Every finding on record at Robertson County Health Care Facility

Based on observation, interview, record review, review of manufacturer's instructions for use, and review of the facility's policy, it was determined the facility failed to ensure insulin pens that required refrigeration were stored in the refrigerator for 1 of 5 medication carts. The findings include: Review of the facility's policy titled, Medication Storage, dated 08/04/2024, revealed medications requiring refrigeration were stored in the refrigerator. Review of the manufacturer's instructions for the Basaglar KwikPen (insulin glargine, used to decrease blood sugar) at www.insulins.lilly.com/basaglar revealed to store the unopened pen in the refrigerator at 36 degrees Fahrenheit (F) to 46 degrees F until the expiration date and at room temperature for 28 days. It also stated to discard the opened pen after 28 days, even if all the insulin had not been used. Review of the manufacturer's instructions for the insulin glargine pen at www.medlineplus.gov/druginfo/med, revealed to store unopened pens in the refrigerator at 36 degrees F to 46 degrees F until the expiration date and at room temperature for up to 28 days. Observation on 06/30/2025 at 11:22 AM of the G-tube medication cart revealed, in the top drawer, there was an unopened Basaglar pen labeled refrigerate for Resident (R) 7. There was also an unopened glargine insulin pen labeled refrigerate for R41. Review of R7's admission Record revealed the facility admitted R7 on 05/24/2021 with diagnoses to include type 2 diabetes, long term (current) use of insulin, and unspecified malignant neoplasm of the intra-abdominal lymph nodes. Review of R7's Physician's Orders revealed an order, dated 02/14/2025 at 6:08 PM, for administration of the glargine insulin pen. Review of R41's admission Record revealed the facility admitted R41 on 02/02/2024 with diagnoses to include type 2 diabetes with diabetic neuropathy, long term (current) use of insulin, and personal history of other malignant neoplasm of large intestine. Review of R41's Physician's Orders revealed an order, dated 05/29/2025 at 1:03 PM, for administration of the Basaglar KwikPen. During interview with Registered Nurse (RN) 1 at the time of the observation on 06/30/2025 at 11:22 AM, she stated night shift nurses put the medications in the cart. She further stated the insulins should have been refrigerated. She stated the insulin might not be effective if not stored properly. She stated the insulin pens for R7 and R41 would be discarded. During interview with the Director of Nursing (DON) on 07/02/2025 at 8:44 AM, she stated the insulin pens were supposed to be stored in the refrigerator until opened. She further stated the Basaglar insulin pen belonging to R41 and the glargine insulin pen belonging to R7 were discarded. She stated the facility paid for replacements. During telephone interview with the Pharmacist on 07/02/2025 at 9:06 AM, he stated glargine and Basaglar insulin pens were safe to store out of the refrigerator for 28 days. He stated the manufacturer's instructions did not state what effect it would have on the resident if the insulin was not refrigerated. He stated he thought it could cause redness at the injection site. He also stated it could possibly not be effective and cause elevated blood sugar levels. He stated the facility threw the insulin pens away because it was unknown when they were delivered or how long they had not been refrigerated. During interview with Administrator 2 on 07/02/2025 at 12:16 PM, she stated her expectation of staff was to follow manufacturer's instructions and the policy on how to store insulin. She stated the pharmacy did a monthly monitor of the medication carts, and nursing also checked the medication carts. She stated she expected nurses to check the medication carts each time they opened them.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a system for controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services was maintained for 1 of 5 sampled employees, Assistant Director of Nursing/Registered Nurse (ADON/RN) 2. Review of the [State] Department for Public Health Tuberculosis (TB) Risk Assessment for ADON/RN2 revealed she had not had a TB risk assessment or tuberculin skin test since 06/19/2024. The findings include: Review of the undated facility's policy titled, Tuberculosis Screening for Employees, taken from the Infection Prevention Manual for Long Term Care, revealed its purpose was to promote resident and employee safety and well being by screening employees for tuberculosis and initiating appropriate follow-up. Further review of the policy revealed the frequency of repeat skin testing of the employee would depend on the facility's annual TB risk assessment for the employee. Review of the [State] Department for Public Health Tuberculosis (TB) Risk Assessment forms for Assistant Director of Nursing/Registered Nurse (ADON/RN) 2 revealed ADON/RN2 had not had a TB risk assessment or a tuberculin skin test (TST) since 06/19/2024. Additionally, ADON/RN2's TST documented as administered on 06/19/2024 was not initialed by the person who administered it and was not documented with the determination of a positive or negative test result. Review of the Centers for Disease Control and Prevention's (CDC) Certificate of Completion for Nursing Home Infection Preventionist Training revealed the Infection Preventionist (IP) had completed the course on 06/24/2025, and the ADON/RN2 had completed the course on 04/14/2025. Review of the [State] Association of Health Care Facilities (KAHCF) Certification of Completion for the Nursing Home Infection Prevention Program revealed the Director of Nursing (DON) had completed the course on 02/17/2018, and the Regional Nurse Consultant (RNC) had completed the course on 06/19/2018. During an interview on 07/02/2025 at 11:25 AM with the current IP and the RNC present, the IP stated she had been employed at the facility for one month and was learning the IP's role. She stated the DON and ADON/RN2 were training her, and the RNC was also a resource. The IP stated when she arrived, the infection prevention recordkeeping was not organized, and she was still trying to correct that as well as learn the IP's job duties. The IP stated the staff TB records were kept in a binder, but the records needed to be brought up-to-date. The RNC stated she and the IP needed to have the DON present to explain about the staff TB records because the DON was responsible for the oversight of the staff TB testing. Both the IP and the RNC stated that TB screening was important to make sure staff and residents were free of an active TB infection. During an interview on 07/02/2025 at 11:37 AM with the DON, she stated the previous IP/ADON quit, and she and the ADON/RN2 were responsible for covering the IP tasks. The DON also stated the ADON/RN2 was in charge of the staff TB monitoring and should not have missed the need for her own TB risk assessment or TST. The DON further stated she and the ADON/RN2 were wearing several hats, while the facility had been recruiting a new IP, and continued to assist with the completion of IP tasks and requirements as well as assist the current IP with her training. The DON stated TB surveillance was important for the staff and residents for infection control, and the ADON/RN2 would have her TB risk assessment and skin test completed today. During an interview on 07/02/2025 at 11:43 AM with ADON/RN2, she stated she did not know how she missed her own annual TB skin test. She stated it was important for the TB test to be done for the safety of the residents. During an interview on 07/02/2025 at 11:40 AM with the RNC, she stated she now realized the facility needed a better system for tracking the TB risk assessments and skin tests for staff to ensure the safety of the residents. The RNC stated it was corporate's expectation the required staff annual TB risk assessments/skin tests be completed annually per the facility's policy. During an interview on 07/02/2025 at 12:29 PM with Administrator 2, she stated the prior Administrator was the acting IP, and she had terminated her employment abruptly on 03/25/2025, leaving the facility's IP position vacant. She also stated the DON and the RNC had assisted with completing some audits and outlined the IP tasks that needed to be done for the month as well as the completion of any required reporting until ADON/RN2 completed her IP certification. Administrator 2 further stated it was a joint effort between the DON and the ADON/RN2 to monitor the staff TB annual risk assessments and TST's which would have included the annual tracking. She stated the DON was ultimately responsible for the monitoring and completion of the staff TB annual risk assessments and TST's, recognizing the IP's role was new to the current IP and to ADON/RN2. She also stated there was still a possibility of TB infections happening, and it was her expectation the facility would be kept up-to-date with TB screening and skin tests annually as indicated in the facility's policy.

Based on interview, record review, and review of the facility's investigation and policy, it was determined the facility failed to protect 2 of 15 sampled residents from resident-to-resident abuse, Resident (R) 2 and R5. 1. On 10/13/2024, R2 entered R5's room uninvited and R5 was heard by staff yelling get out of my room. R2 was care planned for wandering, cussing at staff, and physical behaviors. When the State Registered Nurse Aide (SRNA) 5 responded to R5's call for help, she found R2 with her foot on R5's wheelchair. R5 reported R2 swung at her and hit her on the arm causing a skin tear and a bruise. 2. On 10/21/2024, a second incident occurred between R2 and R5. Staff observed R5 following R2 earlier that day [on 10/21/2024] and told the resident to stop. Later that same day, R5 and R2 were observed in a physical altercation in which R5 grabbed R2's arm and two facility staff had to assist with separating the residents. R5 was observed to have twisted R2's arm which resulted in R2 sustaining a broken wrist. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, not dated, revealed the facility did not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, other residents, friends or other individuals. Further review of the policy revealed it was the policy of the facility that each resident had the right to be free from abuse, neglect, misappropriation, and exploitation. In an interview with the Interim Administrator on 03/26/2025 at 10:45 AM, she stated the facility did not have a policy that addressed residents' behaviors. 1. Review of the Long-Term Care Facility Self-Reported Incident Form Initial Report (IR), dated 03/28/2023 [sic], revealed, on 10/13/2024 at 8:20 PM, the Administrator was notified that a staff member [Kentucky Medication Aide/State Registered Nurse Aide (KMA/SRNA)5] heard yelling coming from R5's room. Upon immediate investigation, she found R2 sitting facing R5 (both in wheelchairs), and R2 had her foot on the wheel of R5's wheelchair. Per the initial report, R5 reported to staff that R2 came into her room uninvited and swung at her, hitting her (R5) in the left upper extremity (LUE), which caused a linear shaped bruise and skin tear. Review of the Long-Term Care Facility Self-Reported Incident Form 5-Day Follow-Up/Final Report (5 Day), dated 10/17/2024, revealed R5 was interviewed by the Administrator on 10/13/2024 at 9:00 PM, and R5 stated R2 entered her room via a wheelchair. R5 stated she told R2 to get out of her room, and R2 began swatting at R5. R5 stated she defended herself and swatted back. a. Review of R2's Face Sheet from her electronic medical record (EMR) revealed the facility admitted the resident on 02/07/2021 with diagnoses which included dementia and legal blindness. Review of R2's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental States [BIMS] score of three of 15, which indicated severe cognitive impairment. Review of R2's Comprehensive Care Plan [CCP], dated 07/09/2024, revealed she was care planned for the focus of behavior problems related to cursing at staff, having physical behaviors, and having frequent confusion regarding the location of her room. The goal was that R2 would have no further physical behaviors through the next review. Interventions placed included if reasonable, staff was to discuss R2's behavior and explain or reinforce why the behavior was inappropriate and/or unacceptable; staff was to minimize the potential for the resident's disruptive behaviors by offering tasks which diverted R2's attention; R2 was to have her behaviors monitored to determine the underlying cause, taking into consideration the time of day, persons involved, and situations that occurred, and the monitoring of the behavior was to be documented along with the potential cause. Review of R2's Nursing Progress Notes, dated 10/13/2024, revealed there was an Incident Note placed that stated a Kentucky Medication Aide (KMA) was in the hallway passing medications and heard R5 yelling get out. Per the note, the KMA noted R2 was sitting in her wheelchair facing R5, and R2 had her foot on R5's wheel on her wheelchair. The note stated the KMA removed R2 from R5's room and noted that R5 had injuries to her arms. R2 was assisted to bed and placed on 15-minute checks. Review of R2's Nursing Progress Notes, dated 10/14/2024, revealed that an Acute Change in Condition Note was placed in R2's EMR stating that R2 had initiated physical aggression toward another resident (R5) and caused injury to R5. The note stated that R2 was in R5's room slapping and kicking at her, and this resulted in a skin tear to R5's left upper extremity. Further review of R2's CCP, dated 10/15/2024, revealed a focus of elopement and wandering, to monitor R2 for wandering and behavior indicators. Continued review of the resident's care plan revealed no documentation to support the resident's 15 minute checks were included on the care plan. Observation of R2 on 03/26/2025 at 3:23 PM revealed that R2 was sitting quietly and calmly in her wheelchair by the nurses' station. In an interview with R2 on 03/25/2025 at 11:00 AM she said that she had no problems other than getting those babies out. Resident (R)2 was unable to answer the State Survey Agency (SSA) Surveyor's questions. In an interview on 03/26/2025 at 11:25 AM with the guardian of R2, F10, he stated that he was made R2's guardian because she had no family. He also stated that he was notified of the incident that occurred on 10/13/2024. Per the interview, F10 stated that when he was contacted, the facility told him that they would have to find another placement for R2. b. Closed record review of R5's Face Sheet from her EMR revealed the facility admitted the resident on 12/05/2022 with diagnoses which included cerebral infarction (stroke), mild cognitive impairment, and anxiety disorder. Review of R5's quarterly MDS, with an ARD of 08/23/2024, revealed the facility assessed the resident to have a BIMS score of 14 of 15, which indicated intact cognition. She was also assessed as having no physical or verbal behavioral symptoms. Review of R5's CCP, dated 02/02/2024, revealed a focus of agitation and an intervention of: before the agitation escalated, guide R5 away from the source of distress. Interventions placed to achieve these goals were for nursing staff to analyze key times, places, circumstances, triggers, and what de-escalated behaviors and to document. On 03/29/2024, R5 was care planned for behaviors of verbal aggression with interventions for staff to intervene before the resident's agitation escalated. Review of R5's Nursing Progress Notes, dated 10/13/2024, revealed there was an Incident Note placed that stated a KMA was in the hallway passing medications and heard R5 yell get out. The KMA noted R2 was sitting in her wheelchair facing R5, and R2 had her foot on R5's wheel on her wheelchair. Per the note, the KMA removed R2 from R5's room and noted that R5 had injuries to her arms, a skin tear on the left upper extremity and dark purple bruising above it. Review of R5's Nursing Progress Notes, dated 10/14/2024, revealed that an Acute Change in Condition Note was placed for R5 stating that R5 had received physical aggression from another resident (R2) that caused injury to R5. The State Survey Agency (SSA) surveyor could not interview R5 as she was discharged from the facility on 10/24/2024 and later passed away. In an interview on 03/26/2025 at 9:33 AM with F3, she stated she was notified of this altercation between R2 and R5. F3 stated the facility staff notified her that R2 went into R5's room and R2 caused R5 to have a skin tear on her arm with bruising. F3 stated the facility did not discuss with her what they were doing to keep both R2 and R5 safe after this incident. She stated she was not a part of the Interdisciplinary Team (IDT) meetings (a multi-disciplinary group where residents' care was discussed) to hear about the resident's care plan interventions. In an interview on 03/26/2025 at 7:49 PM with the Charge Nurse (CN), she stated that on the day the incident occurred, on 10/13/2024, there was adequate staff to supervise and care for the residents. 