Every finding on record at Smoky Mountain Health and Rehabilitation Center

Based on observations and staff interviews, the facility failed to dispose of food stored past the use by date in 1 of 1 dry food storage area, failed to keep beverages off the floor and failed to clean 1 of 1 walk-in refrigerator for food storage. The deficient practice had the potential to affect food served to residents.Findings Included a. On 3/16/26 at 10:40 AM, an observation of the walk-in refrigerator was conducted with the Dietary Manager. The floor under the food storage racks contained a buildup of grey white debris that crumbled when touched. Several areas of the floor were raised, white, and fuzzy in appearance. The food storage racks also had a thick, grey, sticky substance on the metal shelving.During the observation, the Dietary Manager stated that the food storage racks were last cleaned in January of the current year. She reported that the walk-in refrigerator floor was scheduled to be replaced and, for that reason, had not been cleaned. She did not know when the replacement would occur but stated she would clean the floor.b. At 10:48 AM on 3/16/26, the dry food storage area was observed with the Dietary Manager. On the second shelf of a storage rack, two unopened cartons of thickened liquid with a use by date of January 28, 2026, were found. Additionally, five cases of bottled water were stored on the floor beneath the racks.At 10:50 AM on 3/16/26, the Dietary Manager stated she was responsible for putting away food stock upon delivery and that the expired thickened liquid had been overlooked. She explained that the bottled water had been placed there approximately three weeks earlier during a facility water line break. She stated the bottled water would be removed and stored off the floor.On 3/19/26 at 1:49 PM, the Administrator stated that kitchen cleaning protocols, including those for the walk in refrigerator, should have been followed. The Administrator also noted that water should not be stored on the floor and expired food should be discarded.

Based on record reviews and interviews with resident, staff and the Medical Director, the facility failed to ensure an as needed (PRN) psychotropic medication, Clonazepam (a medication primarily used for panic disorder), had a stop date of 14 days for 1 of 5 residents reviewed for unnecessary medications (Resident #44).Findings included:Resident #44 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder.The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #44 was cognitively intact and that she received antianxiety medications during the assessment period.Resident #44's care plan last reviewed on 2/11/26 indicated the use of psychotropic medications with the potential for adverse effects. The goal was to show improvement in mood/decreased behaviors with minimal side effects of the medications taken through next review. Interventions included administering medications per physician's orders.A review of the physician's orders in Resident #44's medical record indicated an order dated 2/19/26 for Clonazepam oral tablet - give one tablet by mouth every 24 hours as needed for anxiety. There was no stop date for the PRN Clonazepam order, and it was entered into the electronic medical record by Nurse #1.An attempt was made to contact Nurse #1, but it was unsuccessful.A review of Resident #44's February and March 2026 medication administration records (MAR) indicated the PRN Clonazepam order that was initiated on 2/19/26 remained an active order. Further review of the MAR indicated Resident #44 received a dose of the PRN Clonazepam on 2/19/26 at 5:31 PM and this dose by administered by Nurse #2.An interview with Resident #44 on 3/18/26 at 3:07 PM revealed she had periods of anxiety which she received Clonazepam for. Resident #44 stated that she had an order to take one at bedtime and a PRN dose which she could get every 12 hours. Resident #44 stated that she did not remember when the order for the PRN dose started, but she has had it for a long time.An interview with Nurse #2 on 3/18/26 at 12:03 PM revealed Resident #44 had anxiety, and she had requested for a PRN dose of Clonazepam on occasion. Nurse #2 stated he could not remember what happened on 2/19/26 and he did not know how the order for PRN Clonazepam was obtained.An interview with the Unit Manager on 3/18/26 at 12:16 PM revealed she was not present on 2/19/26 when the order for PRN Clonazepam was started, but the Medical Director might have seen Resident #44 and told Nurse #1 to enter the medication order. The Unit Manager stated that she did not remember checking the order for PRN Clonazepam, but if she saw the order she would have obtained clarification because it should only be for 14 days for PRN psychotropic medications.A phone interview with the Medical Director on 3/18/26 at 3:19 PM revealed he did not see Resident #44 on 2/19/26 and he did not know how the order for PRN Clonazepam got started on 2/19/26. The Medical Director stated that he suspected it was based on a pharmacy recommendation to try to decrease Resident #44's current Clonazepam dose. The Medical Director stated that he looked at the most recent psychiatric note, but it only indicated the PRN Clonazepam dose with no stop date. The Medical Director stated that the PRN Clonazepam should have a stop date of 14 days because it was a psychotropic medication and he did not know why the nurse put the order in without a stop date.An interview with the Director of Nursing (DON) on 3/18/26 at 3:38 PM revealed the 2/19/26 order for PRN Clonazepam might have been a telephone order from the Medical Director, but it should have had a stop date of 14 days. The DON stated the Unit Manager usually verified new orders received from the medical providers, and they discussed the new orders daily at the morning meeting. The DON stated she was not sure how they had missed Resident #44's PRN Clonazepam order without a stop date.An interview with the Administrator on 3/19/26 at 1:49 PM revealed they reviewed new medications in the morning meetings, but somewhere in the process Resident #44's PRN Clonazepam order that did not have a stop date got missed.

