Every finding on record at Signature Healthcare of Spencer County

Based on interviews, record review, and review of the facility's policies and procedures, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made for two of four sampled residents (Residents (R) 3 and R4).On 3/30/2026 at 3:32 PM, staff found R4 in R3's bed and reported the incident immediately to the Director of Nursing (DON), who was in the facility at the time of the incident. However, the incident was not reported to the Office of Inspector General (OIG) until 04/03/2026, 4 days after the incident. Review of the facility's plan of correction (POC), the facility's education records, and interviews with staff determined the facility implemented their plan of correction as alleged prior to the initiation of this survey with compliance date of 04/03/2026.The findings include:Review of the facility's policy, Resident Rights, revised 01/31/2026, revealed, All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility.Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, revised 01/31/2026, revealed, The facility Administrator is responsible for reporting all investigations' results to applicable State agencies as required by Federal and State law. Further review of the policy revealed, All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two (2) hours after the allegation is made. The policy stated, .all allegations and incidents of abuse, or neglect, as defined in this policy, will be reported 'immediately' as defined in this paragraph.Continued review of the facility's policy clearly stated the following guidelines for reporting: Any abuse allegation must be reported to State within 2 hours from the time the allegation was received.Review of the facility's investigation Initial Report, dated 03/30/2026, revealed the incident occurred on 03/30/2026 at approximately 3:32 PM and the Administrator was notified on 03/30/2026 at 3:55 PM. Continued review revealed the facility's investigation indicated the Kentucky Cabinet for Health and Family Services (DCBS), the Attorney General, and the Ombudsman were all notified on 03/30/2026; however, there were no times indicated for their notifications. The initial report also indicated neither of the residents' family members wanted to contact local law enforcement. Further review of the initial report revealed on 03/30/2026 at 3:32 PM, R4 and R3 were found by staff in R3's bed. Both residents were immediately separated and assessed by licensed nursing staff, which indicated no physical injuries, no signs of distress, no acute medical intervention was required, and no changes in baseline behavior were observed. The initial report also indicated both R3 and R4 were placed on one-to-one supervision, and an investigation was initiated. This document was signed by the Administrator.Review of the facility's investigation Five (5) Day Follow Up, dated 04/03/2026, revealed no concerns were identified after a comprehensive skin assessment had been completed on R3 and R4, there were no injuries noted, no adverse psychosocial symptoms or distress was noted after R3 and R4 were assessed for psychosocial impact, and both residents remained at baseline following the incident. The facility investigation indicated the incident as reported to DCBS and to the Office of Inspector General (OIG), but there was no date and time identified. The report further documented both residents were interviewed, but since both suffer severe cognitive impairment, they could not provide a reliable account of the incident, but neither resident reported any distress or harm, nor did they display any signs and symptoms of distress or psychosocial harm. Review of the facility's investigation summary, dated 03/30/2026, provided at the time of the survey, revealed the facility immediately separated the residents, one-to-one supervision was implemented for both R3 and R4, all staff were re-educated on abuse and the required reporting of abuse, all residents with a BIMS score above 8 were interviewed with no indications of abuse, all residents with a BIMS score of 8 or below had a comprehensive skin assessment completed, with no indications of abuse, and all staff working the date of the incident were interviewed with witness statements taken. The facility's investigation included all the staff interviews, the resident interviews, the residents' skin assessments, and a list of all employees who signed the form confirming the abuse and reporting of abuse education they received immediately following the incident. Further review of the provided facility's investigation in the Witness Statement section, revealed CNA 1 stated that she called for the nurse when she saw two (2) residents in R3's bed. CNA 1 stated she was unsure exactly what was going on, but she got the nurse. Review of LPN 1's witness statement revealed she stated she was alerted by CNA 1 to come to R3's room, and when she went in, she saw R3 and R4 both in R3's bed. LPN 1 went on to state nothing appeared to be forced or coerced, and she alerted another nurse and the DON for assistance. Per continued review of the facility's investigation all staff who provided witness statements did not see anything happening between R3 and R4, nor did anyone notice any behaviors or changes in their mood leading up to the incident.Review of the facility's, Resident Face Sheet, for R4 revealed the facility admitted R4 on 03/07/2025 with the diagnoses including generalized muscle weakness, cognitive communication deficit, depression, and mild dementia. Review of R4's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed R4's with a Brief Interview for Mental Status (BIMS) exam score of seven, which indicated severe cognitive impairment. Review of the facility's, Resident Face Sheet, for R3 revealed the facility admitted R3 on 12/15/2025 with the diagnoses including mild cognitive impairment, aphasia, dysphagia, generalized muscle weakness, and cognitive communication deficit. Review of R3's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed R3 with a Brief Interview for Mental Status (BIMS) score of one, which indicated severe cognitive impairment.Observation on 04/10/2026 at 1:13 PM revealed R3 sitting in his wheelchair outside his room, with Registered Nurse (RN) 1 who was his one-to-one supervision for that shift. Interview with R3 was attempted, but his statements were confused and not appropriate. Observation on 04/10/2026 at 1:26 PM revealed R4 sitting in her wheelchair in front of her television, with her one-to-one supervision sitting in the recliner beside her. Continued observation revealed R4 spoke to the staff person for approximately ten (10) minutes longer, but the conversation was nonsensical. An interview with CNA 1 was attempted on 04/10/2026 at 12:48 PM, with voice message left but there was no return call. An interview with LPN 1 on 04/10/2026 at 11:23 AM, on 03/30/2026 at 3:32 PM, revealed someone alerted her about R3 and R4. LPN1 stated she walked into the room and found R4 laying in R3's bed and she (LPN 1) stated she stuck her head outside R3's room and alerted the DON and asked for assistance. LPN 1 stated both residents have low BIMS scores, and both are terrible historians, and within a few minutes, neither resident was able to recall what happened, or they reported they could not remember. LPN 1 stated that neither R3 nor R4 have ever displayed any sexual acting out behaviors. She stated she reported the incident immediately to the DON. LPN 1 stated that R3 and R4 were both put on one-on-one supervision and currently are still under strict supervision.An interview with the DON on 04/10/2026 at 1:28 PM revealed she stated she was in her office on 03/30/2026 around 3:30 PM, and heard her name from one of the aides, and immediately ran out to R3's room. The DON stated she immediately notified her supervisor, the Clinical Care Consultant and the facility's Administrator, once the residents were separated. The DON stated she also notified the residents' family members as well as the physician, and new orders were implemented for one-on-one supervision for R3 and R4. When asked when notifications of this incident were required to be made, the DON stated they should be made immediately, or at least within two (2) hours of when the allegation was received. The DON stated this is important because it could possibly hinder their investigation, they could possibly receive tags from OIG, and it could lead to disciplinary action, if notifications were not made to State within two (2) hours. The DON went on to state law enforcement would also need to be contacted in some cases.An interview with the Administrator on 04/10/2026 at 3:34 PM revealed he stated he was immediately notified by the DON about the incident via telephone. He stated the DON called the Clinical Care Consultant, but he and the Clinical Care Consultant were together at a sister facility, participating in a mock survey. He stated they immediately went to the facility and assessed the residents, which was approximately 30 minutes after they were notified. The Administrator stated nursing had already started their skin assessments, resident interviews, and staff interviews when he and the Clinica Care Consultant arrived at the facility. The Administrator stated he was unaware that the Clinical Care Consultant did not notify State of incident. He stated this incident should have been reported to State within two (2) hours of the allegation being made, and there could be major consequences when that is not completed within the two (2) hours. The Administrator stated that when he and the Clinical Care Consultant were completing the Five (5) Day Follow Up for their investigation, they discovered that no notification had been made to State at that time. He stated the Clinical Care Consultant made the notification at that time, on 04/03/2026. An interview with the Clinical Care Consultant on 04/10/2026 at 3:45 PM revealed she stated she and the Administrator were at a different facility working through a mock survey when they were notified by the DON of the allegation. She stated they immediately went to the facility and started the investigation, in which residents were assessed and appeared to be fine, no distress or concerns were noted. The Clinical Care Consultant stated as they were completing the Five (5) Day Follow Up for the investigation, she and the Administrator both realized that neither of them had made the required notification to State.

The facility failed to develop a facility assessment that adequately addresses informed staffing decisions to ensure that there are sufficient number of staff with the appropriate competencies and skill sets necessary to care for its' residents needs as identified through residents assessments and plans of care. Interview on 01/23/2026 at 10:40 AM with CEO he stated the facility assessment had total number per week for nurses and nurse aides required depending on census, but did not address specific numbers required on a daily basis to determine residents care needs. Based on interview, review of facility policy, and review of the Signature Healthcare of [NAME] County Facility Assessment, it was determined the Facility Assessment failed to address all required components. The Facility Assessment failed to address the facility census in its determination of staffing needs. It also failed to consider specific staffing needs, including a breakdown of licensed nurses and nurse aides, for each resident unit in the facility and adjust as necessary based on changes to its resident population. Further, the Facility Assessment failed to consider specific staffing needs (including breakdown of licensed nurses and nurse aides) for each shift, such as day, evening, night, and adjust as necessary based on changes to its resident population for each resident in the facility. In addition, the facility failed to ensure that all required disciplines, including the Director of Nursing (DON) and direct care staff, were involved in the development of the Facility Assessment. The failure to complete a thorough Facility Assessment of staffing needs, which included all required components, had the potential to affect all residents of the facility.Findings include:Review of the facility's policy titled, Signature HealthCare of [NAME] County Facility Assessment, date assessment with Quality Assurance and Performance Improvement (QAPI) 04/15/2025, revealed the Facility Assessment was to utilize evidence-based, data-driven methods, determine what resources were necessary to care for the facility's residents competently during both day-to-day operations and emergencies. Continued review of the policy revealed the facility considers census, resident acuity, preferences, and staff competencies to determine the number and competency requirements of staff to meet each resident's needs for day, evening, and night shifts.Review of the Facility Assessment on 01/22/2026 at 1:57 PM revealed the number of licensed nurses providing direct care to be 23 (Average Full Time Equivalent [FTE]) per day for year-end [[NAME]] 2024. The number of nurse aides was determined to be 30 (Average FTE) per day [NAME] 2024. There was no documentation of the facility census used to determine staffing levels. The Facility Assessment did not outline licensed nurse and nurse aide levels for specific units, time of day, or considering weekends. No adjustments were outlined in the Facility Assessment to account for staffing needs for each resident, for each shift, and weekends to modify for the resident population.An interview on 01/23/2026 at 8:25 AM with the Staff Development Coordinator (SDC) revealed she was just learning about the Facility Assessment and how it impacted staffing for the facility. Further interview with the SDS revealed she had not participated in developing the current Facility Assessment.During an interview on 01/23/2026 at 10:20 AM with the Scheduler and Chief Executive Officer (CEO)/Administrator, the Scheduler stated she had only been in the position for a couple of months and did not participate in the Facility Assessment. During the interview, the CEO/Administrator confirmed he did not have a scheduler participate in developing the Facility Assessment.Interview on 01/23/2026 at 10:40 AM with the CEO/ Administrator revealed that when the Facility Assessment is created, it is based on facility census and number of staff required for a week. He confirmed the number of licensed nurses providing direct care was determined to be 23 for a seven-day period, explaining that this was taking into consideration where each nurse worked three days a week on a 12-hour schedule. Per the Administrator, the nurse aides were determined to require 30 in a seven-day period, with each working three days a week on a 12 hour schedule. He stated, Signature Corporate managers and myself work to develop the Facility Assessment. The Director of Nursing [DON] and other management staff are not involved in developing the Facility Assessment. The CEO/Administrator stated, The breakdown of required licensed nurses and nurse aides are posted daily at the entrance to each unit. When the Facility Assessment is developed, we do not put the unit breakdowns in the Facility Assessment. The staffing numbers (hours per resident day [HPRD]) are not included in the Facility Assessment. The CEO/Administrator added, If someone came to review the Facility Assessment and did not have accurate staffing numbers and facility census, that would not provide a true representation of our staffing needs and resident requirements based on the daily census. The CEO/Administrator added, This is something I can address with corporate to assist in making the Facility Assessment more transparent in how the Facility Assessment addresses staffing needs.