2. Review of the Long-Term Care Facility Self-Reported Incident Form Initial Report (IR), dated 10/21/2024, revealed that on 10/21/2024 at 3:05 PM, the Administrator was notified [by LPN2] that a staff member [SRNA5]was walking past the family room in the facility and witnessed an altercation between R2 and R5. The staff member [SRNA5] immediately called for assistance and separated R2 and R5. Review of the Long-Term Care Facility Self-Reported Incident Form 5-Day Follow-Up/Final Report (5 Day), dated 10/25/2024, revealed both R2 and R5 were interviewed by the Administrator, and both did not remember the incident. Per the report, R2 obtained an x-ray for her left wrist which showed a fracture, and an orthopedics consult occurred on 10/22/2024. a. Review of R2's Face Sheet from her electronic medical record (EMR) revealed the facility admitted the resident on 02/07/2021 with diagnoses which included dementia and legal blindness. Review of R2's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 10/03/2024, revealed the facility assessed the resident to have a Brief Interview for Mental States [BIMS] score of three of 15, which indicated severe cognitive impairment. Review of R2's Comprehensive Care Plan [CCP], dated 08/27/2024, revealed that she was care planned for the focus of elopement risk related to wandering and attempting to open a door. The goal for this care plan focus was that R2 would not leave the facility unaccompanied by staff or family. Interventions to achieve this goal was that staff were to provide diversional activities for wandering such as offering coffee, encouraging R2 to go to activities, and providing one to one socialization. Further review revealed R2 was to be monitored for wandering and behavior indicators. Review of the results of R2's mobile x-ray of her left wrist, dated 10/21/2024, revealed a nondisplaced radial styloid (a broken bone near the wrist) fracture of the left wrist. Review of R2's Nursing Progress Notes, dated 10/21/2024, revealed a Behavior Note that stated R2 was in a physical altercation in the television lounge with R5. Resident (R)2 and R5 were separated by staff. Review of R2's Nursing Progress Notes, dated 10/21/2024, revealed an Acute Change in Condition note that detailed the incident in which R5 twisted R2's wrist and broke it. Further review of the note revealed R2 had an abrasion on her left upper lip, top of left hand, and left side of her neck. Review of R2's Orthopedic Specialist Note, dated 10/22/2024, revealed R2 presented to the office with left wrist pain from an altercation with another resident who twisted her arm. Per the note, X-rays were taken at the nursing home the day prior but were retaken at the orthopedic office. The note stated R2 had a nondisplaced radial styloid fracture of the left wrist. Per the note, R2 presented to the orthopedic office wearing a wrist brace since the previous day, 10/21/2024, and had decreased range of motion and discomfort in the left wrist. The note stated there was tenderness with palpation to the left wrist, particularly to the radial styloid. Per the note, the physician placed her into a thumb spica cast for six weeks, at which time there was to be a follow-up and repeated x-rays. In an interview on 03/25/2025 at 11:00 AM, R2 was unable to answer the SSA surveyor's questions. In an interview on 03/26/2025 at 11:25 AM with R2's Guardian (F10), he stated he was notified of the incident that occurred on 10/21/2024. He stated that after this incident, the facility told him the other resident (R5) was the one that had to be moved to a different facility. b. Closed Record Review of R5's Face Sheet from her closed EMR revealed the facility admitted the resident on 12/05/2022 with diagnoses which included cerebral infarction (stroke), mild cognitive impairment, and anxiety disorder. Review of R5's quarterly MDS, with an ARD of 08/23/2024, revealed the facility assessed the resident to have a BIMS score of 14 of 15, which indicated intact cognition. Review of R5's CCP, dated 02/02/2024, revealed a focus of agitation and an intervention of: before the agitation escalated, guide R5 away from the source of distress. Interventions placed to achieve these goals were for nursing staff to analyze key times, places, circumstances, triggers, and what de-escalated behaviors and to document. On 03/29/2024, R5 was care planned for behaviors of verbal aggression with interventions for staff to intervene before the resident's agitation escalated. On 10/22/2024 the focus of behavior symptoms related to an altercation with another resident and having made negative statements was added to her care plan with goals of R5 demonstrating effective coping skills, and demonstrating no further physical behaviors, both through the next review date. Review of R5's Nursing Progress Note, dated 10/21/2024, revealed a Behavior Note that stated R5 was in a physical altercation in the television lounge with R2. The note stated staff separated both residents. Review of R5's Nursing Progress Note, dated 10/22/2024, revealed an IDT Root Cause Analysis Note that stated R5 had a history of aggressive behaviors and confusion and was able to independently ambulate with a wheelchair. Per the note, R5 was separated from R2, placed on one-on-one supervision, and moved to another hallway. The note stated R5 had an immediate BIMS assessment and a head-to-toe assessment after she and R2 were separated. Per the note, R5 could not remember what happened. The State Survey Agency (SSA) Surveyor was unable to observe or interview R5 as she no longer resided at the facility. In an interview on 03/26/2025 at 9:33 AM with Family Member (F) 3, she stated she was notified of the 10/21/2024 altercation between R2 and R5. She stated R5 was moved to a different room on a different hallway after this second altercation between R2 and R5, in which R2's wrist was broken. F3 stated the former Administrator told her that one of the residents had to leave the facility, and it ended up that her family member (R5) was made to leave the facility. F3 stated, after the second incident, R5 had someone with her all the time. In an interview on 03/25/2025 at 3:54 PM with SRNA2, she stated she did not see the altercation between R2 and R5 because she was bathing another resident at that time. She stated, the following day, R2 was sent to the physician due to complaints of wrist pain and came back with a cast on her wrist. SRNA2 stated that R2 was confused and wandered. She stated R5 had been following R2 earlier in the day, and she told R5 to stop. In an interview on 03/26/2025 at 2:46 PM with SRNA4, she stated, on 10/21/2024, she was in the shower room with another SRNA getting a resident out of the whirlpool with the Hoyer Lift when she heard screaming. She stated she could not leave the other SRNA alone with the resident in the lift. She stated she heard yelling for the third time and told the other SRNA she was going to go find out what was going on. She stated she peered into the family room and saw R2 and R5, both in their wheelchairs, hitting each other and fighting. She stated she attempted to separate the two residents but was unable, so she ran to get the nurse (unnamed). She stated she and the nurse got R2 and R5 separated. She stated both residents were upset, and they had experienced previous issues in the past. She stated, earlier that day, the nurse told R5 to stop following R2. In an interview on 03/26/2025 at 10:26 AM with Licensed Practical Nurse (LPN) 2, she stated on 10/21/2024, R2 was going into the day room, and R5 followed R2 into the room, causing a physical altercation. She stated the residents were separated, and the Charge Nurse (CN) assessed the residents and reported the incident to the former Administrator. She stated this time R5 was the aggressor (unlike the first incident several days earlier when R2 was the aggressor). LPN2 stated she was not at the facility when the first incident occurred but heard about it. She stated, with the second incident, she did not remember R5 having any injury, only R2 having scratches and a broken wrist. She stated R2 complained of wrist pain and an outside company came to the facility, took the wrist x-ray, splinted it, and then she went to the orthopedics doctor the next day. She stated she could not remember, prior to these incidents, either R2 or R5 being aggressive or abusive to each other or anyone else. She stated, after the first incident, the facility put stop guards on the door to R5's room. She stated she was not sure about R2's supervision level. She stated the incident occurred later in the day, and she was not sure if staff did any further interventions to keep both residents safe. In an interview on 03/26/2025 at 7:49 PM with the Charge Nurse (CN), she stated she was one of the two nurses at the facility when the altercation occurred on 10/21/2024. The CN stated R5 had gone into the quiet room/family room and grabbed R2 by the arm. She stated, after this incident, R2 complained of arm pain. She stated after she helped the other nurse (LPN2) and SRNA4 separate the two residents, R5 was placed on one-on-one supervision. She stated R2 wandered the facility and tended to call others (staff and residents) names. She stated, earlier in the day, she redirected R5 to stay away from R2. In continued interview with the CN, on 03/26/2025 at 7:49 PM, she stated she did not move R5 to another hallway after the first incident that occurred on 10/13/2024 because R2 wandered the facility, and R5 was often in the hallway and in activities, so they were bound to pass and interact. She stated the day and time of the incident, there were four SRNAs and two nurses working [on 10/21/2024]. She stated she felt this was adequate staff to supervise and care for the residents. In an interview on 03/27/2025 at 10:23 AM with the former Assistant Director of Nursing (ADON), she stated she was not working at the time of the incident on 10/21/2024 when R5 broke R2's wrist. She stated she expected staff to remove a resident from the situation if the resident was exhibiting behaviors and place the resident on one-on-one monitoring. She stated staff was educated on abuse frequently. She stated she expected staff to immediately inform the supervisor if they heard or witnessed abuse. The former ADON stated she expected staff to always know the location of residents that wandered. In an interview with the Director of Nursing (DON) on 03/27/2025 at 10:46 AM, she stated her expectation was for any abuse allegation, staff should make sure the resident(s) were safe and report it immediately. The DON stated R2 wandered and was legally blind. She stated, for this reason, they had to place pink tape around her door after the first incident with R5, to prevent her from entering the wrong room. She stated R2 had accidentally entered R5's room on 10/13/2024, and an altercation occurred where R5 had bruising and a skin tear on her left arm. She stated, when the second altercation occurred on 10/21/2024, staff separated R2 and R5. The DON stated after the first event, she did not think R5 would do anything to R2. She stated she did not know that R5 had been following R2 around the facility earlier on the day of 10/21/2024 when R5 broke R2's wrist. She stated she expected if staff had to redirect R5 multiple times to keep her from pursuing R2, something other than redirection should have been done. She stated staff was educated on abuse upon hire, annually, and in between when needed. She stated it was her expectation that staff kept a close eye on residents that wandered. In an interview on 03/28/2025 at 10:35 AM with R2's Physician, he stated he was notified of both incidents between R2 and R5 (10/13/2024 and 10/21/2024). He stated for the incident on 10/21/2024, he was told R2 and R5 got into a heated argument, and R5 grabbed R2's wrist and broke it. He stated the facility staff told him they separated both residents and put measures in place to keep them apart and safe. He said that R2 later complained of arm pain, and a mobile x-ray came to the facility and found that she had a broken wrist. He stated R2 was splinted at the facility on 10/21/2024, and the following day (10/22/2024), she was sent to an appointment with an orthopedic specialist, who placed her in a spica cast. In an interview on 03/25/2025 at 9:19 AM with the former Administrator, she stated earlier in the week, R2, who was blind and had dementia, had entered R5's room accidentally, prior to the second incident on 10/21/2024. She stated the residents had adjoining rooms. She stated R5 was heard screaming, and when they entered R5's room, she had bruises and scratches on her arm. She stated, a week later, R2 entered the day room and R5 followed her. She stated R5 grabbed R2's arm and twisted it, breaking her wrist. She stated R5 was sent to a psychiatric hospital for medication review and never returned to the facility. In an interview on 03/25/2025 at 10:45 AM with the Interim Administrator, she stated the facility did not have a policy on behaviors, dementia care, supervision or wandering. She stated the reason the facility did not have these policies was that behaviors, dementia care, and supervision was different for each resident, and a policy could not encompass all those differences. She stated she was not the Administrator of the facility at the time of both incidents and had only been the Administrator since the day of the interview [on 03/25/2025]. In another interview with the Interim Administrator on 03/28/2025 at 8:36 PM, she stated it was her expectation that staff report any abuse allegation to her immediately so she could report it to the State Survey Agency (SSA) immediately. She stated staff did abuse training upon hire, annually, and when the need arose (with any allegation of abuse). She stated she expected that SRNAs should report any behaviors to their nurse each time it occurred. She stated she expected nursing staff to implement existing interventions or develop new interventions if those in place did not work to combat the resident's behaviors.