Based on record review and interviews with residents, Responsible Party and staff the facility failed to explain the arbitration agreement document in a manner understood by residents and their Responsible Parties. This was for 3 of 3 residents reviewed for arbitration agreement (Resident #1, Resident #3, Resident #4).Findings includedThe facility's arbitration agreement was reviewed. The arbitration agreement wrote Agreement is not a precondition to admission or the furnishing of services to the resident by the Facility, and (3) this agreement may be rescinded by written notice to the facility within thirty (30) days of signature. If not rescinded within thirty (30) days, this agreement shall remain in effect for all care and services subsequently rendered at the facility, even if such care and services are rendered following the resident's discharge and readmission to the facility. The document included a signature line below verbiage for the resident or responsible party with no further indication of acceptance or declining the document.a. Resident #1 was admitted on [DATE]. A review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] coded him as cognitively intact.On 3/16/26 a review of Resident #1's reviewed arbitration agreement form revealed it was signed by the resident on 12/1/25 and was stamped accept.On 3/19/2026 at 12:00 PM Resident #1 was interviewed. Resident #1 stated the arbitration agreement was reviewed with him after he was admitted to the facility in December 2025. Resident #1 stated he had signed lots of forms after he admitted in December 2025 and understood what arbitration meant. Resident #1 said he did not agree to binding arbitration with the facility when he signed documents in December 2025. b. Resident #3 was admitted on [DATE]. A review of Resident #3's comprehensive MDS dated [DATE] coded her with severe cognitive impairment. On 3/16/26 a review of Resident #3's reviewed arbitration agreement form revealed it was signed on 7/1/25 by the resident's responsible party and was stamped accept.On 3/19/26 at 9:18 AM Resident #3's Responsible Party was interviewed via phone. He stated the arbitration agreement was sent to him by email when the resident was admitted to the facility. He stated he did not recall if the agreement was explained to him by a person. The Responsible Party said the arbitration agreement font was very small and made it difficult to read. He added there was only an option to sign the document or not. There was no option to accept or decline the arbitration agreement. The Responsible Party stated there was only a signature line and he thought the document needed to be signed and sent back to the facility along with the other admission documents sent to him. The Responsible Party stated he did not intend to agree to binding arbitration. c. Resident #4 was admitted on [DATE].A review of Resident #4's comprehensive MDS dated [DATE] coded him with moderate cognitive impairmentOn 3/16/26 a review of Resident #4's reviewed arbitration agreement form was signed by the resident on 12/1/25 and was stamped accept.On 3/19/2026 at 12:07 PM Resident #4 was interviewed and stated he had signed an arbitration agreement after he had been admitted in November 2025. Resident #4 stated he did not know that he did not have to sign the binding arbitration agreement. He added that he was not aware that by signing the arbitration agreement document it placed him into a binding arbitration agreement with the facility. Resident #4 stated he did not want to agree to binding arbitration with the facility. On 3/16/26 at 1:00 PM the Admissions Coordinator stated the facility did not have any residents who had agreed to binding arbitration agreements. The admission Coordinator said she began working at the facility in August 2025 and that all arbitration agreements since then had been completed electronically as part of the admission packet. The admission packet was presented to the residents via a computer tablet for review and signing. She added she was trained to have all residents sign the arbitration agreement form and stamp the form accept to show the arbitration agreement had been read and explained to the resident. The Admissions Coordinator did not stamp accept on the signed arbitration agreements with the understanding they agreed to the binding arbitration.On 3/18/26 at 4:08 PM in a follow-up interview with the Admissions Coordinator, she stated the arbitration agreement form should have an option for the resident or Responsible Party to acknowledge the agreement had been explained to them. The Arbitration agreement form was stamped accept and did not specify the stamped accept was for acknowledgment and not for acceptance of the binding arbitration agreement. The Admissions Coordinator stated she had sent out new arbitration agreement forms to each cognitively intact resident and Responsible Party for those who were not for clarification of agreeing to binding arbitration and acknowledging the arbitration agreement was explained, reviewed, and offered to them. On 3/19/26 at 1:49 PM the Administrator stated as part of the admissions process, the arbitration agreement needed to be explained clearly so the signing resident or responsible party understood the document and what their signature on the agreement meant.