The facility failed to ensure nursing staff followed the standard of care for medication administration medications in a safe manor for one of 93 sample residents. (sample R 8).Review of R8's medication list revealed an allergy to acetaminophen, but the resident continued to receive acetaminophen in different prepared medication.Based on interview, record review, and review of facility documents and policy revealed the facility failed to ensure nursing staff followed the standard of care for medication administration medications in a safe manor for one (Resident (R) 8) of five sampled residents reviewed for unnecessary medications. R8's medication list revealed an allergy to acetaminophen; however, the residents had orders for acetaminophen in two different prepared medications.Findings included:Review of the Medication Administration Policy, revised 06/24/2025, revealed Medications are administered as prescribed in accordance with the manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. The policy stated to note any allergies or contraindications the resident may have prior to medication administration.Review of the Charge Nurse job description, dated 03/2021, revealed that the responsibility of this role was to ensure compliance with all written policies and procedures established by the facility and to verify that all nursing personnel work in compliance with the procedures outlined in the Nursing Policies and Procedures Manual.Review of the procedural resource manual used by nursing staff titled [NAME] and [NAME] Clinical Nursing Skills and Technique, 10th Edition, printed in 2022, Chapter 21.1 titled Administering Oral Medications revealed that the nursing assessment included clarification of incomplete or unclear orders before administration of any medication. The nurse was expected to assess the patient's medical and medication history and the history of allergies. It also revealed that when allergies are present, the resident should wear an allergy bracelet. Per the manual, the nurse was expected to ask the patient to describe allergies and any allergic reactions. Chapter 21.1, titled Implementation, revealed that the nurse was directed to follow the seven rights of medication administration. The seven rights referenced were the right medication, dose, route, time, client, documentation, and reason.Review of R8's Face Sheet revealed he was admitted on [DATE] with multiple co-morbidities, including acute and chronic kidney failure, heart failure, history of pulmonary embolism, and a history of falls. It also revealed a documented allergy to hydrocodone and acetaminophen that would result in a rash.Review of R8's 01/21/2026 Medication Administration Record (MAR) listed an allergy to hydrocodone - acetaminophen. Further review of R8's MAR revealed the resident was currently prescribed oxycodone (Percocet - an opioid which also contains acetaminophen), five milligrams (mg) every six hours, by mouth, as needed for pain (PRN), as well as acetaminophen 650mg every four hours by mouth, PRN.During an interview on 01/22/2026 at 09:25 AM with the Nurse Practitioner (NP), she stated that when it was ordered on the computer, it presented a drop-down box to denote the severity of the allergy. She stated she felt R8 had a sensitivity to hydrocodone but not the acetaminophen and believed it may have been more of an intolerance versus a true allergy, adding that Oxycodone was ordered in the place of the hydrocodone. She added that if a resident received a medication to which they were truly allergic, it could lead to a reaction as severe as anaphylaxis that could be life-threatening.During an interview on 01/23/2026 at 09:20 AM, the Registered Pharmacist (RPh) from the facility's contracted pharmacy, stated that there was a sensitivity listed to hydrocodone and acetaminophen, but it was not specific as to what the sensitivity was. The RPh indicated the resident was previously prescribed Lortab (hydrocodone and acetaminophen) The RPh added that the record was not specific as to which (or both) of the two medications the resident was sensitive to. He stated that hydrocodone was not automatically linked to acetaminophen, as it could be prescribed with ibuprofen or alone. Therefore, it could be listed as an allergy, separate from the acetaminophen, but it could not be prescribed separately by a Nurse Practitioner (NP). The RPh then stated he had no record of clarification for this sensitivity. Since it was not clarified which drug was the concern, and if the Lortab was flagged as a sensitivity, the acetaminophen would have flagged each time any prescription was given that contained that contained that drug, such as in R8's current prescriptions of Percocet or Tylenol that were currently prescribed. The RPh had no explanation as to why this information was not part of the pharmacy record. He stated that if the resident had a true allergy to any medication prescribed, it could result in mild to severe reactions, including death.During an interview on 01/23/2026 at 11:07 AM with the Director of Nursing (DON), she stated that when a drug is listed as an allergy, the pharmacy system will flag it so that it draws attention to the pharmacy, indicating that the Nurse Practitioner (NP) should reassess the order. The DON revealed her expectation that the nurses who administered medications would review the allergy list before administering a medication and follow up with the pharmacy and NP to clarify the order. She would expect this to be documented. She stated that it was the nurse's responsibility to review, question, and follow up on any medication concerns before administering any medications. Further interview with the DON revealed that administering a medication to which a resident was allergic, depending on severity, could result in an anaphylactic response.During an interview with the Administrator on 01/23/2026 at 12:37 PM, he stated that he expected the clinical staff to follow all policies related to medication administration and to work according to their job descriptions. He stated he had worked as a medication technician in the past and was familiar with the five rights of medication administration, which included the right patient, drug, dose, route, and time. He added that, depending on the severity of the allergy, it could be an intolerance or a true allergy that could result in the death of the resident. He expected the nurses administering the medications would question the order and follow up appropriately, as well as document it in the record.

The facility failed to develop and implement a comprehensive care plan for each resident, which includes measurable objectives and time frames to meet a resident's medical nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. This includes revisions as necessary with changes to create a person-centered care plan for each resident for two (2) of 93 sampled residents. (sampled residents 8, and 74.Review of the care plan for Resident (R) 8 did not match the most current orders or needs of the residents. Observation on 01/21/2026 of the R8's room and property revealed R8's wheelchair was without an anti-tipping device, and there were no non-skid strips on the floor and the resident's bed had two (2) half rails used for mobility, the order was for the right side only.Review of the care plan for R74 revealed no history of PTSD nor specific triggers for adverse behaviors, although it was commonly known.Based on observation, interview, record review, and review of the facility's policy, the facility failed to revise the comprehensive care plan as necessary with changes to create a person-centered care plan for two (Resident (R) 8 and R74) of 20 sampled residents. R8's care plan was not revised to reflect current orders for one half rail used for mobility. R74's care plan was not revised when the facility became aware of a diagnosis of post-traumatic stress disorder (PTSD) and failed to address specific triggers for adverse behaviors which were known to the facility.Findings included:Review of the policy titled Comprehensive Care Plans (CCP), last revision dated 02/09/2024, revealed the comprehensive care plan will be revised as necessary with changes.1. Review of R8's Face Sheet revealed he was admitted on [DATE] with diagnoses that included mild dementia, arthritis of his right knee, and a history of falls. Review of R8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/2025 revealed the resident was identified at risk for falls and care planned for this area.Review of R8's orders revealed an order created on 01/12/2026 for the resident's bed to be against the wall. In addition, an order for a mobility bar on the right side only of the resident's bed was also created on 01/12/2026.Review of R8's most recent Care Plan (CP), effective through 01/22/2026, revealed R8 had a risk of falls with multiple interventions listed. Review of the CP revealed that it did not indicate the use of mobility bars while in bed. The CP was not revised to reflect the 0/12/2026 order for a mobility bar only on the right side of the resident's bed.Observation on 01/20/2026 at 1:44 PM, during the initial observation of R8's room, revealed R8 was in his bed with half-sized rails on each side of his bed.During an interview on 01/22/2026 at 8:58 AM with Registered Nurse (RN) MDS1, she stated that the computer kept a historical record of all interventions. She confirmed the hard copy provided to the State Survey Agency (SSA) was the most recent and captured only current and active interventions. She added that all clinical staff had access to the care plan in some form.During an interview on 01/23/2026 at 10:21 AM with Licensed Practical Nurse (LPN) MDS2, she stated that she had worked in this role for less than two years. She participated in the quarterly and annual MDS reviews and knew that if a resident had a new order, a care plan update was necessary. During an interview on 01/23/2026 at 1:23 PM with RN MDS1, she stated that she was involved in an interdisciplinary team (IDT) meeting every morning, which included department heads from each discipline. They discussed concerns, and if new orders had been obtained, a nurse would ensure the order was in, and she would make sure the CP reflected the change.During an interview on 01/23/2026 at 11:07 AM with the Director of Nurses (DON), she stated that CPs were created at the time of admission and that if there are areas of concern that had not been captured already, they would be discussed during the IDT meeting the next working day. The DON stated, Updating the CP is the responsibility of the MDS/CP Nurses, but we all review this and can make corrections. Further interview with the DON revealed she was not sure why the care plan was not updated.During an interview on 01/23/2026 at 12:37 PM with the Administrator, he stated that he expected the CP to be followed and reviewed for accuracy. 2. Review of the Face Sheet for R74 revealed he was admitted on [DATE] with diagnoses that included psychotic disorder with delusions, major depressive disorder, vascular dementia with unspecified severity and mood disturbance, psychotic disorder with hallucinations, cognitive communication deficit, and anxiety. He had an appointed State Guardian and a sister who were listed as contacts. Review of R74's admission paperwork, dated 06/12/2023, revealed no identified military history or history of trauma.Review of a [NAME] Healthcare Psychiatric consult note, dated 05/27/2025, revealed R74 has a previous diagnosis of PTSD related to the Vietnam War in 1965, for which he received outpatient treatment and medications. This record was provided to SSA by the RN MDS1 nurse. Further review of R74's record revealed that this was the first time that a PTSD diagnosis was noted.Review of R74's CP, with the last dated conference on 12/01/2025, revealed an identified behavioral problem and listed the etiology of vascular dementia, anxiety, and hallucinations. As of 07/25/2023, behavior was identified as a problem; however, there was no evidence it was revised to reflect the resident's diagnosis of PTSD and was not specific to reported agitation or outbursts that could be associated with PTSD, such as loud sudden noises, or violent movies with gunfire.During an interview on 01/22/2026 at 3:04 PM with R74's State Guardian, she stated she had heard R74 was a veteran but had never observed the official paperwork. She approved contact with the resident's family. Interview on 01/22/2026 at 3:21 PM with R74's family member (FM74) confirmed the resident had been in the Air Force for about three years but could not elaborate on how it affected him.During an interview on 01/23/2025 at 1:23 PM with RN MDS1, she stated that she was made aware of R74's PTSD history in review of the 05/27/2025 psychiatric consult note. She also stated that he had known triggers such as loud, sudden noises, and in review of the current care plan, she confirmed that it was not specific to that diagnosis or concern. She stated that not making sure that everyone had access to this information in a care plan could cause an increase in his behavior, worsen his psychological condition, and cause the resident distress. She stated the care plan needed to be specific to the needs of this resident.During an interview on 01/23/2026 at 08:50 AM with the Activity Director (AD), she stated she was aware that he did not like sudden noises and war-type movies and that she avoided those with him. She stated that this was common knowledge with the staff, but that she did not recall seeing anything specific to PTSD on his care plan. She added that the care plan is the way the staff is made aware of specific care needs. Not having that information could mean that the residents may not get everything they need.During an interview on 01/23/2026 at 11:07 AM with the DON, she stated she had observed an incident of increased stress with a movie that was on television, and now that they are aware that it could cause him distress, they no longer put him in that situation. She stated that now everyone just knows, through word of mouth and shared during huddle meetings. She stated that when an area is identified, the care plan is usually updated by the CP/MDS nurse or herself. She could not explain how this was omitted.During an interview on 01/23/2026 at 12:37 PM with the Administrator, he stated that the CP/ MDS nurses and the clinical management team reviewed care plans in the IDT meetings daily. The Administrator stated that the CP should have reflected this, and it was the responsibility of the clinical management team to make sure it was correct, specifically the DON and CP/MDS Nurses. He stated that with loud noises, the resident has exhibited more manic type behaviors, adding that not having this information updated on the CP had the potential to cause unnecessary distress to the resident.