Based on interview, record review, document review, and review of the facility's policy, the facility failed to offer the resident and her representative an offer, in writing, of a bed hold before transferring and subsequently discharging Resident (R) 5 from the facility. In addition, the facility failed to recognize the resident's right to have access to a bed hold during her hospital stay for up to 14 days, regardless of the bed hold agreement. The findings include: Review of the facility's document Transfer and Discharge, undated, revealed the bed reservation and bed-hold policy that explained the rights of a resident up to 14 calendar days for hospital admissions. When a resident or responsible party were notified of the exhaustion of the bed hold days, they must specify at the time of their notification whether or not they wished to continue reserving the bed. The document stated both Medicaid and private pay patients [residents] would be notified within 24 hours of the time that payment stopped. Review of the facility's census, dated 10/15/2024 through 11/15/2024, revealed there were beds available each day. Per the census, R5 was marked as a discharge on [DATE] and not as a bed-hold. The census revealed the facility's capacity was 60 residents, and the census averaged 56 residents during that time. The State Survey Agency (SSA) Surveyor requested R5's documentation of discharge planning and R5's Transfer and Discharge form that explained her bed hold, her rights to appeal, and her rights to a bed. However, that was not provided. Review of R5's Face Sheet from her closed electronic medical record (EMR) revealed the facility admitted the resident on 12/05/2022 with diagnoses which included cerebral infarction (stroke), mild cognitive impairment, and anxiety disorder. Further review of R5's EMR revealed she was a Medicaid recipient, and no documentation of the bed hold or transfer discharge agreement was in R5's chart. During an interview with the Ombudsman via telephone on 03/26/2025 at 9:01 AM, she stated she did not believe there were any discussions of a bed hold when R5 was transferred to the hospital on [DATE]. During an interview on 03/26/2025 at 9:40 AM with R5's family member (F) 3, she stated on the date R5 was sent out to the hospital, 10/24/2024, a bed hold was discussed but due to the expected return of the resident from a short stay hospital visit, it was explained to her that should the census require the resident's bed, she would need to begin to pay for a bed hold, otherwise R5's bed would be available upon her return. However, she stated on 10/29/2024, the former Administrator called and told her R5 could not come back because she was too great a risk. During an interview with the Interim Administrator on 03/28/2025 at 8:35 AM, she stated she was not the Administrator when the transfer/discharge occurred and only became the Interim Administrator three days ago, however, believed the policy should have been followed.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised as determined by the resident's needs after each fall for three (3) of seventeen (17) sampled residents, Resident #13, #22, and #28. Resident #13's Comprehensive Care Plan was not revised to reflect new interventions after falls that occurred, on 09/11/2020, 09/12/2020, 09/18/2020, 10/05/2020, 10/09/2020, 10/14/2020, and 10/16/2020. Resident #22's Comprehensive Care Plan was not revised to reflect new interventions for a fall that occurred, on 10/01/2020. Resident #28's Comprehensive Care Plan was not revised to reflect new interventions for falls that occurred, on 07/03/2020, and 08/09/2020. The findings include: Review of the facility's policy, Care Plans - Comprehensive, dated 08/13/2013, revealed the individualized comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs and was developed for each resident. 1. Review of Resident #13's medical record revealed the facility admitted the resident to the facility, on 11/25/2019, with multiple diagnoses, which included Unspecified Dementia with Behavioral Disturbance, Unspecified [MEDICAL CONDITION] Not Due to a Substance or Known Physiological Condition, Major [MEDICAL CONDITION], Anxiety Disorder, Unspecified Dementia Without Behavioral Disturbance, Muscle Weakness (Generalized), Unsteadiness on Feet, History of Falling, Personal History of [MEDICAL CONDITION], Post Traumatic [MEDICAL CONDITION], and Type 2 Diabetes. Review of Resident #13's Annual Minimum Data Set (MDS) Assessment, dated 10/15/2020, revealed the facility assessed Resident #13 as having a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15), indicating moderately impaired cognition. Continued review of the MDS assessment revealed the facility assessed Resident #13 as requiring one (1) person physical assistance with bed mobility and two (2) person physical assistance with transfers between surfaces. Review of Resident #13's Quarterly Fall Risk Assessment, dated 08/06/2020, along with other Fall Risk Assessments, dated 09/18/2020 through 10/14/2020, revealed the resident was at high risk for a potential fall. Review of Resident #13's Comprehensive Care Plan (CCP), initiated 12/06/2019, revealed a fall risk focus with a goal that Resident #13 would not experience any major injuries related to a fall throughout the next review period. Interventions included: assess for fall risk per facility protocol; bed sensor pad alarm to bed, chair pad sensor alarm to the chair, staff education to ensure all alarms were on working positions, educate resident and provide frequent reminders for safety related to confusion and forgetfulness; ensure adequate lighting in the room and corridors; keep call light within reach and answered promptly and educate the resident on the use of the call bell for assistance with transfers; keep the resident clean, warm, dry and comfortable; keep the room free of clutter and obstruction, may have a low bed-leave control out of the resident's reach related to the resident placing the bed in a high position; and obtain labs, x-rays and diagnostic studies per Physician orders [REDACTED]. Continued review of the CCP revealed interventions, initiated on 06/15/2020, which included: one-half side rail for bed mobility and non-skid strips to the left side of the bed. Although Resident #13 fell again on 09/11/2020, 09/12/2020, 09/18/2020, 10/05/2020, 10/09/2020, 10/14/2020, and 10/16/2020, new fall prevention interventions were not updated and revised on the care plan until 10/12/2020 to include: encourage resident to lie down after meals and, on 10/13/2020, anti-roll backs to the wheelchair as ordered. Review of Resident #13's Progress Notes along with a review of the facility's Quality Documents revealed the following: On 09/11/2020 at 3:35 AM, the nurse aide entered the resident's room and noted Resident #13 lying on the floor, next to the bed with his/her head toward the bed's foot. New interventions, after the fall, were to apply a Dycem non-slip pad to the seat of the wheelchair and Physical Therapy (PT) and Occupational Therapy (OT) for bilateral lower extremity strengthening and transfers. The care plan did not reflect these interventions, until 10/13/2020. On 09/12/2020 at 6:32 PM, staff found Resident #13 lying face down on his/her bed with knees on the fall mat. Urine was noted on the floor, and the resident appeared to have spilled the urine after using the urinal. After the fall, a new intervention was to put the resident in bed, lying down, after dinner. This intervention was not reflected in the care plan until 10/12/2020. On 09/18/2020 at 4:34 PM, Resident #13 stated he/she was attempting to transfer from the bed to the chair and said he/she slid out of bed onto the floor. There were no injuries. Interventions included the resident to wear non-skid shoes and the call light to be placed within the resident's reach. The care plan did not reflect these interventions. On 10/05/2020 at 6:46 PM, Resident #13 was found on the floor with the bed alarm in place, but the sound was low. The resident was also trying to use a walker that was in his/her room. Staff removed the walker from the room and replaced the old alarm with a new one. The care plan did not reflect this new intervention. On 10/09/2020 at 7:20 AM, Resident #13 fell when transferring from his/her bed to his/her wheelchair. The bed alarm was sounding, and his/her call bell was within reach; but it was not used by the resident. Interventions, after the fall, included educating staff and the resident on wearing non-skid socks. The care plan did not reflect these interventions. On 10/14/2020 at 6:20 PM, Resident#13 was found on the floor with the alarm sounding. The resident got up without assistance. The resident was continuously educated on safety. There was a small abrasion of the right upper buttock/coccyx area. The resident denied pain. Staff initiated hourly checks as an intervention; but, the care plan did not reflect this intervention. On 10/16/2020 at 3:21 AM, Resident #13 was found sitting on the floor, between the bathroom commode and the wheelchair, with shirt, pants, and non-skid shoes on; the wheelchair alarm was sounding. The resident stated he/she was trying to go to the bathroom. No injuries were noted. Resident #13 was encouraged to ask for assistance before transferring himself. Staff initiated a seventy-two (72) hour bowel and bladder pattern evaluation, on 10/16/2020; but, the care plan did not reflect this new intervention. Interview with State Registered Nurse Aide (SRNA) #2, on 10/29/2020 at 2:30 PM, employed at the facility for twenty-two (22) years, revealed she provided care to Resident #13 frequently. She stated every time Resident #13 fell , the resident said he/she was trying to get to the bathroom. Continued interview with SRNA #2 revealed Resident #13 had a urinary tract infection [MEDICAL CONDITION] and frequently needed to go to the bathroom. Additionally, she stated when the resident said he/she needed to go, he/she did not go when assisted to the toilet. SRNA #2 stated the resident had a chair and a bed alarm in place. She stated the resident used the urinal in the past. She stated the resident was checked every two (2) hours to see if he/she needed to go to the toilet. SRNA #2 stated she did not recall other interventions implemented after Resident #13's falls, and the nurse updated the aides on new interventions during shift report. Interview with SRNA #3, on 10/29/2020 at 2:39 PM, employed at the facility for seven (7) months, revealed she provided care to Resident #13 frequently. Per interview, Resident #13 had alarms on both his bed and wheelchair, and his bed was at the lowest level. SRNA #3 stated the resident fell trying to go unassisted to the bathroom. Continued interview revealed Resident #13 did not obey commands to call for help, but instead tried to get up alone and slid out of bed. In addition, SRNA #3 stated when the resident was asked if he/she needed to go to the bathroom, he/she would answer no. SRNA #3 stated aides were informed of new or revised fall interventions via the nurse at shift report. Interview with Licensed Practical Nurse (LPN) #1, on 10/29/2020 at 3:25 PM, employed at the facility for four (4) years, revealed she provided care to Resident #13. Per interview, Resident #13 had fall prevention interventions to include low bed to the floor and motion sensors to both the bed and the wheelchair. Additionally, she stated Resident #13 had exhibited symptoms of a UTI, she had notified the Physician, and he had ordered a urinalysis to rule out a UTI. LPN #1 stated a Psychiatrist had seen Resident #13 for behaviors. Continued interview revealed when a fall occurred, the staff looked for causative factors, new orders, and new or revised interventions on the care plan. 2. Review of Resident #28's medical record revealed the facility admitted the resident, on 05/20/2019, with [DIAGNOSES REDACTED]. Review of Resident #28's Progress Notes, dated 07/03/2020 at 5:46 PM, revealed the resident was found to be lying on the right side of the fall mat with the geriatric (geri) chair noted to be against the resident. The bed was in the lowest position, the call light was within reach, and the motion sensor to the bed was sounding. A head-to-toe assessment was completed, with an abrasion noted to the right side of the back; vitals signs were obtained. Resident #28 stated he/she was not doing anything at the time of the fall. Review of Resident #28's Progress Notes, dated 08/09/2020 at 3:08 PM, revealed the resident was sitting on the floor with his/her back against the bed and legs outstretched. Neurological checks were initiated at this time. A head-to-toe assessment was completed, vital signs were obtained, and the resident was assisted to bed. The Nurse Practitioner started fifteen (15) minute checks to monitor the resident. Review of Resident #28's CCP revealed a focus, undated, stating the resident had impulsive behaviors without safety judgement and a history of [MEDICAL CONDITION] activity. The goal, undated, stated the resident would not experience any major injuries related to a fall throughout the next review period. Interventions included: falling star program, initiated 11/08/2019; assess for fall risk per facility protocol, initiated 06/10/2019; bed sensor pad alarm to bed, initiated 06/10/2019; check and change every hour with small incontinent products, initiated 06/26/2020; keep call light within reach and answer promptly, initiated 06/10/2019; keep resident clean, warm, dry and comfortable, initiated 06/10/2019; keep room free of clutter and obstruction, initiated 06/10/2019; may have bilateral side rails times two and padded for [MEDICAL CONDITION] activity, initiated 06/11/2019; may have fall mats to the left and the right side of the bed floor, initiated 09/13/2019; pull away alarm while up to the geri chair, initiated 06/10/2019; and resident known to frequently lean forward while in the geri chair and place legs over the arm rest of the geri chair, initiated 11/06/2019. However, there were no new interventions added to the CCP after the resident fell , on 07/03/2020, and 08/09/2020. Additionally, there was no evidence the facility ensured all staff were aware of new interventions to implement after each fall Resident #28 sustained. Interview with SRNA #2, on 10/29/2020 at 2:24 PM, revealed she had cared for Resident #28. She stated she was familiar with the Kardex noting what interventions were in place for residents that were at risk for falls. She stated she could refer to the Kardex, and it would show if a resident required fall mats like Resident #28 did. She stated all information needed to care for the resident should be on the care plan. 3. Review of Resident #22's medical record revealed the resident was admitted , on 07/06/2017, with [DIAGNOSES REDACTED]. Review of Resident #22's Progress Notes, dated 10/01/2020 at 12:32 