Based on record review and staff interviews, the facility failed to complete the Care Area Assessment (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents reviewed for unnecessary medications (Residents #10 and Resident #11). The findings included: a. Resident #10 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia, anxiety disorder, and osteoarthritis. A review of Section V (CAA Summary) of the significant change in status MDS assessment dated [DATE] revealed 10 care areas were triggered for Resident #10. The MDS Coordinator did not provide any information in the analysis of findings for 9 of the 10 triggered areas to describe the nature of Resident 10's problems, possible causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for the following triggered care areas: 1. Delirium 2. Cognitive loss/dementia 3. Visual functions 4. Communication 5. Urinary incontinence and indwelling catheter 6. Behavioral symptoms 7. Falls 8. Pressure ulcer/injury 9. Psychotropic drug usage b. Resident #11 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, and depression. A review of Section V (CAA Summary) of the annual MDS assessment date 08/23/24 revealed 8 care areas were triggered for Resident #11. The facility did not provide any information in analysis of findings for all 8 triggered areas to describe the nature of Resident 11's problems, possible causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for the following triggered care areas: 1. Cognitive loss/dementia 2. Activities of daily living functional/rehabilitation potential 3. Urinary incontinence and indwelling catheter 4. Mood stated 5. Falls 6. Nutritional status 7. Pressure ulcer/injury 8. Psychotropic drug use During an interview conducted on 02/04/25 at 9:55 AM, the MDS Coordinator confirmed 9 of the 10 triggered care areas for Resident #10's MDS dated [DATE] and all 8 triggered care areas for Resident #11's MDS dated [DATE] were submitted without providing pertinent information in the analysis of findings in Section V. She explained she started working as the MDS Coordinator last November and both MDS assessments were submitted by the former MDS Coordinator. She did not know how both incidents occurred and acknowledged that it was an error to submit an annual or significant change in status MDS without completing analysis of findings for all the triggered areas comprehensively. On 02/04/25 at 11:25 AM an interview was conducted with the Director of Nursing. She stated all the CAAs must be individualized and completed comprehensively. It was her expectation for the MDS Coordinators to complete the analysis of findings for all the triggered areas in Section V comprehensively before submission. An interview was conducted with the Administrator on 02/04/25 at 2:54 PM. She expected the MDS Coordinator to follow MDS guidelines to ensure all the CAAs included at least the nature of problems, causative factors, and reasons to proceed to care plan before submission.

Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) application was completed for a resident who had a new psychiatric diagnosis for 1 of 1 resident (Resident #10) reviewed for PASRR. The findings included: Resident #10 was admitted to the facility 9/2/23 with diagnoses that included polyosteoarthritis, and generalized anxiety disorder. Resident #10's care plan initiated on 4/8/24 indicated Resident #10 had actual acute confusional state characterized by behaviors, altered thought process, delusions and hallucinations related to legal blindness and hearing deficit. A review of Resident #10's medical record indicated hallucinations was added to her diagnoses list effective 8/1/24. There was no information in Resident #10's medical record regarding the PASRR number or if a new application for PASRR was completed by facility staff after Resident #10 was diagnosed with hallucinations. The most recent quarterly Minimum Data Set assessment dated [DATE] indicated Resident #10 did not have hallucinations. An interview with the Social Worker (SW) on 2/3/25 at 3:07 PM revealed he had worked at the facility since the end of November 2024, but he did not have anything to do with PASRR. The SW stated that the Business Office Manager was responsible for PASRR, but he was able to look up Resident #10's PASRR information during the interview. The SW shared that Resident #10 currently had a PASRR Level I. An interview with the Business Office Manager on 2/3/25 at 3:11 PM revealed she was responsible for obtaining the PASRR information prior to residents being admitted to the facility, but she was not sure who would have submitted a new PASRR application for residents who had new mental health diagnoses. The Business Office Manager stated that the previous Social Worker used to be responsible for PASRR, but after she left employment the Business Office Manager had taken over obtaining the PASRR information for the new admissions. During a follow-up interview with the Business Office Manager on 2/5/25 at 8:33 AM, she retrieved Resident #10's PASRR information which revealed that the last time a request for evaluation was submitted was on 8/29/23 wherein Resident #10 was given a PASRR Level I. The Business Office Manager stated that the previous Social Worker was responsible for submitting a new PASRR application whenever there were new mental health diagnoses, but she did not know who was supposed to do it now. An interview with the Administrator on 2/5/25 at 8:38 AM revealed the Admissions Director and the Business Office Manager shared responsibility in obtaining PASRR information for new residents. The Administrator stated that they talked about any new mental health diagnoses in the morning meetings, and the Social Worker would be responsible for submitting a new PASRR application, but he had not been trained yet. She further stated that the current Social Worker was getting ready to be trained on the PASRR process. The Administrator shared that the previous Social Worker used to deal with PASRR, but they did have a vacancy at some point, which could have contributed to the PASRR applications not being done.

Based on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside a resident's room that indicated the use of oxygen for 1 of 1 resident reviewed for respiratory care (Resident #239). The findings included: Resident #239 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #239's physician orders revealed an order dated 01/17/25 for oxygen to be administered continuously via nasal cannula at 2 liters per minute, may titrate to keep oxygen (O2) saturation greater than 90%. A review of the Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #239 was cognitively intact and coded for oxygen use. An observation on 02/02/25 at 11:54 AM revealed Resident #239 sitting in his wheelchair by his bed with oxygen being administered by an oxygen concentrator. He was holding the nasal cannula in his left hand and indicated he had just removed the nasal cannula to go to the bathroom. There was no signage posted outside Resident #239's room indicating supplemental oxygen was in use. An observation of Resident #239 on 02/03/25 at 8:13 AM revealed he was sitting in his wheelchair by his bed with oxygen being administered via nasal cannula by an oxygen concentrator. There was no cautionary or safety signage posted outside his room indicating supplemental oxygen was in use. An interview conducted on 02/04/25 9:46 AM with Nurse #1 revealed when there was a new resident with orders for oxygen, the nurse who completed the admission would place oxygen in use signage on the resident's door. She indicated any staff member who was aware of oxygen being in use could put up a sign. She was not aware Resident #239 did not have oxygen signage posted. On 02/04/25 at 9:52 AM an interview was held with the Director of Nursing (DON). She indicated the nurse who admitted a new resident was responsible for placing the oxygen in use signage on the resident's door. The DON continued to voice the oxygen in use signage should have been placed on Resident #239's door and was not certain why the signage was not in place. An interview with the Administrator on 02/05/25 at 9:43 AM revealed nurses should validate physician orders related to oxygen and place oxygen signage on the resident's door.