Observation on 1/21/2026 revealed staff entering a resident's room to deliver food trays. The trays were uncovered and then left while personal care was provided to a resident who was on Enhanced Barrier Precautions. No Protective Personal Equipment was observed in use for two of 93 sampled residents. (Sampled Resident 11, 27).Observation on 1/21/2026 revealed that staff obtained a finger stick blood sugar and brought the dirty machine to the cart, laying it on the cart without a barrier. The nurse wiped the machine with a Clorox wipe, one time, and did not leave it wet according to the facility policy or manufacturer's recommendation. One of 93 sampled Residents (sampled Resident 102) Based on observation, interview, and review of manufacturer's instructions and facility policy, the facility failed to maintain an infection prevention (IP) program designed to help prevent and manage the transmission of diseases and infections for two (Resident (R) 11 and R102) of 20 sampled residents, as well as one supplemental resident (R27.) Staff failed to thoroughly cleanse and disinfect a soiled glucometer in accordance with facility policy and manufacturer's instructions. In addition, staff failed to utilize personal protective equipment (PPE) as required when providing care to a resident on Enhanced Barrier Precautions (EBP).Findings include:Review of the Infection Control (IP) Policy, last revised 01/31/2025, revealed that the facility's Infection Control Policy and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infection.1. Review of the Glucometer Cleaning and Disinfecting Policy, revised 01/24/2024 and reviewed on 01/15/2026, revealed licensed staff were expected to follow the manufacturer's guidelines and recommendations for the cleaning and disinfecting of the glucose monitoring machine.Review of the Assure Platinum Glucometer Cleaning and Disinfecting Competency, dated 02/01/2024, revealed that after cleaning, the glucometer should stay wet from the approved cleaning product for three minutes.Review of the Clorox Healthcare Germicidal Wipes label revealed the recommendation for effective cleaning related to Candida Auris, Clostridium Difficile, and Mycobacterium Bovis; any hard surface cleaned should remain wet for three minutes. For Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV), any hard surface must remain wet for one minute.Observation on 01/21/2026 at 11:03 AM revealed Registered Nurse (RN) 5 used an Assure Platinum brand glucometer to perform glucose monitoring for R102. After performing the test, the nurse placed the soiled glucose monitor on the 400-hall medication cart, without a barrier. RN5 then cleaned the machine with an approved Clorox wipe. She wiped (wet) the machine with a single motion for nine seconds. RN5 then laid the glucometer on a clean paper towel to dry before she returned it to the drawer in the resident's room. RN5 did not use a timer to ensure that the minimum wet (dwell) time necessary for disinfection was met. During an immediate interview with RN5, she stated that the old rule was to leave the machine wet with the cleaning solution for three minutes, but now it was only for one minute, and that it would take at least one minute for the wet surface to dry. She stated she received this training from the new RN Staff Development Coordinator/Infection Preventionist (SDC/IP, RN)2. She emphasized the importance of cleaning the monitor between users, as per the policy, to prevent the spread of germs that could make the resident ill.During an interview on 01/22/2026 at 10:04 AM with SDC/IP1, she stated that the facility had a mandatory skills fair every year for all clinical staff, using handouts, videos, and in-person educational methods. She stated that there had recently been some confusion due to directions for multiple types of glucometers being used in the facility. Directions for the Assure model (observed in use on 01/21/2026 at 11:03 AM), as well as the Even Care model required three minutes of continuous wet surface. However, the newer Freestyle model required only one minute. The wet time required active wiping for the duration of the instructed time. She stated that the facility would be recognizing the previous three-minute wet time and provided signed copies of the updated training that was provided on 01/21/2026 to clinical staff (after surveyor intervention). She stated that each cart has a timer for the nurse to reference (to ensure that the minimum wet time is met). She also stated that each resident had their own glucometer in their rooms, and a dirty machine should not have to come out of the room. However, if a soiled glucometer was cleaned at the medication cart, she expected that before it was placed on the cart, a barrier would be put in place, and a new barrier would be used for a cleaned glucometer. She added it was important to follow the policy and manufacturer recommendations of the machine and cleaning solutions to decrease the risk of cross-contamination and potential illness to the resident.During an interview on 01/23/2026 at 11:07 AM with the Director of Nursing (DON), she stated that she expected that the infection control policy would be followed, adding that when it is not followed, it places the residents and staff at risk of spreading germs and causing illness. Regarding the glucose monitors, she added that residents were provided with glucose monitors in their rooms, and a barrier should be used regardless of where the machine was placed, using a clean barrier with a clean machine. She stated there had been some confusion about the amount of time the machines should remain wet because various models were used which had differing manufacturers' recommendations. Further interview with the DON revealed that the facility would be going back to the three-minute wet time process. During an interview on 01/23/2026 at 12:37 PM with the Administrator, he stated he expected that the IP policy would be followed. He stated that he was aware that not following the precautions could allow germs to spread and cause illness.2. Review of the Enhanced Barrier Precautions (EBP) Policy, last revised on 03/25/2024, revealed EBP was indicated for residents who have indwelling medical devices, regardless of negative Multi-Drug-Resistant Organism (MDRO) status. Per the policy titled Enhanced Barrier Precautions, last reviewed 01/31/2025, signage on the resident's door is used to advise staff and visitors of the need for and type of PPE.Observation on 01/21/2026 at 1:12 PM revealed a sign on the door to R11 and R27's shared room, noting that the resident in Bed A (R11) was on EBP. Observation of the sign revealed instructions for the use of a gown and gloves for contact with the affected resident. PPE supplies were located outside the door in a plastic container. At this time, observation revealed State Registered Nurse Aide (SRNA)1 and SRNA2 entered the room to distribute lunch trays to the two roommates, both of whom required feeding assistance. Further observation revealed that both staff failed to don gloves or gowns prior to entering the room with food trays. The staff next removed the plate lids and uncovered the food, then pulled the curtain for Bed A and closed the door. The survey team knocked and entered the room, as the staff remained behind the curtain and called out Patient care. When the staff finished and exited the enclosure, they went to the sink to wash their hands. The staff were not wearing PPE (gloves and gowns), and none was observed in the trash upon exit. As staff attempted to wash their hands, no paper towels were readily available. Immediate interview at this time with both SRNA1 and SRNA2 revealed that the food plates should have remained covered due to the potential for germ exposure, as well as possible food temperature loss. During a follow-up interview on 1/21/2026 at 2:14 PM, SRNA1 stated that her understanding of EBP was that anytime a staff member has contact with a resident, Personal Protective Equipment [PPE] should be worn. She stated that the resident care that was provided was to pull the resident up in bed for his meal. She acknowledged that the action constituted resident contact, and the appropriate PPE should have been worn. She added, I should have known better. SRNA1 stated that she had received infection control education from SDC/IP1. She understood the reason R11 was on EBP was that he had a gastric tube (g-tube), and it was possible to introduce germs to this resident or he to her without the appropriate PPE. An introduction of germs could increase the risk of illness for either party.During a follow-up interview on 01/21/2026 at 2:17 PM with SRNA2, she stated that the reason PPE was to be worn was to prevent tube-feeding and/or germs from getting on her or the resident. She confirmed previous education from SDC/IP1 and stated she was aware of the sign which related the need for PPE. SRNA2 initially stated that PPE was used. SRNA2 then stated that they were only repositioning the resident in bed. When informed that observation revealed that the SRNAs had not used PPE, SRNA2 did not say anything more.During an interview on 01/22/2026 at 10:04 AM with SDC/IP1, she stated that residents who were on EBP were those who had wounds or indwelling equipment such as gastric tubes. Supplies were kept outside of the resident's room in a plastic bin and were available in the supply room as well. She expected that staff would follow the infection control policy regarding the use of PPE. She also stated that resident food should not be exposed and should have remained covered until it was ready to be eaten, especially if there was resident care, due to the increased risk of germ exposure, which could potentially cause illness.During an interview on 01/23/2026 at 11:07 AM with the DON, she stated that she expected that the infection control policy would be followed, adding that when it is not followed, it places the residents and staff at risk of spreading germs and causing illness. She stated that the resident's EBP status required staff to wear the appropriate PPE anytime there was physical contact with a resident, including being pulled up in bed. She added that supplies were readily available outside the door.During an interview on 01/23/2026 at 12:37 PM with the Administrator, he stated he expected that the IP policy would be followed. He stated that he was aware that not following the precautions could allow germs to spread and cause illness.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow the Legionella Water Management Plan. Additionally, laundry staff were observed on 08/01/2024 to fold linen which touched the laundry room floor and the laundry worker's body. A contractor was observed, on 07/30/2024, cleaning the inside of a fish tank with bare hands, then carrying a bucket into the kitchen to obtain water while meal trays were being prepared. The findings include: Review of facility policy Infection Control, dated 01/23/2024, revealed the facility infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Further review revealed facility infection control polices and procedures applied equally to all personnel, consultants, and contractors. 1. Review of facility policy Legionella Water Management Plan, dated 01/26/2024, revealed the facility had identified areas where Legionella could grow and Spread to include the Unit Two (2) ice machine. Further review revealed the control measures and monitoring included weekly and monthly testing. However, there was no evidence the Unit Two ice machine had been monitored between 01/05/2024 and 07/06/2024. Review of facility policy Water Management Program, dated 07/24/2024, revealed the facility identified areas where biofilms might be present and areas where opportunistic pathogens of premise plumbing might grow and spread to include ice machines. Further review revealed the facility had identified residents that were immunocompromised, at-risk, taking drugs that weaken the immune system, had renal disease, had diabetes, or had chronic lung disease in the facility. Continued review revealed the facility assessed the need to operate ice machines solenoid valves to check hammer arrester monthly and replace as needed. Additionally, the facility assessed the need to clean and disinfect the ice machines no less than quarterly. However, there was no evidence the facility assessed the Unit Two (2) ice machine between 01/05/2024 and 07/06/2024. During an interview with the Plant Operation Director (POD), on 08/02/2024 at 4:00 PM, he stated he checked all required areas for Legionella either weekly or monthly and documents on the checklist. However, he was unable to provide any evidence on his weekly or monthly checklists that he checked the Unit Two ice machine. He further stated it was important to monitor water sources identified by the facility as areas where biofilms might be present because biofilms could cause residents to become sick. During an interview with the Administrator, on 08/02/2024 at 5:55 PM, she stated she expected all staff to follow the facility's policies and procedures. She further stated if the policies and procedures for checking water were not followed, it could lead to bacteria in the water and residents could get sick. 2. Review of the job description for Laundry Worker, undated, revealed the laundry worker performed laundry activities within well established guidelines to ensure that quality standards, safety guidelines and customer service expectations were met. Further review revealed an essential function of the job was to follow infection control and universal precautions policies and procedures to ensure that a sanitary environment was maintained at all times. Observation, on 08/01/2024 at 3:30 PM, revealed Laundry Worker #1 (LW1), folding a sheet by holding it in the air and folding it. Further observation revealed the edge of the sheet touched the laundry room floor and LW1's body while folding the sheet. During an interview with the Environmental Services Director (ESD), on 08/02/2024 at 3:45 PM, she stated laundry staff should utilize the folding table to fold linens and it was not appropriate to allow the linens to touch the floor or a worker's body while folding the linen. She further stated the floor could have dirt or bacteria on it which could cause bacteria to get on the linen, allowing it to be transferred to a resident and potentially making them sick. She continued to state laundry workers did not typically change clothes throughout the shift and could have bacteria from another room or resident on their clothing, which could transfer to the linen. During an interview with the Administrator, on 08/02/2024 at 5:55 PM, she stated she expected all staff, including contractors, to follow the facility's policies and procedures. She further stated if the policies and procedures for proper laundering were not followed, it could lead to bacteria getting on the linens, transferring to residents, and potentially causing the residents to become ill. 3. Observation, on 07/30/2024 at 12:40 PM, revealed a person contracted by the facility to maintain the facility's fish tank, used a cloth and no gloves to clean the inside of the fish tank, then entered the kitchen with a bucket to obtain water. Further observation revealed he did not wash his hands or put on a hair net when entering the kitchen. Continued observation revealed the kitchen was preparing meal trays for facility residents and he walked by a food cart containing resident trays. However, he exited the facility prior to being able to obtain an interview. During an interview with the Administrator, on 08/02/2024 at 5:55 PM, she stated contracted staff were given education on facility Infection Control Policies and Procedures. However, she stated the facility had not provided education to the contracted persons who maintained the fish tank. She further stated they should have been educated on infection control to prevent the spread of germs from the fish tank to the kitchen. She continued to state he should have used a different water source and not entered the kitchen to fill the water bucket.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to prepare, distribute, and serve food in a sanitary manner and in accordance with professional standards for food service safety. Dietary staff failed to wash hands and wear gloves prior to cooking resident foods and checking food temperatures on the steam table during the lunch meal on 07/30/2024. A cook, who was crying, was observed to stand at the tray line for approximately five minutes with no face covering and a contract staff member, who was not wearing a hair net, walked through the kitchen three times by the food cart which was being filled with resident food trays. The findings include: Review of the facility's policy titled Food: Preparation revised 02/2023, revealed all foods were prepared in accordance with the Food and Drug Administration (FDA) Food Code. Per the policy, all staff would practice proper hand washing techniques and glove use and the staff would be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Observation on 07/30/2024 at 11:55 AM in kitchen revealed [NAME] 1 was at the tray line and began plating foods for the lunch meal. [NAME] 1 informed the District Dietary Manager (DDM), that he did not have mashed potatoes prepared yet. The DDM, without first washing her hands, went to the back of the kitchen, brought back a kettle of water and placed it on the stove to boil. She also brought out a plastic bag of potato flakes. The tray line was held up while waiting on the mashed potatoes to be cooked. Continued observation revealed the DDM poured the potato flakes from the bag into the container that she had pulled from steam table and added boiling water, stirred, and placed the mashed potatoes onto the steam table. All tasks were completed without handwashing or gloves. After mixing the potatoes with the boiling water, the DDM checked the temperature of the potatoes. Continued observation at the steam table revealed [NAME] 1 started to cry while standing in front of the tray line while serving food. He had no mask covering his mouth or tears on his face. After approximately five minutes, another staff member came and relieved him. On 07/30/2024 at 12:15 PM, after some resident meals had been plated, the surveyor requested the food temperatures for the foods on the steam table for the lunch meal. The DDM was unable to find or provide the food temperatures. The DDM, without wearing gloves, proceeded to check the food temperatures for the foods on the steam table. Observation on 07/30/2024 at 12:40 PM in the kitchen revealed a contract staff member who services the fish tank entered the kitchen without wearing a hair net. The contact staff was carrying a five-gallon bucket and he passed by a resident food cart which was currently being filled with foods from the tray line. He was noted to fill the bucket in the washroom area of the kitchen three times and take the bucket of water out of the kitchen. Further observation revealed he was noted to be filling the fish tank. An attempt to interview the contract staff was unsuccessful as the contract staff had already left the facility. Interview on 08/02/2024 at 3:45 PM, with the DDM, revealed the facility's dietary manager was responsible for oversight to ensure that staff were wearing appropriate personal protective equipment (PPE) and abiding by guidelines to ensure appropriate food service to residents. Per the DDM, the dietary manager had quit on Sunday prior to the survey and the DDM was currently filling in. She further stated she was in the facility last month but had not been to the facility until 07/30/2024 upon arrival of SSA. Per the DDM, she expected staff to follow the food handling guidelines to ensure safety of food served to residents. She further stated hand washing should be completed anytime a staff member stepped away from the steam table while serving or touched anything else not directly on the steam table. She further stated if appropriate guidelines were not followed the resident goals for nutrition would not be met and could cause an adverse effect to the resident. Interview on 08/02/2024 at 5:55 PM, with the Administrator, revealed she expected the kitchen supervisory staff to educate all the food service staff on sanitation, and handwashing policy and procedures. She stated she expected the Dietary Manager to ensure all the kitchen staff followed the facility's and food code policy and to maintain a clean and sanitary kitchen environment. She further stated the facility has a contract with the fish tank cleaning company and he comes monthly to clean the fish tank. She stated she was not aware he had been utilizing the kitchen area to fill the buckets to refill the fish tank. 50828

