bruise because of the way it looked. EI #5 was asked if RI #14 ever identified who hurt him/her. EI #5 stated the resident only said it was a tall girl from last night. EI #5 was asked how the facility determined EI #15 was responsible. EI #5 replied EI #15 worked the night before and was assigned to RI #14. EI #5 further stated EI #15 was taller than anyone in the building, at around 6' (feet) 2 (inches) or 6'3. During a follow-up interview with the RN, EI #5, on 7/14/2018 at 10:29 AM, she reported that after identifying the bruise, RI #14 was assessed as having a pain scale of eight. According to EI #5, RI #14 appeared to be in pain, as the resident was grabbing at his/her arm and had facial grimacing. An interview was conducted with RI #14 on 7/12/2018 at 9:24 AM. RI #14 was asked if someone had hurt him/her. RI #14 stated an employee twisted his/her arm. When RI #14 was asked to recall what happened, the resident said he/she was hurt. RI #14 stated he/she got up to get the wheelchair that was near the door, when the employee entered the room and threw him/her on the bed. RI #14 stated the employee told him/her not to get up. RI #14 stated that during this incident she felt afraid. RI #14 stated he/she had a bruise on his/her arm extending from the elbow to the wrist and it was red and purple. RI #14 was unable to provide a name of the staff member, but described her as tall, very rude and rough talking. In a statement taken by way of telephone with the CNA, EI #15, on 6/29/2018, EI #15 did acknowledge caring for RI #14 on 6/21/2018; however, she denied the allegations made against her by the resident. On 7/12/2018 at 9:59 AM, an interview was attempted with EI #15, the CNA accused of allegation of physical abuse against RI #14. EI #15 stated she wished she could talk but she could not talk with the State Surveyor about what happened (on 6/21/2018). EI #15 asked for the telephone number to the State Surveyor and stated she may call back; however, no return telephone call was received. EI #15's personnel file revealed EI #15 was hired by the facility on 3/14/2018. Prior to hire, on 2/27/2018, EI #15 was checked on the Alabama Certified Nurse Aide Registry and had no adverse findings. On 3/14/2018, EI #15 received inservice education on Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Resident Rights. On 3/16/2018, EI #15 received inservice education of Dementia/Care of Cognitively Impaired resident. RI #14's Skin Check report dated 6/19/2018 completed by EI #17, a RN revealed on 6/19/2018, no bruises, discoloration, abrasions or skin tears were observed on RI #14. On 7/13/2018 at 3:28 PM, an interview was conducted with EI #8, a CNA. EI #8 acknowledged she worked with RI #14 during the 7:00 AM to 3:00 PM shift on 6/21/2018. EI #8 said she had not observed any bruising or scratches on RI #14 during her shift, only age discoloration. EI #8 said the following day, on 6/22/2018, she saw discoloration on RI #14's arm that was not there before. When asked if RI #14 told her what happened, EI #8 said a tall girl did it. RI #14's progress note completed by EI #12, the Nurse Practitioner, dated 6/22/2018, documented HISTORY OR PRESENT ILLNESS: (RI #14) is seen at the request of nursing and admin. (administration). There is an abuse allegation from the resident. (RI #14) has bruising to (his/her) foreman per nursing. Duration: < (less than) 24 hrs (hours) Severity: moderate Assoc (associative) features: no decreased ROM (range of motion). Able to use both hands/arms, moves all extremities. No uncontrolled pain. On exam (RI #14) is alert and in NAD (no acute distress) . Plan: X rays to be obtained and reviewed. Has prn [MEDICATION NAME] which are effective. Follow up as need, await xrays . ADDENDUM On 6/24 (2018) I have reviewed the xray reports which reveal no acute findings or obvious fractures. On 7/12/2018 at 4:39 PM, an interview was conducted with EI #2, the CNE/Director of Nursing (DON). EI #2 stated she completed the abuse investigation for RI #14. EI #2 was asked how she determined EI #15 was responsible for the abuse of RI #14. EI #2 stated by the description of a very tall CNA. EI #2 stated EI #15 was 6'2, taller than anyone assigned to RI #14's unit. EI #2 further stated EI #15 was assigned to care for RI #14 on 6/21/2018 and 6/22/2018. EI #2 was asked to describe the bruise on RI #14's arm. EI #2 stated it was on the resident's left lower arm, with bruising near the elbow. EI #2 further stated it looked