Based on observations, staff interviews and record review, the facility failed to remove expired medication in accordance with manufacturer's expiration date and failed to date a time sensitive eye drops after it was opened and stored at room temperature for 1 or 2 medications carts observed during medication storage checks (Medication Cart #1). The findings included: Review of the manufacturer's package insert for Latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between 36 to 46 Fahrenheit (F) and protected from light. Once opened, Latanoprost may be stored at room temperature up to 77 F for up to six weeks. An observation was conducted on 02/03/25 at 3:49 PM for Medication Cart #1 in the presence of Nurse #2. The observation revealed the following: - One opened bottle of Latanoprost 0.005% eye drop (medication used to treat glaucoma) for Resident #14 was stored at room temperature without an opening date and ready to be used. A sticker for the nurse to record the opening date remained blank. - One opened bottle of docusate sodium liquid (Medication used to prevent and treat occasional constipation) with concentration of 50 milligrams (mg) per 5 milliliters (ml) expired on 01/31/25 with 15 ounces remaining in the bottle and ready to be used. Review of physician's orders revealed Resident #14 had an active order to receive one drop of Latanoprost solution in both eyes once daily in the evening started 04/18/24. The medication administration records indicated Resident #14 had received Latanoprost eye drops as ordered since its initiation on 04/18/24. During an interview conducted on 02/03/25 at 3:53 PM, Nurse #2 stated the medication carts were checked thoroughly by the third shift nurse on each Sunday to ensure proper storage condition and discard expired medications. Nurse #2 stated they had been instructed to check the medication for expiration each time before administration. She did not know why the eye drops and the stool softener laxative was not identified by the nurse who checked the medication cart last Sunday. She acknowledged that the eye drops needed to be dated after the bottle had been opened and stored in the room temperature, and the expired docusate solution needed to be discarded. An interview was conducted with the Director of Nursing (DON) on 02/04/25 at 10:17 AM. She stated it was her expectation for all the nurses to date latanoprost eye drops once a new bottle was opened, and keep the facility free of expired medication all the time. During an interview conducted with the Administrator on 02/04/25 at 2:54 PM, she expected nursing staff to check the expiration date of medication routinely and date latanoprost once it was opened. It was her expectation for all the nurses to follow the manufacturer's guidelines to ensure the facility was free of expired medications.

Based on a lunch meal tray line observation, record review, and staff interviews the facility failed to serve cod in a three-ounce portion per the menu. This failure had the potential to affect 15 residents with orders for mechanical soft diet texture. Findings included: The menu for the lunch meal on 09/26/23 for residents receiving a mechanical soft diet was 3 ounces of baked cod, a half cup of au gratin potatoes, a half cup of green peas, and a dinner roll. A continuous observation of the lunch meal tray line on 09/26/23 from 12:00 PM through 12:15 PM revealed Cook #1 began plating food and used a number 16 scoop (contained 2-2.25 ounces) to plate cod for residents receiving a mechanical soft diet. Cook #1 was observed giving a level scoop of cod using the number 16 scoop. During the observation Cook #1 dropped the number 16 scoop into an open area on the steam table and retrieved a number 8 scoop (contained 4-5 ounces) from a drawer close to the steam table and continued plating the cod for residents receiving a mechanical soft diet texture. Cook #1 did not use a consistent and level scoop when plating the cod using the number 8 scoop. An interview with the Certified Dietary Manager (CDM) on 09/26/23 at 12:15 PM revealed the menu spreadsheet indicated which utensil was to be used to provide the correct portion size for each item served. She stated a number 8 scoop should have been used to serve fish to residents receiving a mechanical soft diet texture. During a follow-up interview with the CDM on 09/26/23 at 2:43 PM she confirmed the cook or the person plating the food was responsible for ensuring the correct utensil was used to serve the correct portion size. She stated Cook #1 was nervous and she felt that contributed to him using the incorrectly sized serving scoop. In an interview with Cook #1 on 09/26/23 at 2:48 PM he stated the menu indicated which serving utensil was to be used to provide the correct portion size for each item served, but because residents who received a regular diet were receiving a 3-ounce portion of cod, he used a number 16 scoop because that was the closest scoop to 3-ounces he had available. Cook #1 stated after he dropped the number 16 scoop in the steam table, the number 8 scoop was the closest scoop available to him without stopping the tray line and per the menu he should have been using the number 8 scoop anyway. Review of the menu for the lunch meal on 09/26/23 at 3:56 PM revealed an X in the column for the portion size of cod for residents receiving a mechanical soft diet. An interview with the Regional Dietary Consultant on 09/28/23 at 3:57 PM revealed the X on the menu in the column indicating portion size for cod for residents receiving a mechanical soft diet meant they were to receive the same portion size of cod as residents receiving a regular diet. He stated residents receiving a mechanical soft diet for the lunch meal on 09/26/23 should have received a 3-ounce portion of cod and confirmed residents did not receive the correct portion size. An interview with the Administrator on 09/28/23 at 3:34 PM revealed she expected dietary staff to follow the menu and for residents to receive the correct portion size.