Based on observation, interview and review of facility policy, the facility failed to ensure that safe drinking water was available when there was a loss of normal water supply for all residents. The census was 89 residents. The findings include: Review of the Dietary Services Agreement dated [DATE], revealed the contracted company was responsible for following state guidelines, for maintaining an adequate supply of emergency water. Review of the contracted company policy titled Guidelines for Water, not dated, revealed the contract company was to establish a contract with a local vendor to supply bottled water. The inventory guide revealed for non-potable water the amount was to be one gallon per person per day. Observation on [DATE] at 4:20 PM of the facility's emergency water supply revealed the emergency potable water was stored in an approximate 10 foot by 10 foot metal storage building located outside to the back of the facility. The storage building did not have a locking device and floor of the building was a dirt floor covered with gravel. Observation inside the storage building revealed numerous boxes of plastic gallon jugs of water. The boxes of water were sitting on the gravel/dirt flooring of the building. The cardboard boxes were torn open, not intact, with gallon jugs of water lying in different areas of the building, and partially covered with a tarp. The water was not expired; however, there was no heating or cooling device noted to control the temperature of the building. Interview on [DATE] at 9:00 AM with the Maintenance Director revealed the contract company for the kitchen was responsible for provision of non-potable water. He further stated he was not responsible for anything to do with the non-potable water. The Maintenance Director stated he only knew the water had always been stored in the outside building. Interview on [DATE] at 5:55 PM with the Administrator revealed the emergency water was provided by the contracted dietary company but the facility was responsible for the storage of the water. The water should have been in a temperature controlled environment due to the potential for harm of the plastic being to hot or cold which could contaminate the drinking water. 49360

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure the resident environment remained free of accident hazards. On 07/30/2024, chemical products were noted underneath the sink of two bathrooms located near the back nurse's station. Additionally, the doors to both bathrooms were noted to be open with eight residents sitting in wheelchairs near the bathrooms and other residents walking near the bathrooms. The findings include: The facility did not produce an Accident/Supervision Policy upon request from the Administrator on 08/02/2024 10:54 AM . Review of the facility's Resident Rights Policy, revised 09/15/2023, revealed it was the facility's policy all residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Observation, on 07/30/2024 at 9:05 AM, revealed two public bathrooms near the back nurse's station with open doors. Further observation revealed chemical products underneath the sinks of both bathrooms. These products included Dermafungal cream, Hydrogel wound gel, and Disinfectant Wipes. Further observation revealed eight residents sitting in wheelchairs near the bathrooms and other residents walking near the bathrooms. No staff were observed at the nursing station. Review of the Safety Data Sheet (SDS) for the Dermafungal cream, issued 08/18/2014, revealed health hazards could occur including irritation if the product was placed in the eyes or ingested. Further review revealed an emergency and first aid procedure to flush eyes with water for 15 minutes; if ingested, drink large amounts of water and notify the physician. Review of the SDS for the Hydrogel wound gel, issued 08/18/2014, revealed health hazards could occur including irritation if the product was placed in the eyes or ingested. Further review revealed an emergency and first aid procedure to flush eyes with water. Interview with the Administrator, on 08/02/2024 at 10:54 AM, revealed the facility was unable to provide SDS sheets as an exact match for the disinfectant wipes. Review of the disinfectant wipes, located on the store website, effective date of 07/21/2020, revealed a hazard statement that it may cause an allergic skin reaction. Further review revealed if on skin, wash with plenty of water; if skin irritation or rash occurs, get medical advice/attention; wash contaminated clothing before reuse; contaminated work clothing must not be allowed out of the workplace, dispose of contents/container to hazardous or special waste collection point, in accordance with local, regional, national, and/or international regulation. Continued review revealed first aid measures after skin contact to remove affected clothing and wash all exposed skin area with mild soap and water, followed by warm water rinse; if skin irritation or rash occur, rinse skin with water/shower; get medical advice if skin irritation persists. Additionally, after eye contact, rinse eyes with water as a precaution; if eye irritation persists, get medical advice/attention. Further review revealed first aid measures after ingestion were to rinse mouth, do not induce vomiting, if feeling unwell, seek medical advice. During an interview with the Environmental Services Director (ESD), on 08/02/2024, at 3:45 PM, she stated housekeeping sometimes checks under the common bathroom sinks, probably once every two weeks, and if chemicals are present, they should be poured out and thrown away because they would be harmful and could kill a resident. She further stated her department is not responsible for any creams, lotions or disinfectant wipes. During an interview with the Administrator, on 08/02/2024 at 5:55 PM, she stated the facility should have SDS for all chemicals in the building. She further stated the chemicals found under the sinks were not products that should be stored there and must have been left by staff members in the common bathrooms. She continued to state the chemicals could be hazardous to residents including making them sick or causing death.

Based on observation, interview, and facility policy review, the facility failed to ensure the facility was free of pest in for four of 34 sampled residents (Resident [R]11, R29, R44, and R67). The findings include: Review of the facility's policy, titled Pest Control, undated, revealed the facility would establish a program for the control of insects and rodents and all areas would be monitored regularly for any signs of pest/vermin. Observation during initial facility rounds on 07/30/2024 at 10:50 AM, in the room shared by R29 and R44 and in R67's room revealed multiple gnats flying around in the room. Continued observation during facility rounds on 07/30/2024 at 11:01 AM revealed R29 and R44's room shared a bathroom with R67 and there were multiple gnats flying in the bathroom. Observation of Resident (R)11's room on 07/31/2024 at 9:18 AM revealed one gnat flying around the breakfast tray while R11 was attempting to eat breakfast. Observation of R29 and R44's room, R67's room and the shared bathroom between the rooms on 07/31/2024 at 11:36 AM and on 08/01/2024 at 2:56 PM revealed gnats still in the room. During an interview with Licensed Practical Nurse (LPN)3 on 07/31/2024 at 8:52 AM, she stated the gnat issue had been bad in the past. LPN3 stated the pest company came and sprayed in resident rooms, but the gnats kept coming back into resident rooms. During an interview with the Social Services Director (SSD) on 08/02/2024 at 3:19 PM, she stated the department heads did ambassador rounds daily in resident rooms. The SSD stated the ambassador rounds covered things such as foul odors, clean rooms, and checking for ice in water. The SSD stated she saw gnats every once in a while, but it was due to residents leaving food items opened and not in a sealed container. During an interview with the Environmental Services Director (ESD) on 08/02/2024 at 3:45 PM, stated she saw gnats every now and then but did not consider it to be a major issue. The ESD stated the housekeepers used a product called Finito, which was sprayed daily to prevent gnats and flies from being in the facility. During an interview with the Plant Operation Director (POD) on 08/02/2024 at 4:00 PM, he stated gnats and flies have been issues. The POD stated he had seen gnats and flies in the facility over the past week and had notified the pest company to come and spray the facility. The POD stated the spray Finito should kill gnats and flies, but stated the residents kept opened food in the facility, which drew gnats and flies to those areas. The POD stated he would not want gnats to be flying around resident's food during meals. During an interview with the Director of Nursing (DON) on 08/02/2024 at 5:24 PM, she stated she expected the residents to have a homelike environment, which meant no gnats or flies in the facility. The DON stated she did not expect to see gnats and flies in the facility. During an interview with the Administrator on 08/02/2024 at 5:53 PM, she stated she expected all rooms to be comfortable and homelike for all residents in her facility. The Administrator stated gnats and flies had been seen some this week.