PM, revealed the resident was sitting on the floor in front of the wheelchair. Per notes, Resident #22 stated he/she slid out of the wheelchair while attempting to get into the bed. Review of Resident #22's Fall Risk Assessment, dated 08/18/2020, revealed the resident was a fall risk. Review of Resident #22's CCP revealed a focus, undated, stating the resident was a fall risk related to impaired cognition and impaired mobility. The goal, undated, stated the resident would not have any major injuries from falls throughout the next review period. Interventions included: anti-rollbacks to the wheelchair, initiated 10/18/2019; anti-tippers to the wheelchair, initiated 06/05/2018; assess for fall risk per facility protocol, initiated 07/24/2017; educate the resident and provide reminders for safety, initiated 07/24/2017; ensure adequate lighting in room and corridors, initiated 07/24/2017; known to transfer self without waiting for assistance, initiated 09/18/2019; keep call light within reach and answer promptly, initiated 07/24/2017; keep resident clean, warm, dry, and comfortable, initiated 07/24/2017; keep room free of clutter and obstruction, initiated 07/24/2017; Pharmacy to monitor medications and make recommendations, initiated 07/24/2017; and with transfers, extensive assistance with one (1) person, initiated 07/24/2017. No new interventions were added to the CCP, until 10/05/2020, five (5) days after the resident's fall. These new interventions were bed sensor pad alarm to bed, chair pad sensor alarm to chair, falling star program per facility policy, and resident to lie down after meals. Interview with the Interim Director of Nursing (DON), Administrator, and Regional Registered Nurse (RN), on 10/29/2020 at 4:15 PM, revealed quality issues or concerns were discussed daily at the morning meetings. They stated meeting participants were facility management staff and clinical leaders, and in this meeting problems were identified, plans were implemented to address concerns, and effectiveness of the plans was determined by auditing results. Additionally, they stated all falls were discussed daily in the Interdisciplinary Team (IDT) Meeting where the root cause of the fall, determined through a root cause analysis (RCA), and individualized interventions were developed and implemented immediately. Continued interview with the Regional RN and Administrator revealed the MDS Coordinator should have added the new and revised fall interventions to the care plans because this was her responsibility, i.e. updating and revising the care plan. They stated the MDS Coordinator was currently on sick leave.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have a systemic approach with consistent application of implementation of individualized, resident-centered interventions, to reduce individual risks related to hazards in the environment to prevent accidents for three (3) of seventeen (17) sampled residents (Resident #13, #22, and #28). Resident #13 sustained falls on 09/11/2020, 09/12/2020, 09/18/2020, 10/05/2020, 10/09/2020, 10/14/2020, and 10/16/2020. Review of the Comprehensive Care Plan (CCP) revealed the facility did not implement individualized, resident-centered interventions after each fall. Resident #22 had a fall on 10/01/2020. Review of the Comprehensive Care Plan (CCP) revealed the facility did not update the CCP to reflect new interventions after the fall, until 10/05/2020. Resident #28 sustained two (2) falls, on 07/03/2020, and 08/09/2020. Review of the Comprehensive Care Plan (CCP) revealed the facility did not update it to reflect new interventions after each fall. The findings include: Review of the facility's policy, Fall Program, undated, revealed after each fall, the environment would be assessed for causative factors, the care plan would be updated, and all interventions would be documented and personalized. 1. Review of Resident #13's medical record revealed the facility admitted the resident, on 11/25/2019, with multiple diagnoses, which included Unspecified Dementia with Behavioral Disturbance, Unspecified [MEDICAL CONDITION] Not Due to a Substance or Known Physiological Condition, Major [MEDICAL CONDITION], Anxiety Disorder, and Unspecified Dementia Without Behavioral Disturbance. Review of Resident #13's Annual Minimal Data Set (MDS) Assessment, dated 10/15/2020, revealed the facility assessed Resident #13 as having a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15), indicating moderately impaired cognition. Additional review of the MDS assessment revealed the facility assessed Resident #13 as requiring one (1) person physical assistance with bed mobility and two (2) person physical assistance with transfers between surfaces. Review of Resident #13's Comprehensive Care Plan (CCP), initiated 12/06/2019, revealed a fall risk focus with a goal that Resident #13 would not experience any major injuries related to a fall throughout the next review period. Interventions included: assess for fall risk per facility protocol; bed sensor pad alarm to bed, chair pad sensor alarm to the chair, staff education to ensure all alarms were on working positions, educate resident and provide frequent reminders for safety related to confusion and forgetfulness; ensure adequate lighting in the room and corridors; keep call light within reach and answered promptly and educate the resident on the use of the call bell for assistance with transfers; keep the resident clean, warm, dry and comfortable; keep the room free of clutter and obstruction, may have a low bed-leave control out of the resident's reach related to the resident placing the bed in a high position; and obtain labs, x-rays and diagnostic studies per Physician orders [REDACTED]. Continued review of the CCP revealed interventions, initiated on 06/15/2020, which included: one-half side rail for bed mobility and non-skid strips to the left side of the bed. Review of Resident #13's Quarterly Fall Risk Assessment, dated 08/06/2020, along with other Fall Risk Assessments, dated 09/18/2020 through 10/14/2020, revealed the resident was at high risk for a potential fall. Review of Resident #13's Progress Notes along with a review of the facility's Quality Documents revealed the following: On 09/11/2020 at 3:35 AM, the nurse aide entered the resident's room and noted Resident #13 lying on the floor, next to the bed with his/her head toward the bed's foot. New interventions, after the fall, were to apply a Dycem non-slip pad to the seat of the wheelchair and Physical Therapy (PT) and Occupational Therapy (OT) for bilateral lower extremity strengthening and transfers. The care plan did not reflect these interventions, until 10/13/2020. On 09/12/2020 at 6:32 PM, staff found Resident #13 lying face down on his/her bed with knees on the fall mat. Urine was noted on the floor, and the resident appeared to have spilled the urine after using the urinal. After the fall, a new intervention was to put the resident in bed, lying down, after dinner. This intervention was not reflected in the care plan until 10/12/2020. On 09/18/2020 at 4:34 PM, Resident #13 stated he/she was attempting to transfer from the bed to the chair and said he/she slid out of bed onto the floor. There were no injuries. Interventions included the resident to wear non-skid shoes and the call light to be placed within the resident's reach. The care plan did not reflect these interventions. On 10/05/2020 at 6:46 PM, Resident #13 was found on the floor with the bed alarm in place, but the sound was low. The resident was also trying to use a walker that was in his/her room. Staff removed the walker from the room and replaced the old alarm with a new one. The care plan did not reflect this new intervention. On 10/09/2020 at 7:20 AM, Resident #13 fell when transferring from his/her bed to his/her wheelchair. The bed alarm was sounding, and his/her call bell was within reach; but it was not used by the resident. Interventions, after the fall, included educating staff and the resident on wearing non-skid socks. The care plan did not reflect these interventions. On 10/14/2020 at 6:20 PM, Resident#13 was found on the floor with the alarm sounding. The resident got up without assistance. The resident was continuously educated on safety. There was a small abrasion of the right upper buttock/coccyx area. The resident denied pain. Staff initiated hourly checks as an intervention; but, the care plan did not reflect this intervention. On 10/16/2020 at 3:21 AM, Resident #13 was found sitting on the floor, between the bathroom commode and the wheelchair, with shirt, pants, and non-skid shoes on; the wheelchair alarm was sounding. The resident stated he/she was trying to go to the bathroom. No injuries were noted. Resident #13 was encouraged to ask for assistance before transferring himself. Staff initiated a seventy-two (72) hour bowel and bladder pattern evaluation, on 10/16/2020; but, the care plan did not reflect this new intervention. However, the facility failed to have a systemic approach with consistent application of implementation of individualized, resident-centered interventions, as there were no new interventions added to the CCP after Resident #13 fell seven (7) times on the dates of 09/11/2020, 09/12/2020, 09/18/2020, 10/05/2020, 10/09/2020, 10/14/2020, and 10/15/2020. Additionally, there was no evidence the facility ensured all staff were aware of new interventions to implement after each fall Resident #13 sustained. 2. Review of Resident #28's medical record revealed the facility admitted the resident, on 05/20/2019, with [DIAGNOSES REDACTED]. Review of Resident #28's Progress Notes, dated 07/03/2020 at 5:46 PM, revealed the resident was found to be lying on the right side of the fall mat with a geriatric (geri) chair noted to be against the resident. The bed was in the lowest position, the call light was within reach, and the motion sensor to the bed was sounding. A head-to-toe assessment was completed, with an abrasion noted to the right side of the back; vitals signs were obtained. Resident #28 stated he/she was not doing anything when he/she fell . Review of Resident #28's Fall Risk Assessment, dated 07/03/2020, revealed the resident was a high risk for falls. Review of Resident #28's Progress Notes, dated 08/09/2020 at 3:08 PM, revealed the resident was sitting on the floor with his/her back against the bed and legs outstretched. Neurological checks were initiated at this time. A head-to-toe assessment was completed, vital signs obtained, and the resident was assisted to bed. The Nurse Practitioner started fifteen (15) minute checks to monitor the resident. Review of Resident #28's Fall Risk Assessment, dated 08/09/2020, revealed the resident was a high risk for falls. Review of Resident #28's CCP revealed a focus, undated, stating the resident had impulsive behaviors without safety judgement and a history of [MEDICAL CONDITION] activity. The goal, undated, stated the resident would not experience any major injuries related to a fall throughout the next review period. Interventions included: falling star program, initiated 11/08/2019; assess for fall risk per facility protocol, initiated 06/10/2019; bed sensor pad alarm to bed, initiated 06/10/2019; check and change every hour with small incontinent products, initiated 06/26/2020; keep call light within reach and answer promptly, initiated 06/10/2019; keep resident clean, warm, dry and comfortable, initiated 06/10/2019; keep room free of clutter and obstruction, initiated 06/10/2019; may have bilateral side rails times two and padded for [MEDICAL CONDITION] activity, initiated 06/11/2019; may have fall mats to the left and the right side of the bed floor, initiated 09/13/2019; pull away alarm while up to the geri chair, initiated 06/10/2019; and resident known to frequently lean forward while in the geri chair and place legs over arm rest of the geri chair, initiated 11/06/2019. However, there were no new interventions added to the CCP after the resident fell , on 07/03/2020 and 08/09/2020. Additionally, there was no evidence the facility ensured all staff were aware of new interventions to implement after each fall Resident #28 sustained. 3. Review of Resident #22's medical record revealed the resident was admitted to the facility, on 07/06/2017, with [DIAGNOSES REDACTED]. Review of Resident #22's Progress Notes, dated 10/01/2020 at 12:32 PM, revealed the resident was sitting on the floor in front of the wheelchair. Resident #22 stated he/she slid out of the wheelchair while attempting to get into bed. Review of Resident #22's Fall Risk Assessment, dated 08/18/2020, revealed the resident was a fall risk. Review of Resident #22's CCP revealed a focus, undated, stating the resident was a fall risk related to impaired cognition and impaired mobility. The goal, undated, stated the resident would not have any major injuries from falls throughout the next review period. Interventions included: anti-rollbacks to the wheelchair, initiated 10/18/2019; anti-tippers to the wheelchair, initiated 06/05/2018; assess for fall risk per facility protocol, initiated 07/24/2017; educate the resident and provide reminders for safety, initiated 07/24/2017; ensure adequate lighting in room and corridors, initiated 07/24/2017; known to transfer self without waiting for assistance, initiated 09/18/2019; keep call light within reach and answer promptly, initiated 07/24/2017; keep resident clean, warm, dry, and comfortable, initiated 07/24/2017; keep room free of clutter and obstruction, initiated 07/24/2017; Pharmacy to monitor medications and make recommendations, initiated 07/24/2017; and with transfers, extensive assistance with one (1) person, initiated 07/24/2017. No new interventions were added to the CCP, until 10/05/2020, five (5) days after the resident's fall. These new interventions were bed sensor pad alarm to bed, chair pad sensor alarm to chair, falling star program per facility policy, and resident to lie down after meals. Interview with the Administrator, on 10/29/2020 at 4:52 PM, revealed management staff reviewed falls in the morning meetings and determined the causative factor for each fall. She stated once this was determined, staff would put an intervention in place to help reduce a resident's risk for falls in the future. She stated, after a fall, these interventions should be updated and implemented onto a resident's CCP as soon as possible and within reason. This way all staff could be made aware of any changes to better care for residents. She stated for these residents, their care plans should have been updated to reflect new interventions. She stated she was unsure of why the CCP's were not updated to reflect changes and new interventions. The Administrator stated the Minimum Data Set Nurse was responsible for adding these updates, during these instances, to the care plan; however, she was on leave due to surgery.