Based on observations, record review, and staff interviews the facility failed to maintain a resident's privacy by checking her fingerstick blood glucose in the dining room in the presence of other residents and a visitor for 1 of 1 resident (Resident #17). The reasonable person concept was applied to this deficiency and a reasonable person would expect privacy when their fingerstick blood sugar was checked. Findings included: Resident #17 was admitted to the facility 03/06/18 with diagnoses including diabetes and non-Alzheimer's dementia. Review of Resident #17's Physician orders revealed an order dated 07/06/23 to check her blood sugar three times a day and as needed. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was severely cognitively impaired. An observation of Resident #17 on 09/26/23 at 12:26 PM revealed she was sitting in the dining room eating lunch. Three other residents were observed sitting at the table with Resident #17 and were also eating lunch. Nurse #1 approached Resident #17 and checked her fingerstick blood glucose at the dining table. Nurse #1 did not offer to move Resident #17 to a private location. Four additional residents and a visitor were present in the dining room when Nurse #1 checked Resident #17's fingerstick blood glucose. In an interview with Nurse #1 on 09/26/23 at 12:45 PM she confirmed that she should have assisted Resident #17 to private location to check her fingerstick blood glucose. She explained that at the facility where she was previously employed residents' fingerstick blood glucose were routinely checked in the dining room, and she checked Resident #17's fingerstick blood glucose in the dining room while she was eating out of habit. An interview with the Director of Nursing (DON) on 09/28/23 at 3:37 PM revealed she expected that any resident should have their fingerstick blood glucose checked in a private area unless the resident requested otherwise.

Based on record review, observations, and interviews with staff, the facility failed to ensure personal and oral hygiene was provided for a resident dependent on staff to trim and clean visibly dirty fingernails and brush and clean visibly dirty dentures for 1 of 2 residents reviewed for activities of daily living (Resident #35). Findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, and cerebrovascular accident (stroke). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #35 cognition was significantly impaired and extensive assistance was needed for personal hygiene. The MDS assessment did not identify Resident #35 had rejection of care behaviors during the lookback period. Resident #35's care plan for activities of daily living (ADL) and personal care revised on 09/25/23 read in part, Care would be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning. Interventions included provide limited to extensive assistance. a. A continuous observation on 09/25/23 from 12:37 PM to 1:05 PM revealed Resident #35 eating lunch in his room while in bed without assistance from staff. Resident #35 used silverware to eat food from the plate and used his right hand to pick up a piece of bread and take a bite. The middle and ring fingernails on the right hand had a buildup of a thick, dark-colored substance underneath the nails that started at the tip of the finger to approximately the middle part of the nail. The fingernails were approximately 1 centimeter (cm) past the tip of the finger. An observation made on 09/25/23 at 4:06 PM revealed Resident #35's meal tray was removed from the overbed table and there was no change in the appearance of the fingernails on the right hand. The index, middle and ring finger on the left hand were approximately 1 cm past the tip of the finger and a thick dark-colored substance was observed underneath the nails. The buildup started at the tip of the finger to approximately the middle part of the nail. During the observation Resident #35 used the tips of his fingers on the left hand to rub his left eye. An observation and interview were conducted on 09/25/23 at 4:27 PM with the Director of Nursing (DON). The DON observed Resident #35's fingernails on both the left and right hand with the thick, dark-colored substance underneath the nails. The DON stated she would expect nursing staff to offer nail care when the resident's nails are visibly dirty and before Resident #35 started to eat the lunch meal. The DON asked Resident #35, who agreed to allow Nurse Aide (NA) #1 to trim and clean his fingernails. An interview was conducted on 09/26/23 at 2:36 PM with NA #1. NA #1 confirmed she worked the day shift and was assigned to provide personal hygiene care for Resident #35 on 09/25/23. NA #1 stated she did not notice Resident #35's fingernails were dirty prior to the lunch meal and did not provide nail care. NA #1 revealed the DON instructed her to provide nail care and she was able to clean and cut Resident #35's fingernails and he did not reject the care. During an interview on 09/28/23 at 3:55 PM the Administrator stated nursing staff followed the facility's protocol and policy for nail care and if the resident was accepting of the care it was provided. b. Resident #35's care plan for oral hygiene revised on 09/26/23 revealed a care deficit with teeth and the oral cavity related to poor fitting dentures and included the intervention to refer for dental services for lost or damaged dentures. During an observation on 09/26/23 at 4:31 PM Resident #35 willingly showed his upper and lower dentures. Both the upper and lower dentures appeared unclean with a buildup of debris that was white in color and affected multiple teeth and areas on the gums. An observation and interview were conducted on 09/27/23 at 12:06 PM with the DON. There was no change in the appearance of Resident #35's upper and lower dentures and both continued to have a buildup of white colored debris. The DON asked Resident #35 if she could clean his dentures and instructed him to remove them from his mouth and put them on the napkin she held in her hand. Resident #35 followed the instructions and removed both the upper and lower dentures and gave them to the DON. The DON cleaned the dentures and applied a denture adhesive then placed them back into Resident #35's mouth. Resident #35 accepted the care and was able to follow cues from the DON without refusal. The DON stated denture/oral hygiene care was done in the morning and at night and Resident #35 would refuse care at times and would need to ask the assigned NA if denture care was provided on 09/26/23 and 09/27/23. An interview was conducted on 09/27/23 at 4:11 PM with NA #1. NA #1 revealed she was also assigned to provide care for Resident #35 