Based on interview, record review and facility policy review it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted, maintained or enhanceed his or her quality of life, recognizing each resident's individuality for one of 34 sampled residents (Resident (R) 13). The facility must protect and promote the rights of the resident. The findings include: Review of R13's Admission Record revealed the facility admitted the resident on 05/13/2024 with diagnoses including cervical disc disorder with myelopathy, quadriplegia, and cervical fusion. Review of R13's Admission Miminum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of fourteen of fifteen, which indicated R13 was cognitively intact. Review of R13's Baseline Care Plan completed on 05/13/2024 revealed a communication goal for R13 that communication with staff would be understood. Triggers for the need for communication assistance indicated the Resident's communication was not understood and Resident was hearing impaired. Desired approaches for the goal included a communication board, interpreter if needed, facing the resident and speaking directly to them. During an interview on 07/31/2024 at 5:30 PM with R13's Family Member (FM) 1, she stated R13 had been in the facility approximately 3 days when she was contacted by him via video call on his I-Pad. FM1 stated R13 appeared upset, and he communicated to her via speech and sign language he had been abused - he had not had his call light all night. When she and another family member came and spoke with R13 he communicated to them 2 State Registered Nurse Aides (SRNA)'s came into his room after he rang his call light for assistance. He further communicated to the family members he needed assistance rolling over and was unable to make the SRNA's understand. After he was able to communicate his needs to the SRNA's they did assist the resident to turn and reposition. When they left the room he reported he could not find his call light, He further reported to his family he did not have access to the call light all night. Continued interview with FM1 revealed upon admission to the facility she and another family member went to the facility with R13 and informed the staff of R13's deafness, and that he communicated via sign language often. In addition, R13 used a communication book, a white board, and his I-PAD. She further stated she informed staff that if any issues with communication arose, they could contact her or other family member to assist. She further stated their numbers were in R13's IPAD and he could contact them. FM1 further stated initially R13 could not write very much due to the recent surgery and his weakness. During an interview on 08/01/2024 at 2:30 PM with the Occupational Therapist (OT) she stated on the morning of 05/16/2024 when she entered R13's room, he was frustrated and signing. OT stated she handed R13 his IPAD, which was across the room on a table. OT stated R13 pointed to family member's picture on the IPAD and she assisted with video calling. During the call OT was informed by the family member that R13 was signing he had been abused. OT stated she immediately reported to the Nurse on staff and the Social Worker. During an interview on 08/02/2024 at 3:00 PM with the Social Worker (SW) she stated when she was notified of the abuse allegation she notified the daughters and discussed the options. R13 was moved the same day to a different hall. SW stated she spoke with R13 and he stated he felt safe in the facility. SW further stated initially the first few days staff had a hard time with communicating with R13 but communication is better now and R13 and family are very pleased with the facility. During an interview on 08/02/2024 at 4:44 PM with the Assistant Director of Nursing she stated she would expect R13 would have been able to effectively to communicate with staff on arrival to the facility. She stated communication with residents was necessary to assess health needs for the residents. During an interview on 08/02/2024 at 5:25 PM with the Director of Nursing (DON) she stated she was contacted by FM1 regarding the incident and met with 2 family members immediately. R#13 was moved to another hall, all staff were educated on use of the communication board, and other ways to communicate with R13. The DON further stated there had been no further issues. She further stated she expected all resident needs be addressed initially and care planned to be able to meet all resident needs and rights. During an interview on 08/02/2024 at 5:55 PM with the Administrator she stated as soon as the incident was reported an investigation was initiated and needs of R13 were addressed, a room change was made in order to position resident with his left side towards the wall rather than the right, due to left sided weakness. She further stated it was very important for each resident to be able to communicate with staff to avoid the resident feeling isolated, alone and not hinder getting their needs met quickly.

Based on observation, interview, and facility policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for three of 34 sampled residents (Resident [R]29, R44, and R67). The findings include: Review of the facility's policy, titled Resident Rights, effective 06/20/2005, revealed a resident had the right to care in an environment that promoted maintenance or enhancement of each resident's quality of life. Continued review of the facility's policy revealed the resident had the right to a safe, clean, comfortable, and homelike environment, including, but not limited to receiving treatment and support for daily living safely. Observation during initial facility rounds on 07/30/2024 at 10:50 AM, revealed R29 and R44's room shared a bathroom with R67 ' s room. A strong urine odor was noted in the bathroom. Observation of R29 and R44 and R67's shared bathroom on 07/31/2024 at 11:36 AM and on 08/01/2024 at 2:56 PM revealed a strong odor of urine was still present in the shared bathroom. During an interview with the Social Services Director (SSD) on 08/02/2024 at 3:19 PM, she stated the department heads did ambassador rounds daily in resident rooms. The SSD stated the ambassador rounds covered things such as foul odors, clean rooms, and checking for ice in water. The SSD stated she believed all residents had the right to a clean, homelike environment, which meant rooms, especially bathrooms, should not stink. The SSD stated she felt the strong urine odor in the bathroom was caused by the urine being soaked into the floor. During an interview with the Environmental Services Director (ESD) on 08/02/2024 at 3:45 PM, she stated she did not normally smell odors in the facility but had noticed the shared bathroom between R29 and R44's room and R67's room did have urine smell at times. The ESD stated the housekeepers cleaned the bathroom at least twice a day to keep the odors down but stated it did not always work very well. During an interview with the Director of Nursing (DON) on 08/02/2024 at 5:24 PM, she stated she was aware of the bathroom issue but had housekeeping cleaning the room daily and as needed for any urine odors. The DON stated the strong urine odor was where the male resident missed the commode and it hit the floor. During an interview with the Administrator on 08/02/2024 at 5:53 PM, she stated she expected all rooms to be comfortable and homelike for all residents in her facility. The Administrator stated she expected the facility to be free from odors and did not expect any odors during resident care to linger. The Administrator stated she had smelled the urine odor in the shared bathroom and considered it to be a lingering odor. The Administrator stated housekeeping had an ongoing issue with the shared bathroom and cleaned it a couple of times a day.

Based on observation, interview, and review of facility policy, the facility failed to provide food at palatable temperature for hot foods and at a palatable point of service temperature for three of 34 sampled residents (Residents [R]19, R60 and R13). A test tray was requested on 08/02/2024 and the eggs were 90.7 degrees Fahrenheit (F). The findings include: Review of the facility policy, titled Meal Distribution, revised 02/2023 revealed foods were to be transported to the dining locations in a manner that ensures proper temperature maintenance, protected against contamination, and are delivered in a timely and accurate manner. Interview with R19 on 07/31/2024 at 3:40 PM revealed the food was okay but was often cold. Review of admission record revealed the facility admitted R19 on 07/11/2013 with a diagnoses of cerebral palsy. Review of Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 01/21/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated resident was cognitively intact. During an interview with R60 on 08/01/2024, at 11:45 AM, the resident stated the food was fair but was frequently cold. Review of R60's Quarterly MDS with an ARD date of 05/23/2024, revealed a BIMS score of 11 of 15 which indicated moderately impaired cognition. Interview with R13 on 08/01/2024 at 12:00 PM revealed the resident was hard of hearing but he was able to communicate that the food was often cold. Review of R13's admission record revealed the facility admitted the resident on 05/13/2024 with diagnosis of cervical disc disorder with myelopathy, quadriplegia, and cervical fusion. Review of R13's Admission MDS with ARD dated 05/31/2024 revealed a Brief Interview for Mental Status (BIMS) score of fourteen of fifteen, which indicated R13 was cognitively intact. A test tray was requested and observation on 08/02/2024 at 8:26 AM revealed the last food cart was loaded by dietary staff and taken to the 300 Wing. At 8:35 AM, the last resident tray was served and the test tray was removed by the District Dietary Manager (DDM). The tray was immediately placed at the nurse's station and temperatures checked by the DDM. The food was noted to be served in a Styrofoam container with lids. The temperatures were as follows: Scrambled eggs 90.7 degrees Fahrenheit (F), Oatmeal 129.3 degrees F, muffin 104.8 degrees F milk 37.9 degrees F, coffee 146 degrees, and orange juice 37 degrees. During an interview with the DDM on 08/02/2024 at 8:35 AM she stated the food should be served at a temperature that is palatable to the residents. She is not sure why the eggs temperatures were so low. She further stated that food that was not kept at appropriate temperatures could cause foodborne illnesses. Interview on 08/02/2024 at 5:55 PM, with the Administrator, revealed she did a test tray every two weeks for two different meals and had not identified any concerns. She stated she expected foods to be at an appropriate temperature when foods were served to the residents. She further stated she expected the dietary staff to be trained, educated and to follow the food code policy to ensure safety with food served to the residents.

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to develop and implement a care plan for three (3) of forty (40) residents, Resident #69, #71, and #79. The facility failed to develop and implement a care plan to ensure Resident #69 and #71's safety while smoking. In addition, the facility failed to develop a care plan for Resident #79's Mediport. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs, was developed for each resident. The care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. The comprehensive care plan was based on a thorough assessment that included, but was not limited to, the RAI. Review of the CMS RAI Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written plan of care. 1. Review of the clinical record revealed the facility admitted Resident #69 on 01/21/19, with [DIAGNOSES REDACTED]. Review of Resident #69's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) and determined the resident was interviewable. Observation of Resident #69, on 05/28/19 at 2:50 PM, revealed the resident sitting in a wheelchair smoking a cigarette in the courtyard outside. Review of Resident #69's Safe Smoking Evaluation, dated 01/22/19, revealed the facility assessed the resident as a safe smoker and needed constant supervision. Review of Resident #69's Care Plan, dated 01/29/19, revealed safe smoking was not addressed. Continued review of the Care Plan revealed safe smoking was not initiated until 05/28/19, during the survey. Review of Resident #69's Daily Participation Logs, dated (MONTH) 2019 and (MONTH) 2019, revealed the resident smoked on 03/21/19, 04/10/19, 04/17/19, 04/26/19, 04/28/19, and 05/30/19. Interview, on 05/31/19 at 10:30 AM, with the MDS Coordinator revealed she was not aware Resident #69 was a smoker. She stated nursing staff completed the safe smoking evaluation; however, a care plan was not developed for safe smoking. She stated it was an oversight on her part but nursing staff and the Social Services Director (SSD) could update a care plan. Interview with the SSD, on 05/31/19 at 10:58 AM, revealed she was responsible for completing the safe smoking care plans. The SSD stated the facility process was to check for a completed smoking assessment by nursing staff and if the resident was identified as a smoker, then a smoking care plan would be initiated. Further interview revealed Resident #69 did not smoke until (MONTH) 2019 and the care plan should have been developed and implemented in (MONTH) 2019 when the resident smoked in the courtyard. Interview, on 05/31/19 at 2:54 PM, with the Director of Nursing (DON) revealed a care plan should have been developed related to safe smoking for Resident #69. 2. Review of the clinical record revealed the facility admitted Resident #71 on 06/21/18, with [DIAGNOSES REDACTED]. Review of Resident #71's Annual MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) out of fifteen (15) and determined the resident was interviewable. Continued review of the MDS revealed the facility coded the resident had used tobacco in some form during the 7-day look-back period. Review of Resident #71's Safe Smoking Evaluations, dated 10/11/18, 12/07/18, 02/04/19, 04/30/19, and 05/14/19, revealed the facility assessed the resident as a safe smoker and needed constant supervision. Review of Resident #71's Care Plan, dated 07/05/18, revealed a focus area of [MEDICAL CONDITIONS], Chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and Smoker. Interventions included a nicotine patch per order (initiated 09/28/18, 11/05/18, and 12/04/18), and encourage smoking cessation (initiated on 10/10/18). However, there was no documented evidence a care plan was developed and implemented for safe smoking until 05/30/19, during the survey. Interview with the SSD, on 05/31/19 at 1:17 PM revealed nursing staff completed Resident #71's safe smoking evaluation; however, a care plan was not developed for smoking. She stated it was her responsibility to develop the smoking care plan and she missed it. Continued interview, on 05/31/19 at 2:54 PM, with the DON revealed a care plan should have been developed related to safe smoking for Resident #71. 3. Review of the facility's policy, Vascular Access Devices: Accessing/De-Accessing an Implanted Port, dated (MONTH) (YEAR), revealed if the port was not in use, it must be accessed, flushed, and de-accessed at a minimum of once every thirty (30) days. Review of the clinical record for Resident #79 revealed the facility readmitted the resident from the hospital on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident had a Mediport. Review of Resident #79's Care Plan, for admitted [DATE], revealed no plan to address the care of the resident's Mediport. Interview with the MDS Coordinator, on 05/31/19 at 3:47 PM, revealed the MDS Nurse reviewed Resident#79's clinical record and did not see any indication he/she had a Mediport, therefore, she did not develop a care plan for maintenance care of the port after the resident returned from the hospital. She stated there was nothing in any of the assessments to identify the resident had a Mediport. Interview with Registered Nurse (RN) #3, on 05/31/19 at 4:12 PM, revealed she readmitted Resident #79 when he/she returned from the hospital and assessed the resident, but did not identify or address the resident's Mediport. She stated she was aware the resident utilized a Mediport [MEDICAL CONDITION] treatments last year. Interview with the DON, on 05/31/19 at 4:50 PM, revealed Mediports were to be flushed every thirty (30) days. She reviewed Resident #79's record and stated there was nothing in any of the assessments to identify the resident had a Mediport. Upon review of the resident's old care plan, admitted [DATE], she stated she had de-accessed his/her site in (MONTH) (YEAR), and she drew a line through the care plan and wrote D/C (discontinued) instead of updating the interventions for monthly flushes.