like someone wrapped their hand around RI #14's arm. EI #2 stated the bruise looked new, as though it had just happened. EI #2 described the bruise as purple with no yellowing. EI #2 was asked if RI #14 was abused. EI #2 stated there was no doubt in her mind when she saw the bruise that something had happened. EI #2 stated she felt the CNA, EI #15, abused RI #14. EI #2 further stated RI #14 was consistent with the details of what happened and had no history of making false allegations against staff or anyone. The local police report documented . On (MONTH) 22, (YEAR) at 1:45 PM, I (name) was dispatched to an Elder Abuse and Neglect in the 2nd degree call at River City Health Care located at 1350 14th Ave SE Decatur, AL . At 1:49 PM, I arrived on scene and spoke with complainant (EI #2) who was the Director of Nursing. (EI #2) stated at 10:30 AM, a resident (RI #14) informed her of an assault that occurred on (MONTH) 21, (YEAR) at about 9:00 PM. (RI #14) reported that a staff member, (EI #15) assaulted (him/her). (RI #14) was in (his/her) room sitting in (his/her) wheelchair when (EI #15) grabbed (RI #14) by (his/her) arm causing swelling to (his/her) right wrist and bruising to (his/her) left forearm. (EI #15) then threw (RI #14) on (his/her) bed. (EI #2) stated (EI #15) had been suspended and was not present at the scene. (EI #2) and I went to (RI #14's) room where I spoke with (RI #14). (RI #14) stated (he/she) was sitting in (his/her) wheelchair near the entrance to (his/her) room when (EI #15) picked (RI #14) up by (his/her) arms and threw (RI #14) on the bed. I saw that (RI #14) right wrist was swollen and (RI #14) had bruising from (his/her) left wrist to (his/her) elbow. I notified (Name) and (Name) with the Violent Crimes Unit about the incident. (Name) and (Name) arrived on scene and it was turned over to them . This deficiency was cited as a result of the investigation of complaint/report number AL 773.

Based on observations, interviews and review of facility policy titled Food and Nutrition Services Use By Dating Guidelines, the facility failed to ensure the following unopened food items in the walk-in refrigerator were discarded after the best before date: thirteen boxes of thickened dairy drink honey consistency with a best before date of 6/2/18; twenty-four boxes of thickened dairy drink honey consistency with a best before date of 12/5/17; thirty-eight boxes of Sysco Imperial thickened dairy drink nectar consistency with a best before date of 12/11/17; and one unopened box of hashbrowns with a best before date of 5/24/18. This deficient had the potential to affect 10 of 10 residents receiving thickened liquids and all residents receiving meals from dietary: Findings include: A review of a facility policy titled, Food and Nutrition Services Use By Dating Guidelines, with a revision date of 12/1/15, revealed: The following is a guide to use when establishing a use by date for food items. * The manufacturer's expiration date, when available, is the use by for unopened items. On 7/10/18 at 1:16 p.m., Employee Identifier (EI) #4, the Dietary Manager accompanied the surveyor during the initial tour of the kitchen. In the walk-in refrigerator, the surveyor observed the following: (1) thirteen boxes of thickened dairy drink honey consistency with the best before date of 6/2/18; (2) twenty four boxes of thickened dairy drink honey consistency with the best before date of 12/5/17; (3) thirty eight boxes of Sysco Imperial thickened dairy drink nectar consistency with the best before date of 12/11/17; and (4) one unopened box of hashbrowns with the best before date of 5/24/18. An interview was conducted on 7/12/18 at 5:45 p.m. with EI #4, Dietary Manager, regarding the observations on the initial tour. EI #4 was asked, what does the best before date mean. EI #4 said that would be the expiration date we use. EI #4 was asked if the thirteen boxes of thickened dairy drink honey consistency with the best before date of 6/2/18, the twenty four boxes of thickened dairy drink honey consistency with the best before date of 12/5/17, the thirty eight boxes of Sysco Imperial thickened dairy drink nectar consistency with the best before date of 12/11/17 and the box of hashbrowns with the best before date of 5/24/18 should have been discarded. EI #4 , stated yes. EI #4 was then asked what is the harm in not discarding food after the best before date. EI #4 replied it could cause potential illnesses and become bad.