the morning of 09/26/23. NA #1 stated she offered denture care but Resident #35 refused and residents have the right to refuse care and she was unsure what to do if they did. An interview was conducted on 09/27/23 at 12:15 PM with NA #1. NA #1 revealed she was assigned to provide care for Resident #35 on the morning of 09/27/23. NA #1 stated she did not get Resident #35 out of bed, and she did not provide his denture/oral hygiene care. NA #1 revealed she did not provide denture care because Resident #35 was already out of bed and dressed and she assumed the NA who dressed him also provided denture/oral hygiene care. An interview was conducted on 09/27/23 at 12:27 PM with NA #2. NA #2 stated she was instructed to obtain Resident #35's weight and got him out of bed and dressed on the morning of 09/27/23. NA #2 stated she did not provide Resident #35's denture/oral hygiene care. An interview was conducted on 09/28/23 at 3:44 PM with the DON. The DON revealed oral care was provided in the morning before breakfast and she expected NA staff to offer and provide denture/oral hygiene care. The DON revealed it was a misunderstanding when NA #2 got Resident #35 out of bed and dressed to be weighed and NA #1 assumed denture/oral hygiene care was done. The DON stated NA #1 did not check to ensure Resident #35 received denture/oral hygiene care the morning of 09/27/23 and should have. During an interview on 09/28/23 at 3:55 PM the Administrator revealed the nursing staff followed the facility's protocol and policy for denture/oral hygiene care and if the resident was accepting of the care it was provided.

Based on record review and staff interviews the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of fall, medications, weight loss, discharge, and restraints for 5 of 12 sampled residents (Residents #1, #2, #3, #38, and #8). Findings included: 1.a. Resident #1 was admitted to the facility 06/04/19 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (a blood thinner medication) 3 milligrams (mg) was ordered once a day on 12/23/21. Review of Resident #1's December 2021 and January 2022 Medication Administration Records (MAR) revealed she received [MEDICATION(S)] as ordered. The quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #1 did not receive anticoagulant (blood thinner) medication during the look back period. An interview with the MDS Coordinator on 03/02/22 at 09:29 AM confirmed Resident #1 received anticoagulant medication. She stated the quarterly MDS should have reflected Resident #1 received anticoagulant medication on a daily basis and was an error. An interview with the Director of Nursing (DON) on 03/03/22 at 11:02 AM revealed she expected the MDS to be completed correctly but the MDS Coordinator was new and was still receiving training. An interview with the Administrator on 03/03/22 at 04:28 PM revealed she expected the MDS to be completed correctly. 1.b. Review of a note written by Nurse #5 on 12/10/21 at 11:21 PM revealed Resident #1 had an unwitnessed fall, sustained a laceration to her forehead, and was transported to the hospital. The quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #1 had not had a fall since admission/entry or prior assessment. An interview with the MDS Coordinator on 03/02/22 at 09:29 AM revealed she was new to the role of MDS Coordinator and did not have computer access to review Resident #1's medical record for December 2021. An interview with the Director of Nursing (DON) on 03/03/22 at 11:02 AM revealed she expected the MDS to be completed correctly but the MDS Coordinator was new and was still receiving training. An interview with the Administrator on 03/03/22 at 04:28 PM revealed she expected the MDS to be completed correctly. 2. Resident #3 was admitted to the facility 07/26/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (an antipsychotic medication) 25 milligrams (mg) 2 tablets at bedtime was ordered 01/07/22. [MEDICATION(S)] 25mg 1 tablet every day was ordered 01/08/22. Review of Resident #3's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #3 did not receive antipsychotic medication during the look back period. An interview with the MDS Coordinator on 03/02/22 at 09:29 AM confirmed Resident #3 received antipsychotic medication. She stated the quarterly MDS should have reflected Resident #3 received antipsychotic medications on a daily basis and was an error. An interview with the Director of Nursing (DON) on 03/03/22 at 11:02 AM revealed she expected the MDS to be completed correctly but the MDS Coordinator was new and was still receiving training. An interview with the Administrator on 03/03/22 at 04:28 PM revealed she expected the MDS to be completed correctly. 3. Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A 5-day PPS assessment dated [DATE] noted Resident #8 had intact cognition and required supervision with bed mobility. The assessment also indicated bed rails were used daily as a physical restraint. During an observation and interview on 02/28/22 at 9:40 AM, Resident #8 was observed lying in bed with ¼ bed rails in use. Resident #8 explained she used the bed rails to help with bed mobility and they did not restrict her movement. During an interview on 03/03/22 at 10:31 AM, the Minimum Data Set (MDS) Registered Nurse (RN) explained she had only been in the position for approximately 2 months and was still learning the process. The MDS RN further explained when she completed the PPS assessment on 01/16/22 she did not realize it meant the bed rails were a restraint and confirmed Resident #8 used them to assist with bed mobility. She added the bed rails were noted as restraints in error since they did not meet the definition of a restraint and did not restrict Resident #8's movement. During an interview on 03/03/22 at 10:31 AM, the Director of Nursing (DON) revealed the MDS RN was new to the position and still learning the process. The DON stated she would expect for MDS and PPS assessments to be completed accurately. During an interview 03/03/2022 at 3:24 PM, the Administrator stated the MDS RN was new in her position and was being trained by the Regional MDS Consultant. The Administrator stated she would expect for MDS and PPS assessments to be completed accurately. 