Based on interview, facility policy review, and review of an abuse investigation, it was determined the facility failed to ensure residents remained free from abuse for one (1) of forty (40) residents, Resident #47. Resident #47's roommate, Resident #41, threatened to kill the resident. The findings include: Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, revised (MONTH) 2019, revealed it is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property. The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Abuse included physical abuse, mental abuse, verbal abuse, and sexual abuse. Verbal abuse was the use of oral, written, or gestured language that included any threat, or any frightening, disparaging, or derogatory language, to a resident or their families, or within hearing distance, regardless of age, ability to comprehend, or disability. Review of the facility's Resident Rights, revised 08/08/18, revealed all residents had the right to be treated with respect and dignity. All residents would be treated in a manner and in an environment, which promoted maintenance or enhancement of quality of life. The facility would make every effort to support each resident in exercising his/her right to ensure the residents were always treated with respect, kindness, and dignity. Review of a facility Investigation, dated 05/13/19, revealed Resident #41 yelled out to staff and was unable to calm himself/herself. Resident #47 asked Resident #41 to be quiet and Resident #41 verbally threatened Resident #47. The investigation further detailed Resident #41 was on [MEDICATION NAME] for [MEDICAL CONDITION] and had multiple [MEDICATION NAME] changes and recurring [MEDICAL CONDITION] for [MEDICAL CONDITION]. Interview with Resident #47, on 05/28/19 at 3:16 PM, revealed he/she and Resident #41 used to be roommates. Resident #47 stated Resident #41 had a fit, talked about killing people, even his/her sister, and yelled and cursed at staff. He/she stated Resident #41 said he/she was going to kill Resident #47 while he/she slept. Interview with Resident #41, on 05/29/19 at 8:25 AM, revealed he/she did not remember the verbal altercation with Resident #47. Resident #41 stated he/she was upset because Resident #47 talked to his/her sister about him/her and Resident #41 did not want anyone talking about him/her. Resident #41 stated he/she was going to kill Resident #47, but he/she did not mean it. Interview with the Certified Occupational Therapist Assistant (COPT), on 05/29/19 at 8:29 AM, revealed he/she had worked with Resident #41 recently and had seen Resident #41 agitated by raising his/her voice. Resident #41 spoke about situations involving his/her death, but never killing anyone or himself/herself. The COPT did not know anything about the incident between Resident #41 and #47. Interview with Certified Nursing Assistant (CNA) #3, on 05/29/19 at 8:47 AM, revealed she felt Resident #41 had some mental health concerns due to the fact the resident would yell out loudly using foul language at no particular person or for any reason. CNA #3 stated on the day of the incident between Resident #41 and #47, Resident #41 had been using foul language and yelling toward Resident #47. CNA #3 stated Resident #41 became easily agitated after having a [MEDICAL CONDITION] and that was when the foul language began. Interview with CNA #2, on 05/29/19 at 9:22 AM, revealed she had witnessed Resident #41 in the past yelling and randomly cursing staff. Interview with the Social Worker (SW), on 05/29/19 at 3:37 PM, revealed Resident #41 yelled and cursed at staff and expressed a lot of disruptive behavior. The SW stated Resident #41 had some medication changes, which could have contributed to the agitation and cursing at staff. The SW revealed Resident #41 had an unstable relationship with his/her sister and got very upset after her visits. Interview with Family Member #2, on 05/31/19 at 3:47 PM, reveal it was not unusual for Resident #41 to cuss and yell at staff. Resident #41 was upset with her for putting him/her in a nursing home. Interview with Register Nurse (RN) #1, on 05/30/19 at 8:53 AM, revealed Resident #41 had a [MEDICAL CONDITION] and medication changes, which could have contributed to Resident #41's increased agitation. Interview with the Director of Nursing (DON), on 05/30/19 at 10:22 AM, revealed staff heard Resident #41 threaten to kill Resident #47. Interview with the Administrator, on 05/30/19 at 1:55 PM, revealed he was responsible to ensure the safety and wellbeing of residents and staff. The Administrator stated he received a call from the DON explaining the situation involving Resident #41 and #47. He called the facility and spoke with RN #1, who told him Resident #47 told her he/she was verbally threatened by Resident #41.

Based on interview, record review, and facility policy review, it was determined the facility failed to obtain physician orders [REDACTED].#79. The findings included: Review of the facility's policy, Vascular Access Devices: Accessing/De-Accessing an Implanted Port, dated (MONTH) (YEAR), revealed if the port was not in use, it must be accessed, flushed, and de-accessed at a minimum of once every thirty (30) days. Staff was to document the procedure and resident tolerance in the nurses' notes or flow sheet. Review of the clinical record for Resident #79 revealed the facility readmitted the resident from the hospital on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident had a Mediport. Review of Resident #79's admission orders [REDACTED]. Review of Resident #79's current Physician Orders, as of 05/28/19, revealed no orders for the Mediport's maintenance care. Review of Resident #79's electronic Medication Administration Records (MAR) and Treatment Administration Records (TAR), dated (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019, revealed no orders for care of the Mediport. However, the facility produced a handwritten MAR for a Mediport flush completed on 04/28/19. Interview with Registered Nurse (RN) #3, on 05/31/19 at 4:12 PM, revealed she completed Resident #79's admission assessment and was familiar with the resident and his/her needs. She stated she did an assessment but did not identify or address the resident's Mediport. She was aware the resident had a Mediport, which was used for his/[MEDICAL CONDITION] treatments. She stated she did not address the Mediport since it was not accessed and did not obtain orders to continue the maintenance of the Mediport. Interview with the Director of Nursing (DON), on 05/31/19 at 3:50 PM, revealed Mediports were to be flushed every thirty (30) days, which required a physician order [REDACTED]. The DON stated the order should have been obtained and placed on the MAR indicated [REDACTED]

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to prevent the transmission of infections for one (1) of forty (40) residents, Resident #87. Observation revealed Resident #87 was on contact isolation precautions and staff failed to utilized appropriate Personal Protective Equipment (PPE) while in the resident's room. The findings include: Review of the facility's In-service Training, Isolation, Personal Protective Equipment, and Infection Control, dated 05/28/19, revealed Contact Precautions signs were posted on resident doors with instructions for everyone to clean hands when entering and leaving the room; doctors and staff must gown and glove at the door; and doctors and staff were to use patient dedicated or disposable equipment, and clean and disinfect shared equipment. If the patient had diarrhea ([MEDICAL CONDITION]), use contact [MEDICATION NAME] Precautions, which included washing or sanitizing hands when entering and exiting the room, and using a gown and gloves (mask and eye cover were used on an as needed bases). Review of the facility's policy, [MEDICAL CONDITION], revised (MONTH) (YEAR), revealed measures were taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents. Steps toward prevention and early intervention included frequent handwashing with soap and water by staff and residents, and increased awareness of symptoms and risk factors among staff, residents, and visitors, and universal glove use. Observation of Resident #87's room, on 05/28/19 at 8:48 AM, revealed a contract precaution sign on the door. The nurse at the nurse's desk signified the resident had diarrhea ([MEDICAL CONDITION]) and physicians, staff, and visitors were to use contact precautions, which included washing or sanitizing hands when entering and exiting the room, and wearing a gown and gloves. Observation, on 05/28/19 at 12:12 PM, revealed the Speech Therapist in Resident #87's room without wearing PPE. Interview with the Speech Therapist, on 05/28/19 at 12:17 PM, revealed she was not aware of the sign posted at Resident #87's room. The Speech Therapist stated Resident #87 was not in contact isolation before he/she left for the hospital and she did not notice the sign when the resident returned. The Speech Therapist also stated since she did not see the sign, she did not wear the required PPE, and she did not know why the resident was in contact isolation. The Speech Therapist explained without wearing the appropriate PPE, it could cause a widespread infection in the facility and put other residents' health at risk. According to the Speech Therapist, she should have checked with the nurse about Resident #87's [DIAGNOSES REDACTED]. Interview with Certified Nursing Assistant (CNA) #3, on 05/29/19 at 8:47 AM, revealed resident room doors had a label to identify contact isolation and to contact the nurse for more information. The CNA stated staff was to don the appropriate PPE before entering a resident's isolation room and remove the PPE upon exiting. Interview with Registered Nurse (RN) #1, on 05/29/19 at 9:43 AM, revealed staff was to perform hand hygiene and don PPE prior to entering a contact isolation room. Interview with the Assistance Director of Nursing (ADON), on 05/30/19 at 9:31 AM, revealed staff was to don gloves and gown prior to entering a contact isolation room, and remove the PPE prior to exiting, along with performing hand hygiene. Interview with the Director of Nursing (DON), on 05/30/19 at 10:22 AM, revealed staff was to abide by the policies and procedures for using PPE and all staff had taken training, either face to face or on the computer, regarding PPE. According to the DON, PPE was kept in the center of each hallway and staff was to take the needed PPE to the resident's door and put it on prior to entering the room. Interview with the Staff Development, on 05/30/19 at 11:15 AM, revealed if a resident had a sign on the door that they were in contact isolation, the sign informed staff and others what to put on or told them to see a nurse at the nurses' station. Staff sanitized hands and put on PPE prior to entering the room, and removed the PPE prior to exiting. She stated staff was trained on infection control face-to-face and via the computer. Interview with the Administrator, on 05/30/19 at 1:55 PM, revealed staff should follow the policy and procedures for using PPE when attending to residents in contact isolation