Based on interview, review of the facility's online reports to the state agency, and review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility failed to ensure allegations of verbal and physical abuse were timely reported to the state agency. This deficient practice involved nine residents (Resident Identifier (RI) #9, RI #42, RI #69, RI #70,RI #161, RI #172, RI #178, RI #229 and RI #230) and five of 12 abuse allegations reviewed. Findings include: The facility policy titled, OPS 300 Abuse Prohibition, with a revision date of 11/28/2017, revealed the following: . PR[NAME]ESS . 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following. 6.2 Report allegations involving abuse (physical, verbal, . mental) not later than two hours after the allegation is made . 1) Review of the facility's online report to the state agency revealed an allegation of verbal abuse was reported to EI #11, Social Services, by RI #9's spouse. RI #9's spouse alleged the nurse cursed at RI #9 on 12/28/2017 at 5:02 PM. The allegation was not reported to the state agency until 12/29/2017 at 10:11 AM. On 7/11/2018 at 3:17 PM, Employee Identifier (EI) #1, the Administrator/Abuse Coordinator,was asked the abuse allegation that occurred on 12/28/2017 at 5:02 PM involving RI #9 that was not reported to the state agency until 12/29/2017 at 10:00 AM. When asked when should it have been reported, EI #1 replied, within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred. 2) Review of the facility's online report to the state agency revealed physical abuse was witnessed by Employee Identifier (EI) #16, Licensed Practical Nurse (LPN) on 1/18/2018 at 2:15 AM. EI #16 heard something in the resident's room and entered to observe RI #230 hitting RI #229 with his cap. The abuse was not reported to the state agency until 1/18/2018 at 3:18 PM. On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked the abuse allegation concerning RI #229 and RI #230 that occurred on 1/18/18 at 2:15 AM and was reported to the state agency until 1/18/18 at 3:18 PM. EI #1 was asked when should it have been reported. EI #1 replied, within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred. 3) Review of the facility's online report to the state agency revealed an incident that occurred on 5/7/2018 at 11:45 AM, in which facility staff witnessed RI #69 pushed RI #172 in the chest. This allegation of physical abuse was not reported to the state agency until 5/15/2018 at 4:57 PM. On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked about the abuse allegation on 5/7/2018 involving RI #172 and RI #69 that was not reported to the state agency until 5/15/2018 at 4:57 PM. When asked when it should have been reported, EI #1 said, within two hours from the incident on 5/7/2018. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred. 4) Review of the facility's online report to the state agency revealed an incident witnessed by facility staff on 5/23/2018 at 5:00 PM, in which RI #161 took some napkins from beside RI #42. In response, RI #42 was observed by staff repeatedly slapping RI #161's forearms to get the napkins back. This incident was not reported to the state agency until 5/24/2018 at 1:53 PM. On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked about the abuse allegation on 5/23/2018 at 5:00 PM involving RI #161 and RI #42 that was not reported to the state agency until 5/24/2018 at 1:50 PM. EI #1 was asked when should it have been reported. EI #1 said, within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred. 5) Review of the facility's online report to the state agency revealed an allegation of physical abuse that occurred on 6/5/2018 at 3:00 PM. RI #70 reported to facility staff that RI #178 hit him/her and pulled his/her hair. This allegation of abuse was not reported to the state agency until 6/6/2018 at 11:55 AM. On 7/11/2018 at 3:17 PM, EI #1, the Administrator/Abuse Coordinator,was asked about the abuse allegation on 6/5/2018 at 3:00 PM involving RI #70 and RI #178 that was not reported to the State Agency until 6/6/2018 at 11:50 AM. When asked when should it have been reported, EI #1 said, it should have been reported within two hours of the incident. When EI #1 was asked what the time frames were for reporting abuse allegations to the state agency, EI #1 replied, any type of physical abuse should be reported in two hours. EI #1 was asked why the abuse allegations were not reported to the state agency within two hours. EI #1 said, a variety of things, to include staff misunderstanding of the regulations and thinking reporting was only required within two hours if injury occurred. This deficiency was cited as a result of the investigation of complaint/report number AL 777.