Based on interview, record review, and facility policy review, it was determined the facility failed to protect one (1) of six (6) sampled residents, (Resident #1) from physical abuse. On 06/27/2020 at approximately 1:30 PM, Resident #1 asked State Registered Nursing Assistant (SRNA) #3, (the alleged perpetrator) to assist him/her to the bathroom. SRNA #3 told Resident #1 to wait until after she made another resident's bed. Resident #1 told SRNA #3 to forget about helping him/her to the bathroom, to leave him/her alone. He/She proceeded to ask SRNA #1 for help to the bathroom. While Resident #1 was asking SRNA #1 for help, SRNA #3 came and jerked Resident #1's wheelchair around and took off with the resident's fingers in the spokes of the wheelchair. Resident #1 began yelling, saying she was hurting his/her fingers while hitting SRNA #3 telling her to stop. The findings include: Review of the facility's Abuse Prevention Policy, dated 02/2004, revealed it is the policy of this facility to encourage residents, families, and staff to report concerns, incidents, and grievances without the fear of retribution. This facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, the staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. It is the goal of this facility to achieve and maintain an abuse-free environment. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of Resident #1's closed medical record revealed the facility admitted the resident on 03/11/2020 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact and interviewable. Also, per the MDS, the resident was dependent on two (2) staff assistance for toileting. Review of Resident #1's Comprehensive Care Plan, initiated 03/11/2020, revealed the resident was at risk for toileting elimination deficit related to impaired mobility/balance, with a goal that the resident will be clean, warm and odor-free through adequate toileting. Intervention included staff assistance with toileting. The care plan revealed Resident #1 was at risk for routine care needs related to requiring assistance, with a goal that the resident will have needs met by the assistance of staff as needed. Intervention included two (2) caregivers for providing care. In addition, Resident #1 was at risk for psychosocial well being related to past life stressors identified as physical abuse by a family member. Interventions included inform resident of care to be delivered BEFORE starting care-give resident time to process. Resident #1 was discharged to another Skilled Nursing Facility on 07/03/2020; therefore was unavailable for observation and interview during the survey. Review of the Ombudsman report, dated 06/30/2020, at 6:17 PM, revealed she received a phone call from Registered Nurse (RN) #1 on 06/30/2020 stating she reported an alleged abuse incident to facility administration involving Resident #1 on 06/27/2020. Per the report, the Ombudsman called the facility to speak with Resident #1. Resident #1 stated that on Saturday afternoon, 06/27/2020 he/she was in his/her room when SRNA #3 walked in. Resident #1 asked SRNA #3 if she would take him/her to the bathroom. With linens in her hands, SRNA #3 told Resident #1 that she had to make someone's bed first. Resident #1 then rolled out into the hallway close to the nurses' station. She saw a second aide, SRNA #1, and asked her to assist to the bathroom. Resident #1 said SRNA #1 replied that she needed to chart before she could assist. Resident #1 stated that SRNA #3 grabbed his/her wheelchair from behind and jerked it around very fast. Resident #1's fingers were in the wheelchair spokes when the wheelchair was turned. Resident #1 admits to hitting SRNA #3, saying he/she was caught off guard and acting in self-defense. Resident #1 stated that his/her fingers were still very sore and swollen. Resident #1 stated he/she was scared of SRNA #3 and was having trouble sleeping. Per the report, Resident #1 told the Ombudsman he/she worried that SRNA #3 was going to hurt him/her and stated, she tears my nerves all to pieces. Review of a facility investigation summary, dated 07/03/2020 (initiated 06/29/2020, three days after the incident), signed by the Administrator, revealed after the investigation, the facility determined that SRNA #3 went to turn the resident's wheelchair to take him/her to the bathroom as asked, and his/her fingers were on the wheel. The resident has exhibited no psychosocial issues related to the incident and continues to be at his/her normal baseline with functioning. The resident has had acute monitoring every shift with no injury noted. X-ray of the right hand was done on June 30, 2020, and results were negative. The resident is able to use his/her right hand and move all digits and range is within normal limits. SRNA #3 was re-educated regarding providing care to residents and making sure they hear what you say before assisting with activities of daily living (ADL) and to make sure all hands and feet are up before assisting residents who are in wheelchairs. Interview with SRNA #1, on 07/06/2020 at 1:54 PM, employed at the facility four (4) years, revealed Resident #1 asked to be pulled up in his/her wheelchair. SRNA #3 walked up and Resident #1 told SRNA #3 she had caused him/her enough grief already and did not want her help. SRNA #3 proceeded to push Resident #1's wheelchair from behind, even after being told not to. In addition, SRNA #1 stated, I don't think SRNA #3 meant to catch Resident #1's fingers in the spokes of the wheelchair; however, she went against what Resident #1 asked her not to do. Continued interview revealed SRNA #1 felt the wheelchair was pushed rudely and aggressively and she said yes, adding this was not the first time SRNA #3 had been reported for rude behavior. SRNA #1 stated Resident #1 revealed to her that he/she and SRNA #3 did not get along and did not have a good relationship. Interview with SRNA #2, on 07/06/2020 at 2:07 PM, employed at the facility approximately three (3) years, revealed she did not witness the incident; however, she was working the date of the incident. She revealed she made several complaints against the aide to the Assistant Director of Nursing (ADON) and the Administrator for being mean, rude, and screaming at a resident in the past and the ADON told her the resident that was allegedly yelled by SRNA #3 was yelled at was hard of hearing. SRNA #2 said it was not necessary to yell at someone even if they are hard of hearing. Also, she said SRNA #3 revealed that Resident #1 did not like her. Telephonic interview with Registered Nurse (RN) #1, on 07/06/2020 at 11:09 AM, employed at the facility eight (8) years, revealed she was the nurse on duty the day of the alleged incident. She was on the phone when she heard Resident #1 yelling. She got off the phone and observed SRNA #1 motioning for her to come to where Resident #1 and SRNA #3 were at. When she got to that section of the hallway, SRNA #3 was saying to Resident #1, I'm sorry J----, I'm sorry J----, then SRNA #3 walked away. Resident #1 told RN #1 that SRNA #3 grabbed his/her wheelchair after being told not to, started pushing it, catching his/her fingers in the spokes of the wheel. The resident yelled out in pain. In addition, Resident #1 stated he/she felt threatened by SRNA #3, and this was not the first time he/she had trouble with SRNA #3. Additionally, RN #1 said SRNA #3 reported she did not know that Resident #1's fingers were near the wheelchair spokes. RN #1 stated she called the Director of Nursing (DON) at home to report the incident. The DON said she needed to talk to the Social Worker, then call her back. The DON instructed RN #1 to have SRNA #3 clock out, leave the facility, and then file an incident report. Head to toe assessment was performed on Resident #1 by RN #1 and Resident #1's daughter and Physician were notified of the incident. Continued interview with RN #1 revealed the event happened around 1:30 PM on 06/27/2020. She stated the DON did not come in when the event was reported. She came in to staff the unit around 9:00 PM due to a call-in and the Administrator was on vacation. RN #1 stated she did not have further conversation with the DON or Administrator and they did not ask her for a written statement of the event, until she contacted them on Monday, 06/29/2020, about reporting the incident. She revealed she read the Administrator's written report regarding the incident and did not agree with the statement that Resident #1 felt safe because Resident #1 told RN #1 he/she felt threatened and RN #1 said she informed the Administrator. She said it was very obvious the act was abusive, intentionally grabbing the wheelchair, turning it aggressively and catching the resident's fingers in the spokes of the wheelchair hurting them, after going against the resident's request to leave him/her alone. Telephonic interview with the Social Service Director (SSD) on 07/07/2020 at 12:05 PM, employed at the facility three years (3), and as Social Service Director approximately two (2) months, revealed she was not working the day of the incident and was not called. She learned about the incident when she returned to work on Monday, 06/29/2020, stating her understanding was it was an accident report. She does not recall it reported as an alleged abuse. On Tuesday, 06/30/2020, she learned from the DON this had been reported by the nurse as an alleged abuse incident. The SSD and the DON talked to Resident #1. Resident #1 told them she asked SRNA #3's assistance to the bathroom. SRNA #3 told him/her she would be back. Resident #1 then asked another SRNA to help him/her to the bathroom. SRNA #3 came up behind him/her, turned the wheelchair around, and caught his/her hand in the wheel. According to the SSD, Resident #1 reported he/she yelled and punched SRNA #3 several times to make her stop. She further stated she did not think it was right for SRNA #3 to go against the resident's request to leave him/her alone. Telephonic interview with the DON on 07/07/2020 at 12:27 PM, employed at the facility less than two (2) months, revealed she was called by RN #1 on 06/27/2020 around 2:00 PM to report the incident between Resident #1 and SRNA #3. She recalls being told that Resident #1 was ready to go to the bathroom and SRNA #3 could not assist at the time. When SRNA #3 was ready to assist, she came up from behind the wheelchair and began backing the wheelchair up. Resident #1's hand was caught in the wheel. She instructed RN #1 to have SRNA #3 clock out and leave the facility and to complete an incident report. She did not talk to RN #1 further that day regarding the incident or the other SRNA's on duty at the time of the incident. The DON stated she regarded this incident as an accident. When asked if it was standard practice to send staff home after an accident, the DON replied yes. Interview with the facility Administrator on 07/06/2020 at 3:00 PM revealed the incident happened on 06/27/2020. She did not report the incident to the Office of Inspector General (OIG) until 06/30/2020 because when she initially heard about the incident, it was reported as an accident. The accident report was the SRNA pushed Resident #1's wheelchair, catching the resident's hand in the spokes of the wheel. No one alleged the incident as abuse. Additional interview revealed RN #1 called the Administrator on 06/29/2020 asking why the reported incident had not been investigated and reported as per policy. RN #1 said the aggressive behavior demonstrated by SRNA #3 toward Resident #1 was abusive. The Administrator stated RN #1 had given Resident #1 the Ombudsman's phone number. Continued interview with the Administrator revealed the facility failed to identify the incident as an allegation of abuse. However, further interview revealed the facility should have initiated an investigation immediately and interviewed Resident #1 as well as SRNA #3 on 06/27/2020, as well as obtained written statements. She expects all residents to be free from abuse and that abuse or alleged abuse is reported and investigated immediately per policy.