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all medications were securely stored to restrict access to only authorized personnel as evidenced by one (1) of eight (8) medication carts observed unlocked, and unattended by staff on the 200 Hallway. The findings include: Review of the facility's policy, Storage of Medications, 4.1, dated (MONTH) (YEAR), revealed in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications were allowed access to the medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. Observation, on 04/04/18 at 11:40 AM, revealed a medication cart on the 200 Hallway unlocked and unattended by staff. The cart remained unlocked and unattended for at least thirteen (13) minutes. At 11:53 AM, Licensed Practical Nurse (LPN) #2 walked up and locked the medication cart. Interview, on 04/05/18 at 1:40 PM, with LPN #5 revealed it was not acceptable for a medication cart to be unlocked when not in use. She stated medications should be securely stored because the facility would not want residents, or anyone else not unauthorized to administer medications, to have access to the contents of the cart. She stated if the cart was not in use by one of the nurses, it should be locked. LPN #5 stated there were cognitively impaired residents who might be independently mobile and could pass by the carts. In addition, she stated after 5:00 PM, the exit and entrance nearest the 200 Hallway was the only access into and out of the building for visitors. Therefore, she stated visitors could pass by the medication carts stationed on the 200 Hallway, as they made their way to other hallways and commons areas of the building. Interview, on 04/05/18 at 1:45 PM, with LPN #2 revealed she did not realize the medication cart was unlocked when she approached it on 04/04/18 at 11:53 AM. She stated medication carts were to remain locked when not attended by staff because the facility had residents who might wander. LPN #2 stated she might have been nervous since surveyors were in the building. LPN #2 stated the keys to a mediation cart should remain with the nurse assigned to the cart and that nurse should be the only individual with access to the medications in the cart. She stated if the medication cart was unlocked, then anyone in the building could access the contents of the cart. Interview, on 04/05/18 at 2:15 PM, with the Assistant Director of Nursing (ADON) revealed only nurses or persons otherwise authorized to administer medications or audit the medication carts should have access to the contents of the carts. She stated securing of medications via locked storage was the facility's policy and was in place to prevent residents, family members, contractors, vendors, or others from having access to the contents of the carts. She stated the carts should always be locked when not in use. She stated even if a nurse was at the nurses' station, he/she might be called away from the nurses' station to provide resident care, or could be otherwise occupied, and not able to see the cart from the nurses' station. The ADON stated she monitored locked medication carts by making rounds on the units and if she discovered an unlocked medication or treatment cart, she immediately re-educated the nurse assigned to the cart.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assess or re-evaluate the use of a restraint for one (1) of twenty-one (21) sampled residents, Resident #8. Resident #8 had an activity tray attached to the wheelchair that was not removed during meals or when the resident was not engaged in activities. Per interviews, the tray was to prevent the resident from standing; however, the facility did not assess the tray as a restraint. The findings include: Review of the facility's policy, Use of Restraints, revised 11/22/16, revealed restraints were only used for the safety and well-being of the resident(s), and only after consideration, evaluation, and the use of all other viable alternatives. A physical restraint was any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that an individual could not remove easily and which restricted the resident's freedom of movement or normal access to his/her body. Examples of devices that might be considered physical restraints included lap cushions and trays that a resident could not remove. An order from the Physician was to be obtained and was not to be written for an as needed basis. Guidelines to follow for residents using restraints included residents would have restraint free times, which included during meal times. The documentation for use of a restraint included resident symptoms, conditions of the associated environment, and how the device benefited the resident by addressing the medical symptom. Further review revealed the resident care plan was to include interventions that not only addressed the medical symptom, but also the underlying problem, and include measures taken to systematically reduce or eliminate the need for restraint use. The facility would regularly review residents using restraints to determine whether reduction of restraint use, least restrictive methods, or total restraint elimination could be achieved. Review of Resident #8's clinical record revealed the facility readmitted the resident on 04/17/17, with [DIAGNOSES REDACTED]. Review of Resident #8's annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was rarely/never understood and his/her cognitive skills for daily decision making were severely impaired. According to the MDS, the resident did not have physical restraints, and had two (2) non-injury falls and one (1) fall with injury. Review of a Physician Order, dated 10/04/17, revealed an order for [REDACTED]. Review of Resident #8's Care Plan, dated 04/25/16, revealed the resident had a self-care deficit with an intervention added on 10/04/17, for an activity tray as needed for sensory input. Review of Resident #8's Certified Nursing Assistant (CNA) Care Plan, not dated, revealed to place the tray to the wheelchair as tolerated as need for activities. Check every thirty (30) minutes and release every two (2) hours. Observation, on 04/03/18 at 8:48 AM, revealed Resident #8 in a wheelchair with an activity tray attached in front of the resident. Resident #8 was at the dining table and attempted to reach over the tray to acquire the breakfast bowls on the table. The Activity Director moved the food up to the edge of the table for Resident #8 to reach. At 10:00 AM, Resident #8 was in the dining hall not engaged in an activity, and was in the wheelchair with the activity tray secured to the chair. At 1:06 PM, Resident #8 was in the wheelchair with the activity tray secured to the wheelchair while sitting at the dining table. Resident #8 attempted to reach over the tray to acquire cups of food and drink. At 2:51 PM, the resident was pushing against the activity tray in an outward motion on both sides of the tray for one (1) minute. Staff was supervising several residents and did not remove the activity tray when Resident #8 was physically pushing the tray outward. Review of Resident #8's Physical Restraint Elimination Review, dated 01/15/18, revealed the activity tray was used as a diversional activity when the resident displayed increased anxiety, and placed and removed as the resident requested. Staff assessed the activity tray was not a restraint. Interview with CNA #1, on 04/04/18 at 9:10 AM, revealed Resident #8 had the activity tray because Resident #8 continued to attempt to stand up from the wheelchair and fall despite staff supervision and chair alarms. Interview with the Assistant Director of Nursing (ADON), on 04/04/18 at 9:10 AM, revealed Resident #8 would become anxious and attempt to stand up. She stated Resident #8 continually attempted to stand up, which was one reason for the attachment of the activity tray to the wheelchair. Interview with Resident #8's Daughter, on 04/05/18 at 9:58 AM, revealed Resident #8 had the activity tray attached to the wheelchair because the resident wanted to stand up and kept falling. The Daughter stated the facility had used the tray for several months. She stated Resident #8 had the activity tray in place all the time, even when the resident was at the dining table during meals. She further stated she requested the facility to put something in front of Resident #8 to prevent falls. Continued interview with CNA #1, on 04/05/18 at 9:20 AM, revealed activity trays were to be removed during meals and residents were to be able to release the tray or it was considered a restraint. Interview with CNA #2, on 04/05/18 at 9:35 AM, revealed activity trays were to be removed during meals. She stated the trays were to be used during activities such as crafts. She stated any tray, which the resident could not remove, was considered a restraint. She stated the CNA care plan for Resident #8 was for as needed use, and the CNAs were not able to document the reason for the placement of the tray, monitoring, or release of the tray. Interview with Registered Nurse (RN) #3, on 04/05/18 at 10:40 AM, revealed as needed orders for an activity tray were not to be written on any document. She stated the activity tray needed to be removed during meals and was not to remain on the wheelchair except during activities. She stated the use of an activity tray for anxiety was a restraint. She further stated the use of the activity tray was to be defined by a physician's orders [REDACTED].>Interview with RN #1, on 04/05/18 at 11:30 AM, revealed any type of tray that could be considered a restraint was to be constantly re-evaluated for the resident's care and services. She stated an order of need and use was to be obtained from the physician. She stated the facility used activity trays with Dementia residents to decrease anxiety. She further stated activity trays should not be left in front of a resident when not in an activity or having anxiety because then it became a restraint. Interview with the Staff Development Director, on 04/05/18 at 11:15 AM, revealed the facility was a restraint free facility and staff was to use the least restrictive manner to keep residents safe. She stated the facility had one (1) activity tray in the building and it was to be used for participation in activities. She stated the tray was not to be used during meals, and was to assist the resident to complete activities. She further stated the resident was to be able to remove the activity tray. Interview with the Activity Director, on 04/05/18 at 1:30 PM, revealed activity trays were used to assist residents with range of motion, cognition, and other physical issues to aide with participation of a scheduled activity. She stated the CNAs or nurses placed the activity tray on Resident #8 wheelchair during periods of anxiety. She stated the tray was to be removed at meal times and she was not responsible to remove or monitor the tray when it was secured to the wheelchair. Interview with the 600 Unit Manager (UM), on 04/05/18 at 1:40 PM, revealed the activity tray was used as needed with Resident #8 for activity participation and when Resident #8 became anxious to provide sensory input. She stated trays were to be removed during meals and she expected nursing staff to take the tray off. She stated the use of the activity tray needed a physician's orders [REDACTED]. Continued interview with the ADON, on 04/05/18 at 1:55 PM, revealed an activity tray was to be ordered that included parameters for use, monitored, and care planned appropriately. She stated the activity tray was not to be used as needed and was to be removed for meals. Interview with the Director of Nursing (DON), 04/05/18 at 2:10 PM, revealed any type of tray placed in front of a resident was to be care planned specific to the resident needs, monitored, and required a physician order [REDACTED].#8 and she was not sure why the tray was in use on 04/03/18. She stated the facility was to uphold the no restraint policy, which was the facility's core belief. She stated staff was to remove trays before meals, and if they did not, it was considered a restraint. She stated she audited devices to aide in movement alerts or for safety by completing walking rounds on the floor. She further stated if there was a question about the use of a device, it was discussed in the morning meeting with all management staff for its appropriateness. Interview with the Administrator, on 04/05/18 at 3:00 PM, revealed the facility was to be restraint free. He stated it was nurse managements responsibility to monitor devices that might be restraints. He stated during morning meetings, alarms, activity trays, or like devices were tracked on the white board and discussions included the use and need of the device. He stated a device became a restrictive device when it prevented a resident from standing up. He stated he was unsure if activity trays were to be removed during meals.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for two (2) of twenty-one (21) sampled residents, Resident #8 and #31. Per staff interviews, an activity tray was attached to Resident #8's wheelchair to prevent falls and anxiety; however, was not part of the resident's fall and anxiety care plan. In addition, the facility did not revise Resident #31's care plan to include the resident's preference related to toileting. The findings include: Review of the facility's policy, Care Plans-Comprehensive, dated 10/31/17, revealed the resident care plan was to have measurable objectives to meet the physical and mental needs of the resident. The care plan was to include how the facility would assist the resident to meet the goals. Further review revealed care plans were implemented after review of the residents' problem areas, causes, and interventions to reflect action, treatment, or procedure to meet the resident goals. Continued review revealed care plans were ongoing and revised as information about the resident, and resident's condition changed. The care plan was to reflect the current status of the resident and be updated with the changes of the resident. 1. Review of the facility's policy, Use of Restraints, revised 11/22/16, revealed restraints were only used for the safety and well-being of the resident(s), and only after consideration, evaluation, and the use of all other viable alternatives. A physical restraint was any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that an individual could not remove easily and which restricted the resident's freedom of movement or normal access to his/her body. Examples of devices that might be considered physical restraints included lap cushions and trays that a resident could not remove. An order from the Physician was to be obtained and was not to be written for an as needed basis. Guidelines to follow for residents using restraints included residents would have restraint free times, which included during meal times. The documentation for use of a restraint included resident symptoms, conditions of the associated environment, and how the device benefited the resident by addressing the medical symptom. Further review revealed the resident care plan was to include interventions that not only addressed the medical symptom, but also the underlying problem, and include measures taken to systematically reduce or eliminate the need for restraint use. The facility would regularly review residents using restraints to determine whether reduction of restraint use, least restrictive methods, or total restraint elimination could be achieved. Review of Resident #8's clinical record revealed the facility readmitted the resident on 04/17/17, with [DIAGNOSES REDACTED]. Review of Resident #8's annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was rarely/never understood and his/her cognitive skills for daily decision making were severely impaired. According to the MDS, the resident did not have physical restraints, and had two (2) non-injury falls and one (1) fall with injury. The facility had not administered medication for anxiety in the last seven (7) days. Review of a Physician Order, dated 10/04/17, revealed an order for [REDACTED]. Review of Resident #8's Care Plan, dated 04/25/16, revealed the resident had a self-care deficit with an intervention added on 10/04/17, for an activity tray as needed for sensory input. The resident was at risk for anxiety with interventions to allow resident to verbalize feeling of depression and provide one to one when he/she was distress. Review of Resident #8's Certified Nursing Assistant (CNA) Care Plan, not dated, revealed to place the tray to the wheelchair as tolerated as need for activities. Check every thirty (30) minutes and release every two (2) hours. Observation, on 04/03/18 at 8:48 AM, revealed Resident #8 in a wheelchair with an activity tray attached to the wheelchair in front of the resident. Resident #8 was at the dining table and attempted to reach over the tray to acquire the breakfast bowls on the table. The Activity Director moved the food up to the edge of the table for Resident #8 to reach. At 10:00 AM, Resident #8 was in the dining hall not engaged in an activity, and was in the wheelchair with the activity tray secured to the chair. At 1:06 PM, Resident #8 was in the wheelchair with the activity tray secured to the wheelchair while sitting at the dining table. Resident #8 attempted to reach over the tray to acquire cups of food and drink. At 2:51 PM, the resident was pushing against the activity tray in an outward motion on both sides of the tray for one (1) minute. Staff was supervising several residents and did not remove the activity tray when Resident #8 was physically pushing the tray outward. Review of Resident #8's Physical Restraint Elimination Review, dated 01/15/18, revealed the activity tray was used as a diversional activity when the resident displayed increased anxiety, and placed and removed as the resident requested. Staff assessed the activity tray was not a restraint. Interview with CNA #1, on 04/04/18 at 9:10 AM, revealed Resident #8 had the activity tray attached to the chair because Resident #8 continued to attempt to stand up from the wheelchair and fall despite staff supervision and chair alarms. She further stated it was also used when she/he was anxious. Interview with the Assistant Director of Nursing (ADON), on 04/04/18 at 9:10 AM, revealed Resident #8 would become anxious and attempt to stand up, which was why an activity tray was affixed to the wheelchair. Interview with Resident #8's Daughter, on 04/05/18 at 9:58 AM, revealed Resident #8 had the activity tray attached to the wheelchair because the resident wanted to stand up and kept falling. She further stated she requested the facility put something in front of Resident #8 to prevent falls. Continued review of Resident #8's Care Plan revealed the resident was at risk for fall related injury; however, there was not an intervention to use the activity tray for fall prevention nor for when the resident expressed anxiety. In addition, the care plan did not direct staff to remove the activity tray during meals. Review of Resident #8's Progress Notes, dated 10/04/17 through 04/05/18, revealed no documented increase in anxiety that required placement of the activity tray to promote a sense of security with diversion activity, as noted in the 01/15/18 Restraint Elimination Review. Interview with CNA #3, on 04/05/18 at 9:20 AM, revealed nurses updated the CNA care plans and CNAs reviewed the care plans with shift report. She stated an activity tray had to be on the residents' care plan for use. She further stated an activity tray was to be used for activities, and the care plan should reflect exactly why the tray was used, parameters, and the tray was to be removed during meals. She further stated Resident #8 became anxious frequently and the tray was an effective tool to calm the resident. Interview with Registered Nurse (RN) #3, on 04/05/18 at 10:40 AM, revealed care plans were updated with additions of safety devices, falls, and equipment used to care for the resident. The care plan should reflect the reason the device was added, when it was to be used, and to include least restrictive interventions first. She further stated activity trays were not to be used as needed. She stated any nurse could update resident care plans. Interview with RN #1, on 04/05/18 at 11:30 AM, revealed care plans were to be updated with new orders, changes in condition, falls, and with the addition of safety interventions. She stated the activity trays were used for residents with high anxiety to keep the residents in a small enclosure to make the residents feel safe. She stated activity trays were to be care planned in any identified area of need after an order was obtained, with clear parameters, and monitoring initiated. Interview with the Staff Development Director, on 04/05/18 at 11:15 AM, revealed staff was educated on resident care planning upon hire and on an as needed basis. She stated the facility audited care plans as a team during morning meetings if an event occurred, or quarterly with care plan review, MDS assessments, and when reviewing care with the resident or family. She stated activity tray use should be placed under the problem identified, the reason for the tray use, and parameters of use. She stated nurses could update care plans and the nurse managers were to ensure the care plans were up to date. Interview with the 600 Unit Manager (UM), on 04/05/18 at 1:40 PM, revealed care plans were used for planning resident care. The care plan was to have specific reasons for the use of an activity tray, parameters, and monitoring of the device. She stated Resident #8 had the activity tray under the Activities of Daily Living Care for sensory input. She stated the family had requested a device be placed in front of Resident #8 to aide with safety due to the increased number of falls in a short period of time, which was not care planned nor were there documented attempts to try least restrictive alternatives. She stated she audited care plans during morning meetings and quarterly with MDS assessments. Continued interview with the ADON, on 04/05/18 at 1:55 PM, revealed she monitored care plans during the team meeting every morning if an event occurred, and reviewed the new interventions initiated by the nurse. She stated she also helped review care plans quarterly with the MDS assessments. She stated it was the nurses and nurse management's responsibility to update the care plans. The ADON stated care plans were essential for directing resident care and safety. Interview with the Director of Nursing (DON), on 04/05/18 at 2:10 PM, revealed nurses and nurse management were responsible to ensure care plans matched how the residents were cared for in the facility. She stated nurse management was to ensure the picture of care was up to date. 2. Review of the facility's policy, Full Life Conference, revealed the conference was conducted to demonstrate to the resident, family, and resident representative that the facility was dedicated to the provision of person-centered care to achieve the resident's highest practicable well-being and outcomes of the resident's on-going health and safety concerns. The policy stated the team would encourage the resident and resident representative to include any personal and cultural preferences to be incorporated into the goals of care. In addition, the Full Life Conference could be used as the initial care plan conference when information from the conference was used to generate the resident's plan of care. Review of the clinical record revealed the facility admitted Resident #31 on 01/26/18, with [DIAGNOSES REDACTED]. Review of the admission MDS, dated [DATE], revealed the facility assessed Resident #31 with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) and determined the resident not interviewable. The resident was occasionally incontinent of urine and incontinent of bowel and required extensive assistance of one (1) person for toileting. Review of the Care Plan Conference Summary, dated 01/30/18, revealed Resident #31 would get up one (1) time during the night around 4:00 AM to use the bathroom and would usually sleep until around 8:00 AM. Review of Resident #31's Bowel and Bladder Incontinence Care Plan, dated 02/08/18, revealed the resident would be kept clean, dry, and comfortable daily. There was no intervention to include the resident's preference to toilet at 4:00 AM according to his/her Care Plan Conference Summary. Review of Resident #31's CNA Care Plan, undated, revealed the resident required assistance of one (1) person for toileting on the commode and was incontinent of bladder and bowel. Observation, on 04/04/18 at 11:46 AM, revealed Resident #31 seated in a wheelchair located in the Unit 2 common area. There was an alarm attached to the resident's clothing and the wheelchair. Interview with Licensed Practical Nurse (LPN) #1, on 04/05/18 at 2:14 PM, revealed Resident #31 would stand up unassisted from the wheelchair and get out of bed unassisted at night. The LPN revealed a wheelchair and bed alarm were placed to ensure safety and notified staff when the resident got up and needed supervision. Interview with CNA #2, on 04/05/18 at 10:10 AM, revealed Resident #31 was not on a toileting schedule. The CNA stated the resident would forget where the bathroom was and revealed he/she was discovered early in the morning of 04/05/18 with his/her pants down sitting on a urine soaked bed. The CNA revealed the purpose of the care plan was to communicate resident needs to assist staff when providing care. Interview with LPN #6, on 04/05/18 at 9:30 AM, revealed Resident #31 was not on a toileting schedule because he/she was able to alert staff when needed. The LPN revealed the Unit Manager (UM) was responsible for revising the care plan with new interventions. She further revealed the purpose of the care plan was to establish the resident's care needs. Interview with the 600 UM, on 04/05/18 at 11:25 AM, revealed she was responsible for updating the care plan as needed. The UM revealed the care plan communicated resident needs and preferences. According to the UM, staff was still trying to figure out the resident's preferences. Interview with the DON, on 04/05/18 at 3:05 PM, revealed she had not identified any concerns with care plans. Interview with the Administrator, on 04/05/18 at 3:00 PM, revealed care plan review was part of the daily clinical meeting. He stated he expected the nurse managers to make sure the care plans were correct. He further stated he was not aware of issues with care plans not being up to date. The Administrator stated he was responsible for all aspects of care for the residents within the facility.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to provide an environment free of accidents by not implementing interventions for the safety of one (1) of six (6) sampled residents, Resident #1. A Certified Nursing Assistant (CNA) failed to transfer the resident with the assistance of two people. This failure resulted in Resident #1 falling and sustaining a fractured femur which required hospitalization and surgery. The findings include: Review of the facility's policy regarding Transfer Activities, effective 12/2010, revealed the procedural steps under the title Bed to Wheelchair Transfer addressed obtaining the assistance of another individual if necessary for safer transfer. Record review revealed the facility admitted Resident #1 on 06/16/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as needing extensive assistance with transfers and a two (2) plus person physical assist. Review of the Comprehensive Care Plan for Resident #1 revealed the facility identified a problem with the resident's ability to perform activities of daily living (ADL). The facility assessed Resident #1 as requiring assist with all care needs related to his/her diagnosis. A two person lift was required during transfers as noted under the Approach (intervention) column on the Care Plan. However, per record review it was revealed CNA #1 attempted to transfer Resident #1 alone and resulted in Resident #1 and CNA #1 falling to the floor. Resident #1 sustained a fractured femur and required hospitalization and surgical intervention. Review of the facility's investigation, dated 06/22/12, revealed on 06/18/12 at approximately 6:15 AM, CNA #1 was assisting Resident #1 to the chair when the CNA and resident lost their balance and fell towards the resident's dresser. The CNA put her hand between the resident's head and the dresser to prevent head injury as they fell . The CNA believed her leg fell on top of the resident during the fall. There was conflicting information as to whether a gait belt was used. The RN answered the call for help and assessed the resident who denied any injury at that time and was transferred to the chair per the resident's request. The MD was called and pain medication was ordered. An X-ray of the left leg was obtained with results indicating an oblique fracture to the femur. The resident had surgery on 06/19/12 to repair the fracture and was re-admitted on [DATE]. Interview with Resident #1 on 06/26/12 at 2:45 PM, revealed he/she fell when getting into the wheelchair. The resident stated he/she was a two (2) person assist most of the time; however, only one person was helping him/her when the fall occurred. Interview, on 06/27/12 at 2:00 PM by telephone, with CNA #1 revealed she attempted to transfer Resident #1 from his/her bed to the wheelchair by herself, even though it was documented on the comprehensive care plan to transfer the resident with assist of two (2). Both she and the resident fell . Review of the hand written statement by RN #1, dated 06/18/12, revealed she heard the CNA yell for help and upon entering the room found the CNA and the resident sitting in the floor next to the bed with the resident's back against the night stand. The resident complained of pain in his/her left outer knee with pain radiating to his/her hip. After assisting the resident to the wheelchair, the RN examined the resident and found no visible signs of injury. The resident stated a gait belt was not used during the transfer. Interview, on 06/27/12 at 3:30 PM, with the Director of Nursing revealed the Comprehensive Care Plan for Resident #1 stated the resident was to be a transfer with two (2) people and a gait belt. The Comprehensive Care Plan was not followed by CNA #1, which resulted in the fractured femur to Resident #1.