Based on medical record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed within fourteen days when Resident Identifier (RI) #10 elected to receive Hospice services. This affected one of six residents reviewed for Hospice. Findings include: RI #10 was admitted to the facility on [DATE]. RI #10's physician's orders [REDACTED]. admitted to . Hospice on 5/15/17 for [MEDICAL CONDITION] . RI #10's medical record revealed a Significant Change MDS was completed on 9/28/17. On 7/12/18 at 6:20 PM, an interview was completed with Employee Identifier (EI) #13, the MDS Coordinator. EI #13 stated RI #10 was admitted to Hospice on 5/15/17. EI #13 stated a Significant Change MDS should have been completed when RI #10 was admitted to Hospice. EI #13 further stated the Significant Change MDS was overlooked when RI #10 was admitted to Hospice and was completed and submitted late on 9/28/17.

Based on observations, interviews and a review of the facility's policy titled, (Name of Company) JOB DESCRIPTION: CENTERS, the facility failed to ensure: 1. ceiling tiles in the dining room of the Memory Unit were clean and in good repair, 2. ceiling tiles in the laundry room were clean and in good repair and 3. flow vents were not dripping liquid condensation onto the floor in the hallway of the Memory Unit. This affected one of three units and the facility's laundry area and had the potential to affect 155 residents living in the facility. Findings Include: A review of the facility's policy titled, (Name of Company) JOB DESCRIPTION: CENTERS, with a revision date of 8/9/2012, revealed: POSITION TITLE: Maintenance . 5. Makes minor repairs on handrails, windows, flooring, walls, ceilings, . On 8/3/2017 at 10:30 a.m., five ceiling tiles in the dining room were observed to have a brown stain. On 8/3/2017 at 10:35 a.m., one ceiling tile above the clothing rack in the laundry room was observed to be sagging and had a brown stain. On 8/3/2017 at 3:14 p.m., a liquid was observed dripping from the ceiling vent outside the activity room on the Memory Unit. An interview was conducted on 8/3/2017 at 10:35 a.m. with Employee Identifier (EI) #1, the Laundry Supervisor. EI #1 was asked, was there a leak in the ceiling. EI #1 replied, bad rain would cause dripping above the clothes rack. EI #1 was asked, how long the leak had been there. EI #1 replied, one week. EI #1 was asked, had the leak been reported and when. EI #1 replied, yes, she reported the leak to her supervisor last week when she noticed it. An interview was conducted on 8/3/2017 at 3:14 p.m. with EI #3, the Maintenance Director. EI #3 was asked, had the stained and sagging ceiling tile in the laundry room been reported to him. EI #3 said, No. EI #3 was asked, what was the discolored substance on the ceiling tiles. EI #3 replied, I'm not a scientist so I don't know if it's mold, mildew or what. EI #3 was asked, what was causing the dripping liquid from the vent in the Activity Room. EI #3 replied, Condensation. EI #3 was asked, were there leaks in the dining Room on the Memory Unit. EI #3 replied, Condensation from the vents and not actually a leak. EI #3 was asked, was there anything he could do to prevent the condensation from leaking from the vents. EI #3 replied, Insulate the pipes and put AC (air conditioner) tape around the foam. EI #3 was asked, what was the potential harm in condensation dripping on the floor. EI #3 replied, Slip hazard. This tag was cited as a result of the investigation of complaint/report number AL 258.