Based on interviews, record review, and review of the facility's policy, it was determined the facility failed to ensure its abuse policy and procedures were implemented for one (1) of six (6) sampled residents (Resident #1). The facility failed to implement their written abuse policies related to completing a thorough investigation after Registered Nurse (RN) #1 reported to the Director of Nursing (DON) that Resident #1 alleged that SRNA #3 came and jerked his/her wheelchair around and took off, after the resident told SRNA #3 not to, with the resident's fingers in the spokes. Resident #1 yelled and complained of pain to fingers on his/her right hand. (Refer to F600) The findings include: Review of the facility's Abuse Investigations Policy, undated, revealed all reports of resident abuse, neglect, and injuries of an unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will investigate the alleged incident. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The individual conducting the investigation will, as a minimum: Review the completed forms; Review the resident's medical record to determine events leading up to the incident; Interview the person (s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Ensure the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors; Interview other residents to whom the accused employee provides care or services; and Review all events leading up to the alleged event. Witness reports will be obtained in writing. Witnesses will be required to sign and date such reports. Review of Resident #1's closed medical record revealed the facility admitted the resident on 03/11/2020 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact and interviewable. Also, per the MDS, the resident was dependent on two (2) staff assistance for toileting. A review of the Ombudsman report, dated 06/30/2020 at 6:17 PM, revealed she received a phone call from Registered Nurse (RN) #1 on 06/30/2020 stating she reported an alleged abuse incident to facility administration involving Resident #1 on 06/27/2020. Per the report, the Ombudsman called the facility to speak with Resident #1. Resident #1 told the Ombudsman that on Saturday afternoon, 06/27/2020 he/she was in his/her room when SRNA #3 walked in. Resident #1 told the Ombudsman that he/she asked SRNA #3 if she would take him/her to the bathroom. With linens in her hand, SRNA #3 told Resident #1 that she had to make someone's bed first. Resident #1 then rolled out into the hallway close to the nurses' station. She saw SRNA #1, and asked her for assistance getting to the bathroom and SRNA #1 told the resident she needed to chart before she could assist. Resident #1 stated that SRNA #3 grabbed his/her wheelchair from behind and jerked it around very fast while Resident #1 was telling SRNA #3 to leave him/her alone. Resident #1's fingers were in the wheelchair spokes when the wheelchair was turned. Per the report, Resident #1 stated his/her fingers were still very sore and swollen. Per the report, Resident #1 stated he/she was scared of SRNA #3 and was having trouble sleeping and stated he/she worried SRNA #3 was going to hurt him/her and stated, she tears my nerves all to pieces. Review of Resident #1's Medical Record Progress Notes dated 06/27/2020 at 3:19 PM written by RN #1 revealed Resident #1 asked SRNA #3 to go to the bathroom. SRNA #3 told Resident #1 to wait until she mad another resident's bed. Resident #1 asked SRNA #1 to help with toileting and SRNA #1 told the resident to wait one second while she charted. Resident #1 sat waiting and SRNA #3 came and jerked the wheelchair around and took off with the resident's fingers in the spokes. Resident #1 slapped her and yelled at her because she hurt his/her fingers. Interview with SRNA #1, on 07/06/2020 at 1:54 PM, employed at the facility four (4) years, revealed on 06/27/2020 around 1:30 PM, Resident #1 asked SRNA #1 to pull him/her up in the wheelchair when SRNA #3 walked up and Resident #1 told SRNA #3 she had caused him/her enough grief already and did not want her help. SRNA #3 proceeded to push Resident #1's wheelchair from behind, even after being told not to and even though she didn't think SRNA #3 intended to catch Resident #1's fingers in the wheel, she went against what Resident #1 asked her not to do. She stated SRNA #3 rudely and aggressively jerked the wheel chair. She said she immediately motioned for RN #1 to come to the scene. Telephonic interview with RN #1, on 07/06/2020 at 11:09 AM, revealed she was the nurse on duty the day of the alleged incident on 06/27/2020 around 1:30 PM. She said she was on the phone when she heard Resident #1 yelling. She got off the phone and observed SRNA #1 motioning for her to come to where Resident #1 and SRNA #3 were. When she got to that section of the hallway, SRNA #3 was saying to Resident #1, I'm sorry J---, I'm sorry J---, then SRNA #3 walked away. Resident #1 told RN #1 that SRNA #3 grabbed his/her wheelchair after being told not to, started pushing it, catching his/her fingers in the spokes of the wheel. Also, Resident #1 stated he/she felt threatened by SRNA #3, and this was not the first time he/she had trouble with SRNA #3. RN#1 stated she called the Director of Nursing (DON) at home to report the incident. The DON said she needed to talk to the Social Worker, then call her back. The DON called back and instructed RN #1 to have SRNA #3 clock out, leave the facility, and then file an incident report. She stated the DON did not come to the facility to conduct and investigation and did not tell RN #1 to report the incident to the State Agency. She stated the DON cam to the facility around 9:00 PM to handle a staff issue but did not initiate an investigation at that time. Continued interview with RN #1 revealed she did not have further conversation with the DON or Administrator until she contacted them on Monday, 06/29/2020, about reporting the incident. She revealed she read the Administrator's written report regarding the incident and did not agree with the statement that Resident #1 felt safe. Resident #1 told RN #1 she felt threatened. Additionally, RN#1 said it was very obvious the act was abusive, intentionally grabbing the wheelchair, turning it aggressively and catching the resident's fingers in the spokes of the wheelchair hurting them, after going against the resident's request to leave him/her alone. Telephonic interview with the Social Service Director (SSD) on 07/07/2020 at 12:05 PM, revealed she was not working the day of the incident, nor was she called on 06/27/2020. She learned about it when she returned to work on Monday, 6/29/2020, stating her understanding was it was an accident report not an abuse allegation. She stated on 06/30/2020, she learned from the DON that RN #1 reported the incident as an abuse incident. Telephonic interview with the Director of Nursing (DON) on 07/07/2020 at 12:27 PM, employed at the facility less than two (2) months, revealed she was called by RN #1 on 06/27/2020 around 2:00 PM to report the incident between Resident #1 and SRNA #3. She recalls from the conversation, Resident #1 was ready to go to the bathroom and SRNA #3 could not assist at the time. When SRNA #3 could help, she came up from behind the wheelchair and began backing it up. Resident #1's hand got caught in the wheel. She instructed RN #1 to have SRNA #3 clock out and leave the facility and to complete an incident report. She did not talk to RN #1 further that day regarding the incident or the other SRNA's on duty at the time. The DON stated she regarded this incident as an accident and that is was the standard practice to send staff home after an accident. Continued interview with the DON revealed she failed to identify the reported incident as an allegation of abuse. As a result, an investigation was not immediately initiated. Additionally, the DON stated the expectation is an alleged abuse be reported immediately to facility management, within two hours of occurrence to appropriate regulatory agencies if injury, and within twenty-four (24) hours of occurrence if without injury. Likewise, a facility investigation report was to be completed within five days. Interview with the facility Administrator on 07/06/2020 at 3:00 PM revealed the incident happened on 06/27/2020. She did not report the incident to the Office of Inspector General (OIG) until 06/30/2020 because when she initially heard about the incident, it was reported as an accident. The accident report was the SRNA pushed Resident #1's wheelchair, catching the resident's hand in the spokes of the wheel. Additional interviews revealed RN #1 called the Administrator on 07/29/2020 asking why the reported incident had not been investigated and reported as per policy. RN #1 said the aggressive behavior demonstrated by SRNA #3 toward Resident #1 was abusive. The Administrator stated RN #1 had given Resident #1 the Ombudsman's phone number. Continued interview with the Administrator revealed the facility failed to identify the incident as an allegation of abuse; therefore, an investigation was not immediately initiated. However, further interviews revealed the facility should have initiated an investigation immediately and interviewed Resident #1 as well as SRNA #3 on 06/27/2020, as well as obtained written statements from all staff on duty at the time of the incident. Further interview revealed there was no documented evidence of staff interviews, affected resident follow-up, witness statements, or any interviews related to the incident. Staff interviews confirmed interviews did not occur until three (3) days after the incident was reported.

Based on interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure an allegation of abuse was reported immediately, but no later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator and State Agencies as per State Law for one (1) of six (6) sampled residents (Resident #1). Registered Nurse (RN) #1 reported to the Director of Nursing (DON) on 06/27/2020, at approximately 1:30 PM, she heard Resident #1 yelling from the hallway and went to investigate what was happening. Resident #1 told RN #1 that State Registered Nursing Assistant (SRNA) #3 came and jerked his/her wheelchair around, after Resident #1 told SRNA #3 to leave him/her alone and took off with the resident's fingers in the spokes. Resident #1 said she slapped SRNA #3 and yelled at her because she hurt his/her fingers. Additionally, Resident #1 told RN #1 she felt threatened by SRNA #3. There was no documented evidence the facility reported the allegation to State Agencies within two (2) hours of the facility learning of the allegation on 06/27/2020. The incident was not reported to State Agencies until 06/30/2020. (Refer to F600) The findings include: Review of the facility's policy titled, Reporting Abuse to State Agencies and Other Entities/Individuals, undated, all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: The State licensing/certification agency responsible for surveying/licensing the facility; The local/state Ombudsman; The Resident's Representative of Record; Adult Protective Services; Law enforcement officials; The Attending Physician and the facility Medical Director. Notices will include the name of the resident, room number, type of abuse committed, date, and time the alleged incident occurred and what immediate action was taken by the facility. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed with a written report of the investigation findings within five (5) working days of the occurrence of the incident. Review of Resident #1's closed medical record revealed the facility admitted the resident on 03/11/2020 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact and interviewable. Also, per the MDS, the resident was dependent on two (2) staff assistance for toileting. A review of the Ombudsman report, dated 06/30/2020 at 6:17 PM, revealed she received a phone call from Registered Nurse (RN) #1 on 06/30/2020 stating she reported an alleged abuse incident to facility administration involving Resident #1 on 06/27/2020. Per the report, the Ombudsman called the facility to speak with Resident #1. Resident #1 told the Ombudsman that on Saturday afternoon, 06/27/2020 he/she was in his/her room when SRNA #3 walked in. Resident #1 told the Ombudsman that he/she asked SRNA #3 if she would take him/her to the bathroom. With linens in her hand, SRNA #3 told Resident #1 that she had to make someone's bed first. Resident #1 then rolled out into the hallway close to the nurses' station. She saw SRNA #1, and asked her for assistance getting to the bathroom and SRNA #1 told the resident she needed to chart before she could assist. Resident #1 stated that SRNA #3 grabbed his/her wheelchair from behind and jerked it around very fast while Resident #1 was telling SRNA #3 to leave him/her alone. Resident #1's fingers were in the wheelchair spokes when the wheelchair was turned. Per the report, Resident #1 stated his/her fingers were still very sore and swollen. Per the report, Resident #1 stated he/she was scared of SRNA #3 and was having trouble sleeping and stated he/she worried SRNA #3 was going to hurt him/her and stated, she tears my nerves all to pieces. Interview with SRNA #1, on 07/06/2020 at 1:54 PM, employed at the facility four (4) years, revealed on 06/27/2020 around 1:30 PM, Resident #1 asked SRNA #1 to pull him/her up in the wheelchair when SRNA #3 walked up and Resident #1 told SRNA #3 she had caused him/her enough grief already and did not want her help. SRNA #3 proceeded to push Resident #1's wheelchair from behind, even after being told not to and even though she didn't think SRNA #3 intended to catch Resident #1's fingers in the wheel, she went against what Resident #1 asked her not to do. She stated SRNA #3 rudely and aggressively jerked the wheel chair. She said she immediately motioned for RN #1 to come to the scene. Telephonic interview with RN #1, on 07/06/2020 at 11:09 AM, revealed she was the nurse on duty the day of the alleged incident on 06/27/2020. She said she was on the phone when she heard Resident #1 yelling. She got off the phone and observed SRNA #1 motioning for her to come to where Resident #1 and SRNA #3 were. When she got to that section of the hallway, SRNA #3 was saying to Resident #1, I'm sorry J---, I'm sorry J---, then SRNA #3 walked away. Resident #1 told RN #1 that SRNA #3 grabbed his/her wheelchair after being told not to, started pushing it, catching his/her fingers in the spokes of the wheel. Also, Resident #1 stated he/she felt threatened by SRNA #3, and this was not the first time he/she had trouble with SRNA #3. RN#1 stated she called the Director of Nursing (DON) at home to report the incident. The DON said she needed to talk to the Social Worker, then call her back. The DON called back and instructed RN #1 to have SRNA #3 clock out, leave the facility, and then file an incident report. She stated the DON did not come to the facility to conduct and investigation and did not tell RN #1 to report the incident to the State Agency. Continued interview with RN #1 revealed she did not have further conversation with the DON or Administrator until she contacted them on Monday, 06/29/2020, about reporting the incident. She revealed she read the Administrator's written report regarding the incident and did not agree with the statement that Resident #1 felt safe. Resident #1 told RN #1 she felt threatened. Additionally, RN#1 said it was very obvious the act was abusive, intentionally grabbing the wheelchair, turning it aggressively and catching the resident's fingers in the spokes of the wheelchair hurting them, after going against the resident's request to leave him/her alone. Telephonic interview with the Director of Nursing (DON) on 07/07/2020 at 12:27 PM, revealed she was called by RN #1 on 06/27/2020 around 2:00 PM to report the incident between Resident #1 and SRNA #3. She stated she recalled being told that Resident #1 was ready to go to the bathroom and SRNA #3 could not assist at the time. When SRNA #3 was ready to assist, she came up from behind the wheelchair and began backing the wheelchair up and Resident #1's hand was caught in the wheel. She stated she instructed RN #1 to have SRNA #3 clock out and leave the facility and to complete an incident report. She did not talk to RN #1 further that day regarding the incident or the other SRNA's on duty at the time of the incident. The DON stated she regarded this incident as an accident and not as abuse so she did not report the incident to the State Agency. Additionally, the DON stated the expectation was for alleged abuse to be reported immediately to facility management, within two hours of occurrence to appropriate regulatory agencies. Interview with the facility Administrator on 07/06/2020 at 3:00 PM revealed the incident happened on 06/27/2020. She did not report the incident to the Office of Inspector General (OIG) until 06/30/2020 because when she initially heard about the incident, she perceived it as an accident, not as abuse. Additional interview with the Administrator revealed when RN #1 called the Administrator on 07/29/2020 and asked why the reported incident had not been investigated and reported to regulatory agencies as per policy until RN #1 said the aggressive behavior demonstrated by SRNA #3 toward Resident #1 was abusive and the facility failed to identify the incident as an allegation of abuse; therefore, it was not reported within two (2) hours and an investigation was not immediately initiated. However, further interviews revealed the facility should have reported the incident and initiated an investigation immediately. She expected all residents to be free from abuse and that abuse or alleged abuse should be reported and investigated immediately per policy.