Based on interviews, record review and review of the facility's policy, it was determined the facility failed to follow the comprehensive care plan for one (1) of six (6) sampled residents, Resident #1. The facility transferred Resident #1 with the assist of one (1) person even though the comprehensive care plan had identified Resident #1 as requiring two (2) person assist for transfers. Resident #1 sustained a fall that resulted in a fractured femur during the transfer. The findings include: Review of the Transfer Activities policy, effective 12/2010, revealed a gait belt was recommended for use during a transfer but was not a requirement of the facility. Additionally, the procedural steps under the titled Bed to Wheelchair Transfer addressed obtaining the assistance of another individual, if necessary for safer transfer. Record review revealed the facility admitted Resident #1 on 06/16/10 with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 as requiring extensive assist with transfers and a two (2) plus person physical assist. Review of the Comprehensive Care Plan for Resident #1 revealed an identified problem with the resident's ability to perform the activities of daily living (ADL). It stated Resident #1 required assist with all care needs related to his/her diagnosis. The approach column of the care plan identified a two (2) person lift was required for transfers. The transfer of Resident #1, on 06/18/12, was attempted alone by Certified Nursing Assistant (CNA) #1 and resulted in Resident #1 and CNA #1 falling to the floor. Resident #1 sustained a fractured femur and required hospitalization and surgical intervention. Review of the Certified Nursing Assistant Care Plan, dated 04/30/11, revealed under the heading Transfers, Resident #1 was able to bear weight, was weight bearing as tolerated and was to be transferred with the assist of one person. The use of a gait belt was not marked. Interview, on 06/26/12 at 4:26 PM, with Registered Nurse (RN) Unit Manager #1 revealed the nurses monitor the CNA Care Plan to ensure accuracy. Updates and changes were addressed during morning meetings of the Interdisciplinary Team (IDT). Interview, on 06/26/12 at 4:45 PM, with RN Unit Manager #2 revealed the IDT reviews the CNA Care Plan and new orders were reviewed and updated on the CNA Care Plan. She revealed Resident #1 had always been a two (2) person assist and had never transferred alone. However, that was not what was on the CNA Care Plan but was on the Comprehensive Care Plan. Interview, on 06/27/12 by telephone at 2:00 PM, with CNA #1 revealed she was following the CNA Care Plan when transferring Resident #1 when the fall occurred. CNA #1 stated "I was just going by the care plan," referring to the CNA Care Plan. She stated to her knowledge, the resident had always been a one person transfer. Review of the interview statements obtained by the facility during their investigation, dated 06/18/12, revealed CNA #5, CNA #6 and CNA #8 had stated Resident #1 was a transfer with the assist of one according to the CNA Care Plan. Interview, on 06/27/12 at 3:30 PM, with the Director of Nursing revealed the Comprehensive Care Plan directed that the resident was to be a transfer with two (2) people and a gait belt. The Nursing Care Plan was not followed which resulted in a fractured femur to Resident #1. In addition, she revealed it was the IDT's responsibility to ensure the CNA care plan was accurate.