4. Resident # 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Dietary Manager's progress note dated 2/8/2022 revealed Resident #2 experienced significant weight loss over the last 90 to 180 days. Review of the Registered Dietician's progress notes dated 2/11/2022 indicated Resident #2's current body weight was 147 pounds, and the resident experienced a 12% weight loss in the last 90 days. Review of weights recorded in the medical record for Resident #2 revealed she weighed 171pounds on 8/10/2021 and 145 pounds on 2/17/2022. This indicated a 15.2% weight loss in this 6-month period. Review of the Minimum Data Set (MDS) Significant Change in Status assessment dated [DATE] did not indicate Resident #2 had experienced significant weight loss. The Dietary Manager was interviewed on 3/3/2022 at 9:45 AM. She revealed the MDS for Resident #2 dated 2/17/2022 should have indicated she had a significant weight loss. A telephone interview was conducted with the Regional MDS Consultant on 3/3/2022 at 12:38 PM. She stated the MDS dated [DATE] for Resident #2 was incorrect and did not reflect the resident's significant weight loss. During an interview 3/3/2022 at 3:24 PM, the Administrator stated not indicating the significant weight loss on Resident #2's MDS dated [DATE] was an error. 5. Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the MDS discharge assessment dated [DATE] noted Resident #38 had been discharge-return not anticipated to an acute hospital. Review of the care plan revealed Resident #38 was to return home with home health services after a short stay for rehabilitation. Review of a nursing progress note dated 11/12/21 revealed Resident #38 had been discharged to home with home health services. An interview with the MDS nurse on 3/2/22 at 9:05am revealed the MDS assessment should have noted Resident #38 had been discharged to the community. An interview with the Director of Nursing on 3/3/22 at 10:36am revealed she expected MDS assessments to be accurate.

Based on observations and staff interview the facility failed to remove expired medications that were available for resident use from 2 of 2 medication carts and 1 of 1 medication storage rooms observed for medication storage. Findings included: 1. An observation of the medication cart for even numbered rooms of 200 hall and all of 300 hall on 03/03/22 at 01:29 PM revealed an opened 887 milliliter (ml) bottle of [CONDITION(S)]-Stat (a ready-to-drink liquid for urinary tract health) with an expiration date of 01/11/22 and an opened bottle of ceravite tablets (a multivitamin) with an expiration date of 01/2022 were available for resident use in the medication cart. An interview with Nurse #4 on 03/03/22 at 01:30 PM revealed she was assigned the medication cart for the even numbered rooms of the 200 hall and all the rooms for 300 hall on 03/03/22 on the 07:00 AM to 07:00 PM shift. She stated medication carts were to be checked daily for expired medication and she had not checked her medication cart since she began her shift at 07:00 AM. Nurse #4 stated she had not administered ceravite or [CONDITION(S)]-Stat on her shift on 03/03/22. An interview with the Director of Nursing (DON) on 03/03/22 at 01:55 PM revealed she expected nursing staff to check expiration dates of medications at the time of administration and medication carts were to be checked for expired medications each night shift. The DON stated she had developed 2 check off lists of tasks, one for the day shift and one for the night shift, that were to be completed each shift. She explained a task on the night shift check off list included checking medication carts for expired medications. A follow-up interview with the DON on 03/03/22 at 02:15 PM revealed she reviewed the check off list of tasks for night shift for past 4 nights and night shift nursing staff had accidentally completed the day shift check off lists, which did not include checking medication carts for expired medications. An interview with the Administrator on 03/03/22 at 04:28 PM revealed she expected medications to be used or discarded on or before their expiration date. 2. An observation of the medication cart for the odd numbered rooms of 200 hall and all of 100 hall on 03/03/22 at 01:33 PM revealed an opened 887 ml bottle of Pro-Stat (a liquid protein supplement) with an expiration date of 02/26/22 was available for resident use in the medication cart. An interview with Medication Aide (MA) #2 on 03/03/22 at 01:35 PM revealed she was assigned the medication cart for the odd numbered rooms of 200 hall and all of 100 hall on 03/03/22 for the 07:00 AM to 03:00 PM shift. She stated she did not check expiration dates of medication on the cart unless she had to add or replace a medication to her medication cart. MA #2 stated she thought medication carts were checked for expired medications on night shift. She stated she had not administered any Pro-Stat on 03/03/22 because all residents who were scheduled to receive Pro-Stat on her shift refused the supplement. An interview with the Director of Nursing (DON) on 03/03/22 at 01:55 PM revealed she expected nursing staff to check expiration dates of medications at the time of administration and medication carts were to be checked for expired medications each night shift. The DON stated she had developed 2 check off lists of tasks, one for the day shift and one for the night shift, that were to be completed each shift. She explained a task on the night shift check off list included checking medication carts for expired medications. A follow-up interview with the DON on 03/03/22 at 02:15 PM revealed she reviewed the check off list of tasks for night shift for past 4 nights and night shift nursing staff had accidentally completed the day shift check off lists, which did not include checking medication carts for expired medications. An interview with the Administrator on 03/03/22 at 04:28 PM revealed she expected medications to be used or discarded on or before their expiration date. 3. An observation of the medication storage room on 03/03/22 at 01:49 PM revealed two 887 ml bottles of [CONDITION(S)]-Stat with an expiration date of 01/11/22 were available for resident use. An interview with the Director of Nursing (DON) on 03/03/22 at 01:55 PM revealed she expected night shift nursing staff to check the medication storage room for expired medications each shift. The DON stated she had developed 2 check off lists of tasks, one for the day shift and one for the night shift, that were to be completed each shift. She explained a task on the night shift check off list included checking the medication storage room for expired medications. A follow-up interview with the DON on 03/03/22 at 02:15 PM revealed she reviewed the check off list of tasks for night shift for past 4 nights and night shift nursing staff had accidentally completed the day shift check off lists, which did not include checking the medication storage room for expired medications. An interview with the Administrator on 03/03/22 at 04:28 PM revealed she expected medications to be used or discarded on or before their expiration date.