Based on interview, record review and review of the facility's Policy, it was determined the facility failed to ensure PRN (as needed) orders for [MEDICAL CONDITION] drugs were limited to fourteen (14) days except when extended by the physician or prescribing practitioner beyond fourteen (14) days with documented rationale in the resident's medical record for one (1) out of nineteen (19) sampled residents (Resident #157). Record Review revealed no documented evidence of duration or rationale for the use of a PRN [MEDICATION NAME] order for Resident #157. The findings include: Review of the facility's Policy, titled Medication Monitoring and Management, undated, revealed the policy is to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences. Continued review revealed, as needed (PRN) orders would include an indication for use. Per the policy, if the PRN medication is used to modify a behavior, the indication(s) for use is clearly defined in objective terms, e.g., what specific symptom(s) is being addressed. Further review revealed the resident is monitored for the effectiveness of the medication or possible adverse consequence. Results are to be documented in the resident's active record. Record review revealed the facility admitted Resident #157 on 03/27/19 with the [DIAGNOSES REDACTED]. Review of Resident #157's Admission Minimum Data Set (MDS) Assessment, dated 04/03/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), indicating moderate cognitive impairment. Review of Section N, Medications, revealed Resident #157 had received one (1) antianxiety medication during the seven (7) day look back period. Review of Resident #157's Comprehensive Care Plan, with the admission date of [DATE], revealed a Focus Area of [MEDICAL CONDITION] Medication Use related to the [DIAGNOSES REDACTED]. Continued review revealed a goal that the Psychoactive medications will not result in adverse effects with interventions to include staff should administer medications as ordered, Abnormal Involuntary Movement Scale (AIMS) per the facility's protocol, to assess for the continued need for psychoactive medications through the facility's Gradual Dose Reduction (GDR) process, to notify the Physician of complications, adverse reactions, worsening behavior issues and/or pharmacy recommendations in regards to [MEDICAL CONDITION] medications, to observe for side effects from medication use such as Headache, Dizziness, Postural [MEDICAL CONDITION], Dry Mouth, [MEDICAL CONDITION] Somnolence, Constipation, Tremors, Nausea, Falls, [MEDICAL CONDITION] and Anxiety, for Pharmacy to review medications and make recommendations and to utilize psychiatric services as needed and per the physician's orders [REDACTED].>Review of Resident #157's Physician order [REDACTED]. Review of Resident #157's Medication Administration Record [REDACTED]. Interview with the Facility's Medical Director and Resident #157's Physician, on 04/23/19 at 3:00 PM, revealed he was aware that PRN [MEDICAL CONDITION] medications should be ordered for only fourteen (14) days and if there was a need to extend the order this needs to be documented on the order to ensure compliance with the new regulations. Continued interview revealed he felt resident #157 did not need to have the medications scheduled; however, he still wanted the resident to have them as needed so he should have indicated a stop date on the order and limited the order to fourteen (14) days. Interview with Licensed Practical Nurse (LPN) #1, on 04/23/19 at 2:00 PM, revealed she was usually assigned to care for resident #157. Continued interview revealed at times, Resident #157 could become very anxious and resistive to care. Per interview, Resident #157 is often not redirectable and is combative with care. LPN #1 stated Resident #157 has received [MEDICATION NAME] several times on an as needed bases. She stated she would often times be aggressive with staff and argumentative, thinking someone stole her purse and they would not give it back to her. She stated PRN [MEDICAL CONDITION] medications should only be utilized for fourteen (14) days and if there was a need to continue the dose, the physician should be contacted to renew the script. She stated the doctor needs to be contacted to clarify the order to obtain an end date with a rational for the [MEDICATION NAME] PRN medication. Interview with the Director of Nursing (DON), on 04/23/19 at 2:30 PM, revealed it was her expectation for PRN [MEDICAL CONDITION] medications to only be utilized for fourteen (14) days and then only as needed. Continued interview revealed there should be an end date and rational for all [MEDICAL CONDITION] as needed medications; however, often times doctors are finding this difficult to do and need to be reminded by clarifying the order. Interview with the facility's Administrator, on 04/23/19 at 2:45 PM, revealed it was her expectation that PRN [MEDICAL CONDITION] medications only be utilized for fourteen (14) days. She stated when this new regulation came into place; she had a long discussion with the facility's Medical Director and their Pharmacy Consultant to ensure compliance. She stated their Medical Director often times would not write stop dates for PRN medications and staff have to catch this and get the order clarified as well as a rational. She stated this is difficult for the staff at times; however, she expects the order to be clarified if not written correctly.

Based interview, record review, and of review of the facility's Policies, it was determined the facility failed to develop a Comprehensive Plan of Care which reflected the correct code status for one (1) of fourteen (14) sampled residents (Resident #5). Resident #5 was care planned for Full Code when the resident had chosen Do Not Resuscitate (DNR) status. The findings include: Review of the facility Admission Care Plans-Temporary Policy, dated [DATE], revealed a preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission and will serve as the resident's plan of care until the comprehensive care plan was developed. Review of the facility Care Plans-Comprehensive Policy, dated [DATE], revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was to be developed for each resident, reflecting the resident's expressed wishes regarding care and treatment goals. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Further review of the medical record revealed a Do Not Resuscitate (DNR) Consent Form which was signed by Resident #5 on [DATE], co-signed by the admitting nurse on [DATE], and signed by the physician on [DATE]. Review of the Admission physician's orders [REDACTED]. Review of Resident #5's archived Admission-Temporary Care Plan, dated [DATE] included DNR (Do Not Resuscitate) code status. However, review of Resident #5's Comprehensive Care Plan, dated [DATE] entitled Advanced Directive revealed a goal stating Advanced Directives would be honored per resident/family wishes. The interventions revealed Full Code. Interview on [DATE] at 12:35 PM, with the MDS Nurse, revealed she had been the MDS Coordinator since 2014. The MDS Nurse revealed she developed residents' Comprehensive Care Plans using the MDS Resident Assessment Instrument (RAI), and the Care Area Assessments (CAA's) to care plan triggered areas. She further stated she also reviewed physician's orders [REDACTED]. Further interview with the MDS Nurse revealed she did not know why the Admission-Temporary Care Plan had the resident coded as a DNR and the Comprehensive Care Plan had the resident coded as a Full Code. She stated, I guess I just made a mistake. When asked what the consequences might have been for the resident related to having the incorrect code status on the Comprehensive Care Plan, the MDS Nurse stated, The resident might have gotten something she/he didn't wish for. Interview on [DATE] at 1:15 PM, with Licensed Practical Nurse (LPN) #2, who admitted Resident #5 to the facility, revealed she did not usually write the Admission-Temporary Care Plans for new admissions and this was done by either the Director of Nursing (DON) or the MDS Nurse. Further interview with LPN #2, revealed if a resident expired, she would check the chart specifically for physician's orders [REDACTED]. Interview with the DON, on [DATE] at 12:10 PM, revealed she or the admitting nurse completed the Admission-Temporary Care Plans and the MDS Nurse was responsible for completing the Comprehensive Care Plans. Further interview revealed she had no idea how a code status could be changed from DNR to Full Code from the Admission-Temporary Care Plan to the Comprehensive Care Plan.

Based on observation, interview, and review of the facility's policies it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as was possible for three (3) of thirty-four (34) residents bathrooms. (Bathrooms in Rooms 109, 113, and 134) Observation during initial tour on 04/14/16 revealed sharp exposed bolt anchors at the base of the toilets in Bathrooms for Rooms #109, 113, and 134. The findings include: Review of the facility's Policy titled, Homelike Environment, dated 08/01/13, revealed residents were to be provided with a safe homelike environment. Review of the facility's Policy titled, Maintenance Service, dated 08/01/13, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Further review of the policy, revealed the functions of maintenance personnel included maintaining the plumbing fixtures. Observation, during environmental tour on 04/14/16 at 10:10 AM, revealed Bathrooms in Rooms 109, 113, and 134 had sharp exposed bolt anchors at the base of the toilets. Interview, on 04/14/16 at 1:15 PM, with the Maintenance Supervisor, revealed the anchor bolts at the base of the toilet should have been cut off and/or a plastic protective cap placed over the bolts. Continued interview revealed it was important for the anchor bolts to be cut and/or capped for the safety of the residents. Interview, on 04/14/16 at 1:54 PM, with the facility Administrator, revealed it was her expectation for the facility to maintain a safe homelike environment for the residents. Continued interview revealed the toilet anchor bolts should have been cut down and/or a plastic safety cap placed over the bolts to ensure the safety of the residents and staff.