Based on interviews, record review and hospital record review, the facility failed to ensure Resident Identifier (RI) #36, a resident with cognitive impairment, at high risk for falls, who experienced multiple falls at the facility, was not left unsupervised at the nurses station on 06/01/16. While at the nurses station RI #36 had an unwitnessed fall from a Broda chair and sustained a cut/laceration to the right forehead. RI #36 was transferred to a local ER (emergency room ), diagnosed as having a Laceration to the Forehead, and received 12 sutures. This affected RI #36, one of three residents sampled for falls. Finding Include: RI #36 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Admission Minimum Data Set assessment, with an Assessment Reference Date of 03/25/16, assessed RI #36 to have short and long term memory problems with moderately impaired (decisions poor, cues/supervision required) cognitive skills for daily decision making. Under Section G - Functional Status, RI #36 was also assessed as needing extensive assistance (with two person physical assist) with transfers and not being steady when moving from seated to standing position. Under Section J - Health Condition, RI #36 was assessed as having had two or more falls during this assessment period. RI #36's Fall Risk Evaluation form dated 04/11/16, revealed RI #36 scores a 17 on the evaluation. According to the form a score of 12 or above indicates high risk for fall. RI #36's care plan titled Resident is a risk for falls: Impaired mobility, degenerative dementia Alzheimer's type with Behavioral Disorder, poor safety awareness . Anxiety, weakness, Bipolar Disorder . Delusions, incontinence, unsteady gait. with a revision date of 06/23/2016, revealed RI #36 had four falls in March with no injuries (3/19/16, 03/21/16, 3/21/16 and 3/22/16), two falls in April with no injures (4/9/16 and 4/10/16), five falls in May; three with no injuries and two with bruises (5/18/16, 5/20/16, 5/29/16, 5/30/16 and 5/31/16) and four falls in June; three with no injuries and one with an injury (6/01/16, 6/7/16, 6/20/16 and 06/22/16). On 06/01/2016 at 3:57 p.m., the Division of Health Care Facilities Complaint Unit received an Anonymous call which revealed the following: . (RI #36) fell today and busted (his/her) head . The nurse left the resident alone and the resident fell . A review of RI #36's Event Summary Report documented the following: . Date/Time of Event: 6/1/16 9:35 AM Event: Fall Injury(ies): Cut/laceration Location: Nurses station Condition: Confused . Transferred to Hospital: Yes Date/Time: 6/1/16 9:50 AM Transferred By Whom: EMS (Emergency Medical Services) . First Aid Administered: Yes Date/Time: 6/1/10:25 AM . Circumstances of the event and immediate actions taken: RESIDENT SITTING IN BRODA CHAIR AT NURSE STATION FOUND LYING IN FLOOR ON SIDE BLOOD ON FOREHEAD ASSESS FOR INJURIES, DUE TO LACERATION TO RT (right) FOREHEAD ORDER TO SEND TO ER (emergency room ) FOR EVAL (Evaluation) . How staff became aware of fall: Unwitnessed . Activity during incident: Other Description: ATTEMPTING TO RISE AND WALK . Fall related to ambulation status: Yes If Yes, Explain: UNABLE TO WALK DUE TO WEAKNESS . Resident history of: Unsteady Gait . Cognitive/behavior factors prior to fall: Agitated, Alert, Poor safety awareness . A form with RI #36's name on it titled First Response EMS dated 6/1/2016, documented: . DISPATCHED TO ABOVE LOCATION EMERGENCY TRAFFIC WITH IMMEDIATE RESPONSE FOR FALL WITH LACERATION. AOS (arrived on scene) TO FIND ELDERLY FEMALE SUBJECT SUPINE ON FLOOR WITH STAFF TENDING TO PATIENT. THEY REPORT PT (patient) WAS JUST BROUGHT OUT IN FRONT OF DESK BY STAFF. STATE FALL WAS UNWITNESSED HOWEVER THEY HEARD IT. PT WITH LACERATION TO RIGHT FOREHEAD. BLEEDING CONTROLLED WITH 4X (by) 4 . PT DENIES PAIN OTHER THAN (His/her) HEAD . PT CONTINUES TO C/O (complain of) HEAD HURTING . A review of the RI #36's ER hospital records dated 06/01/16, documented: . admitting [DIAGNOSES REDACTED]. HPI (history/physical information)-Head Injury . Head Injury Location: reports: frontal . Quality of Pain: reports: burning . Onset/Duration: reports: abrupt, this morning . Method of of Injury: reports: direct blow, fell . Physical Exam- Neurological . Head Injury: lacerations (right forehead about 1inch) . -LACERATION/WOUND REPAIR . **Face Wound Location: Other: forehead Wound Length: 1 inch . Wound Repaired with: Sutures . Number of Sutures: 12 . - Departure ***DIAGNOSIS***: Laceration of forehead . On 07/14/16 at 11:52 a.m., the