Based on observation, interview and review of the Microdot Meter Specifications, and Microdot Test Strip package Insert for blood glucose test strips (used for fingersticks to measure the amount of glucose in the blood), it was determined the facility failed to ensure proper storage of biologicals. Observation revealed bottles of glucose test strips were not dated when opened, and were not labeled with a discard date after opened. The findings include: Review of the facility's Diabetic Resident List, revealed ten (10) out of twenty (20) residents who were diagnosed with [REDACTED]. Review of the facility's Diabetes Protocol, undated, revealed no specific instructions regarding the use of blood glucose test strips other than documenting the results of the finger stick blood sugar on the Medication Administration Record [REDACTED]. Review of the Microdot Meter Specifications, revealed strip life after opening was three (3) months. Review of the Microdot Test Strip package Insert, reference dated 1989, revealed storage and handling instructions included, Do not use Microdot Test Strips more than three (3) months after the vial is first opened. Write the discard date on the vial when you first open it. Observation on 04/13/16 at 10:45 AM, revealed Licensed Practical Nurse (LPN) #1 performed a blood glucose test on a resident using a Microdot blood glucose test strip from a bottle which had been opened; however, not labeled with the date opened. Interview with LPN #1 revealed the test strip bottle should have been dated when opened and would be good for thirty (30) days after opened. Observation on 04/13/16 at 2:00 PM of Medication Storage room [ROOM NUMBER], revealed three (3) opened Microdot brand glucose test strip bottles, in a supply-carrying tray on the counter, which had been opened; however, did not have the date opened or the discard date written on the bottles. Interview on 04/14/16 at 11:00 AM with LPN #2, she had been employed at the facility for four (4) years and was assigned today to do blood glucose testing. Observation of the Medication Cart she was using, revealed three (3) bottles of Microdot blood glucose test strips in the drawer that were all dated when opened. Further observation revealed a discard date was not recorded on the bottles. Interview on 04/14/16 at 1:10 PM, with LPN #3, revealed she had been employed at the facility for one (1) year. LPN #3 revealed blood glucose test strips should be dated on the top of the bottle with the date opened; however, she was unaware of when the test strips should be discarded after the bottle was opened. LPN further revealed she knew the test strip bottles needed to be dated when opened because that was how it was done at the Nursing Home where she previously worked. Observation on 04/14/16 at 11:10 AM of Medication Storage room [ROOM NUMBER], revealed one (1) opened and undated Microdot brand glucose test strip bottle remained in the supply-carrying tray observed on 04/13/16. Interview on 04/14/16 at 11:25 AM, with the Administrator who accompanied the surveyor to Medication Storage room [ROOM NUMBER], revealed she did not know there was a discard date for glucose test strips. After review of the Microdot Test Strip package Insert, and the Microdot Meter Instruction Manual, the Administrator stated she needed to incorporate into facility policy the Microdot test strip instructions including dating bottles of test strips when opened and writing the discard date on the bottle label in the space provided. The Administrator further stated she would need to in-service all nurses on dating the glucose test strip bottles.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to store, distribute and serve food under sanitary conditions as evidenced by observation of outdated food products in the walk-in cooler and dented cans of food available for resident consumption. The findings include: 1. Review of the facility's policy titled, "Use of Leftovers", undated, revealed leftover food was to be used within seventy-two (72) hours or discarded. Observation, during the initial tour of the kitchen on 05/05/15 at 11:10 AM, of the walk-in cooler revealed food items dated 04/29/15, which included two (2) trays of Styrofoam cups of fruit and pudding snacks, and a container with five (5) hard boiled eggs. Additionally, there was a plastic container with four (4) donuts and a plastic bag with one (1) donut, which were undated, and a plastic sandwich container with a sandwich dated 04/05/15. Interview, on 05/07/15 at 10:36 AM, with the Dietary Manager revealed the facility's policy was to use or discard leftover food after seventy-two (72) hours. She revealed all food items in the walk-in cooler which were greater than seventy-two (72) hours should have been discarded prior to the observation by the Surveyor on 05/05/15. 2. Review of the facility's policy titled, "Dry Storage", undated, revealed damaged cans would be identified for removal, and stored together in the storeroom in a separate and distinct area away from other food items. Observation, on 05/06/15 at 8:55 AM, of the dry storage room revealed four dented cans which included one (1) can of vegetable soup, one (1) can of tropical fruit salad, one (1) can of apple pie filling and one (1) can of cherry pie filling, all stored on the shelves available for resident consumption. Continued interview with the Dietary Manager on 05/07/15 at 10:36 AM, revealed there was a labeled crate in the store room for dented cans to be placed in. The Dietary Manager revealed she didn't know why the dented cans were stored on the shelves, unless dietary staff had been "rushing" to put the "stock up" and just missed seeing the cans were dented.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as was possible. Observation of the soiled utility room on the Cedar Brook Hall revealed the door to the room did not remain locked and the room contained chemicals. The facility reported having fourteen (14) residents who wandered throughout the facility. The findings include: Review of the facility's policy titled, "Storage Areas, Maintenance" dated 08/01/13, revealed materials including chemical toxins that might pose a safety hazard to vulnerable residents should be monitored and/or stored safely. Observation during initial tour of the facility on 05/27/14 at 2:13 PM, revealed the soiled utility room on the Cedar Brook Hall was unlocked. Continued observation revealed the storage area of the room contained chemicals which included: Sani-Cloth with Bleach Wipes; Sani-Cloth Bleach Germicidal Disposable Wipes; a thirty-two (32) ounce bottle of Cavicide Surface Disinfectant/Decontaminate Cleaner; and a mop bucket with soiled water that contained Stride Floral SC Neutral Cleaner floor cleaner. Further observation on 05/29/14 at 9:31 AM, revealed the soiled utility room once again was unlocked and contained the same chemicals. Interview with Housekeeper #6 on 05/29/14 at 10:16 AM, revealed Stride was the chemical that was used to clean the floors and would have been in the mop bucket in the soiled utility room. Review of the facility's Materials Safety Data Sheet (MSDS) for Sani-Cloth with Bleach Wipes, revealed this product was a "Hazardous Chemical" as defined by the Occupational Safety and Health Administration (OSHA) Hazard Communication Standard, 29 CFR 1910.1200. Continued review revealed staff should wear protective eyewear when handling the product. Further review revealed, the wipes might be irritating to the eyes or skin. Review of the facility's MSDS for PDI Sani-Cloth Bleach Germicidal Wipes, revealed this product was a "Hazardous Chemical" as defined by the OSHA Hazard Communication Standard, 29 CFR 1910.1200. Continued review revealed staff should wear protective eyewear when handling the product and the product might be irritating to the eyes or skin. Review of the facility's MSDS for Cavicide Surface Disinfectant/Decontaminate Cleaner, revealed this product was a flammable liquid which contained Isopropanol Aqueous solution (alcohol). Further review revealed contact with eyes might cause reversible damage and the product might be harmful if swallowed. Review of the facility's MSDS for Stride Floral SC Neutral Cleaner, revealed this product was irritating to the eyes, mouth and skin. Interview with the Director of Nursing (DON) on 05/29/14 at 9:31 AM, revealed the door to the soiled utility room had a lock which required a push button code to access the area. The DON indicated however, the push button code lock was malfunctioning. The DON stated the door should have remained locked to protect the safety of the residents. Continued interview with the DON revealed the facility had fourteen (14) residents with a Brief Interview for Mental Status (BIMS) score of below eight (8) indicating those residents were cognitively impaired. The DON stated eight (8) of the fourteen (14) residents were mobile without staff's assistance. Interview with the Housekeeping Supervisor on 05/29/14 at 1:13 PM, revealed chemicals used to clean were her responsibility and were locked in the Housekeeping storage area of the dirty utility room. Further interview revealed chemicals should be locked for the safety of the residents. Interview with the Maintenance Director on 05/29/14 at 1:01 PM, revealed it was his responsibility to ensure the locks on the doors functioned correctly. He revealed the malfunctioning lock had not been reported to his department for repair. The Maintenance Director stated the facility's procedure was for his department to check the egress doors for the integrity of the locks and to ensure the alarms were functioning properly. Further interview revealed his department did not have a system in place to ensure the proper functioning of the locks on the interior doors. Interview with the Administrator on 05/29/14 at 10:38 AM, revealed the facility's procedure was to ensure chemicals were monitored or secured. The Administrator stated the chemicals should have been secured behind a locked door. According to the Administrator, the soiled utility room door not remaining locked was a safety risk for residents. Further interview revealed the locks were to be replaced immediately.

Based on observation, interview and review of the facility's handbook on resident's rights, it was determined the facility failed to promote care for one (1) unsampled resident (Unsampled Resident A) in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. The findings include: Review of the facility handbook, titled "Resident's Rights For Resident's in Kentucky Long Term Care Facilities", revealed the following: "Each resident shall be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs". Clinical record review revealed Unsampled Resident A was admitted by the facility on 08/27/07 with [DIAGNOSES REDACTED]. Observation, on 10/26/12 at 8:50 AM, revealed Unsampled Resident A was being transported down the hall by Certified Nursing Assistant (CNA) #1. Continued observation revealed the resident was wearing a hospital-type gown, was not covered by a sheet or blanket, and the resident's body was exposed on his/her left side. Further observation revealed CNA #1 left the resident sitting in the hallway while she left to assist another resident. Upon surveyor request, on 10/26/12 at 9:00 AM, the Director of Nursing (DON) came out of her office to observe the resident. The DON covered the resident with a blanket and stated it was inappropriate for a resident to be exposed in such a way in a public area. Interview with CNA #1, on 10/26/12 at 10:58 AM, revealed she did not notice Unsampled Resident A's skin was exposed and it did not occur to her to cover the resident with a blanket. She stated it was a dignity issue for a resident's body to be exposed in a public area.

Based on observation, interview, and review of facility policy, the facility failed to provide effective housekeeping and maintenance services necessary to ensure a sanitary, orderly, and comfortable interior. Splintered door edges were observed in six resident rooms. A door frame and wall were observed to be in need of paint and a soiled wall was observed in a resident room. Two medication carts were observed to have dried spills and pill residue. The findings include: A review of the facility's maintenance policy (dated 01/09/03) revealed that maintenance services were to be provided to all areas of the building, grounds, and equipment. A review of the task listing policy/procedure (no date given) for Certified Medication Technicians (CMTs) revealed the CMTs were responsible to clean the medication carts daily between 12:45 PM and 1:00 PM, and at the end of their shift. Observations of the facility from 08/30/11 through 09/01/11, revealed the following areas were in need of maintenance/housekeeping services: 1. Rough, splintered door edges were observed in resident rooms 110, 112, 117, 121, 131, and 134. 2. The wall in resident room 108 was observed to have an area in need of paint. 3. The door frame in resident room 121 was in need of paint. 4. The medication carts were observed to have pill residue and a dried yellow substance that had been spilled on them. An interview with the Maintenance Supervisor (MS) on 08/31/11, at 4:45 PM, revealed staff was to submit work orders to inform maintenance staff of items in need of repair. The MS stated he made occasional rounds to observe for areas requiring repair but did not make rounds on a routine or regular basis. An interview with the Charge Nurse (CN) on 09/01/11, at 10:45 AM, revealed the CMTs were required to clean the medication carts; however, the CN was unaware of a schedule for cleaning. An interview with the Certified Medication Technician (CMT) on 09/01/11, at 12:10 PM, revealed the CMT usually cleaned the carts on Sundays. The CMT also stated there was no "sign off" sheet to document when carts were cleaned. An interview with the Director of Nursing (DON) conducted on 09/01/11, at 12:20 PM, revealed nurses were supposed to monitor the CMTs to ensure carts were clean and that whoever spilled substances cleaned up their spill.

Based on observation, interview, and review of facility policy, it was determined the facility failed to label and store all drugs in accordance with currently accepted professional principles and according to manufacturer's recommendations. The facility failed to ensure Calcitonin-Salmon Nasal Spray was stored in an upright position per manufacturer's recommendations and failed to ensure two multi-dose vials were dated with the date the vials were opened. The findings include: A review of the facility's policy/procedure (no date given) regarding medication storage revealed the date opened and the initials of the first person to use the vial were to be recorded on multi-dose vials on the vial label or accessory label affixed for that purpose. The facility failed to have a policy on the proper storage of Calcitonin-Salmon Nasal Spray. 1. Observation on 09/01/11, at 10:45 AM, of the medication cart revealed a box that contained Calcitonin-Salmon Nasal Spray (used to treat osteoporosis) was stored lying down in a medication cart drawer. Further observation revealed the medication was prescribed for unsampled Resident #15. Review of the pharmacy's printed label on the medication revealed the following instructions: Refrigerate until opened, store at room temperature in an upright position. Review of the manufacturer's recommendation printed on the opened bottle of Calcitonin-Salmon Nasal Spray and on the manufacturer's insert found in the box of the nasal spray, revealed an opened bottle of Calcitonin-Salmon Nasal Spray should be stored at room temperature in an "upright" position for up to 35 days. Interview on 09/11/11, at 10:50 AM, with Certified Medication Technician (CMT) #1 revealed Calcitonin-Salmon Nasal Spray should be stored upright to prevent the medication from leaking out. The CMT stated the medication drawer was not designed to keep the nasal spray in an upright position. Interview on 09/11/11, at 10:55 AM, with the Director of Nurses (DON) revealed Calcitonin-Salmon Nasal Spray was used for the treatment of [REDACTED]. The DON stated the facility should follow the manufacturer's recommendation regarding the proper storage of the nasal spray. 2. Observations of the medication carts on 09/01/11, revealed two multi-dose vials had been opened. A 30 cc vial of normal saline and 10 cc vial of Heparin lock solution were observed to have been opened but did not have any labeling to indicate when the vials had first been opened and available for resident use. An interview with the facility's Administrator on 09/01/11, at 1:50 PM, revealed the facility's policy was for multi-use vials to be dated and initialed when first opened but the floor nurse had opened the vials and forgotten to date them. The Administrator further stated the Director of Nursing was responsible to check the carts/medication room daily but had not completed that task yet today.