surveyor conducted a phone interview with Employee Identifier (EI) #3, the Assistant Director of Nursing (ADON). The surveyor asked EI #3 what type care RI #36 required. EI #3 said RI #36 was pretty much dependent on staff. The surveyor asked EI #3 what was RI #36's cognition. EI #3 said confused. The surveyor asked EI #3 was RI #36 ambulatory. EI #3 said RI #36 could stand and pivot but was not ambulatory. The surveyor asked EI #3 did RI #36 have a history of falls. EI #3 said RI #36 did. The surveyor asked EI #3 did she remember RI #36 falling on 06/01/16. EI #3 said she did not personally remember the fall. EI #3 said RI #36 had so many falls. The surveyor asked EI #3 what type fall interventions were in place for RI #36. EI #3 said the facility try to keep RI #36 in a high visible area. When asked who observed RI #36 fall on 06/01/16, EI #3 said she did not recall. EI #3 said if she remembered, EI #5, the Licensed Practical Nurse (LPN) assigned to care for RI #36 on 06/01/16 turned her back to pass medications and when she turned around RI #36 was on the floor. The surveyor read RI #36's Event Summary Report form dated 06/01/16 and asked EI #3, what does found on the floor mean. EI #3 said it meant that it was unwitnessed. EI #3 said someone found RI #36. On 07/14/16 at 1:20 p.m., the surveyor attempted to contact EI #19, the Certified Nursing Assistant (CNA) assigned to care for RI #36 on 06/01/16. EI #19 could not be reached. On 07/14/16 at 1:43 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 what type care did RI #36 require. EI #2 replied, Extensive. EI #2 said RI #36 had declined and you really could not judge her cognition. EI #2 said RI #36 would open his/her eyes but all of his/her needs had to be anticipated. When the surveyor asked EI #2 if RI #36 was ambulatory, EI #2 replied, No. The surveyor asked EI #2 if RI #36 had any falls while at the facility. EI #2 said yes. The surveyor asked EI #2 what were some of the causes of the falls. EI #2 said RI #36 will try to get out of bed or the chair at times. The surveyor asked EI #2 what interventions were in place for RI #36's falls. EI #2 said RI #36 had several. EI #2 said she could not remember all of the interventions but she knew when RI #36 is up they try to encourage RI #36 to stay in a visible area. The surveyor asked EI #2, on 06/01/16, did RI #36 have a fall. EI #2 replied, Yes. The surveyor asked EI #2 how did RI #36 fall. EI #2 said RI #36 tried to get out of his/her Broda chair and was found next to the chair on the floor. The surveyor asked EI #2 did RI #36 have any injuries. EI #2 replied RI #36 had a cut to the forehead. The surveyor asked EI #2 was the fall witnessed. EI #2 said she thought one of the CNAs came out of a room and saw RI #36 next to the Broda chair. On 07/14/16 at 2:32 p.m., the surveyor conducted a phone interview with EI #5, the LPN caring for RI #36 on 06/01/16, the morning RI #36 was found lying on the floor at the nurses station. The surveyor asked EI #5 did RI #36 have a fall on 06/01/16. EI #5 replied RI #36 did. EI #5 said she had to send RI #36 out to get sutures in the forehead. The surveyor asked EI #5 what happened. EI #5 said RI #36 is constantly trying to get out of bed or his/her chair. EI #5 said RI #36 had been gotten up in the Broda chair and was at the nurses station so that anyone passing by would be able to keep their eyes on RI #36 to keep him/her safe. EI #5 said she stepped down the hall to give medications. The surveyor asked EI #5 did she go on the inside of the resident's rooms while passing medications. EI #5 replied yes. EI #5 said a CNA called her and told her RI #36 was on the floor. EI #5 said she did an assessment and found RI #36 had a laceration on the forehead. EI #5 said she alerted the Administrator and DON and told them she needed to send RI #36 out to get stitches and have the hospital check RI #36's forehead to make sure he/she was OK. When asked by the surveyor how long she was out of vision of RI #36, EI #5 replied she could not say for sure probably about 2-3 minutes. The surveyor asked EI #5 where were the CNAs. EI #5 said they were probably doing their jobs. The surveyor asked EI #5 who witnessed the fall. EI #5 replied there were no witnesses to the fall. The surveyor asked EI #5 does the facility try to keep RI #36 in visible site. EI #5 replied they did. The surveyor asked EI #5 did she inform the CNAs she was going to pass medications and would not be at the nurses station. EI #5 said she did not recall if she did or not.