Based on record review and staff interviews, the facility failed to implement their abuse policy and procedure in the areas of protection and reporting by: 1) not immediately suspending the staff members suspected to have been involved in the alleged abuse, pending the outcome of the investigation, which allowed them to continue providing care to residents and 2) not reporting an allegation of staff-to-resident abuse to Adult Protective Services for 1 of 3 residents reviewed for abuse (Resident #7). Findings included: A review of the facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 3/10/2017 and read in part, Employees accused of being directly involved in allegations of abuse, neglect, exploitation, or misappropriation of property will be suspended immediately from duty pending the outcome of the investigation. The Administrator will ensure for all allegations that involve abuse .Adult Protective Services are notified immediately but no later than 2 hours after the allegation is received and determination of alleged abuse is made. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. A review of an abuse investigation dated 10/23/21 revealed Resident #7 told a staff member, a big black girl slapped me last night. Resident #7 made the statement to the Payroll/Receptionist on 10/23/21 at 12:30pm during her rounds as the manager on call. She notified the nurses in the facility and the interim Administrator. On 10/23/21, the Payroll/Receptionist interviewed residents and none had any concerns about being abused. Residents were interviewed again on 10/24/21 and 10/25/21 with no negative outcomes. Staff were interviewed and abuse education was conducted by Nurse #2 on 10/23/21. There was no documentation that Adult Protective Services was notified. An interview with the Payroll/Receptionist on 3/2/22 at 8:39am revealed on 10/23/21 at 12:30pm, she was making rounds in the facility when Resident #7 stated a big black girl slapped him last night. She notified the interim Director of Nursing. She stated she did not report the allegation to Adult Protective Services, stating that was outside of her scope. She stated on 10/24/21, the interim Administrator instructed her to take Nurse Aide #1 (NA) and NA #2 into the conference room and get their statements. The interim Administrator talked with NA #1 and NA #2 by phone. NA #1 and NA #2 were suspended on 10/24/21 around noon. Review of NA #1's statement, dated 10/24/21, revealed the resident room #'s for which she provided care on 10/23/21 and that no resident said she hurt them. Review of NA #2's statement, dated 10/24/21, revealed the resident names for which she provided care on 10/23/21, which included Resident #7. Review of the time records provided by the facility revealed the following: NA #1 worked: 10/22/21 6:57am-7:04pm 10/23/21 6:58am-7:07pm 10/24/21 7:03am-12:25pm NA #2 worked: 10/22/21 6:58am-7:03pm 10/23/21 6:59am-7:06pm 10/24/21 7:04am-12:53pm An interview with NA #2 on 3/2/22 at 10:56am revealed she was an agency nurse aide who worked 12 hour shifts during the day at the facility. On 10/23/21, she worked 7am-7pm and cared for Resident #7 during her shift. No one said anything to her on 10/23/21 about there being an allegation of abuse. On 10/24/21, she reported to work at 7am and she cared for Resident #7 on 10/24/21 as well. Around noon she was called to the conference room where the interim Administrator talked with her over the phone. NA #2 stated the interim Administrator suspended her for an allegation of abuse, but she was not told who made the allegation or who the allegation was against. An interview with NA #1 on 3/2/22 at 1:11pm revealed she was an agency nurse aide who worked 12 hour shifts during the day at the facility. On 10/23/21 she worked 7am-7pm but did not care for Resident #7. On 10/24/21, she worked 7am-noon. Around noon she was called to the conference room where the interim Administrator talked with her over the phone. NA #2 stated the interim Administrator suspended her for an allegation of abuse, stating she fit the description stated by the resident. An interview with the interim Director of Nursing (DON) on 3/4/22 at 9:29am revealed she was not in the facility on 10/23/21 or 10/24/21, stating it was in her contract that she was not required to be in the facility on the weekends. She stated Charge Nurse #1 was going to investigate the allegation. An interview with the interim Administrator on 3/4/22 at 1:11pm revealed the facility's Administrator was out of the state the weekend of 10/23/21 through 10/24/21 and she was covering in the Administrator's absence. She stated she was notified of the allegation on 10/23/21, but unable to recall who notified her or at what time. She stated when she was notified, she was traveling and was not in the facility. She stated she delegated the investigation to Charge Nurse #1, who would have notified all parties, including Adult Protective Services. She stated there was no employee in the building that met the description of the abuser or that worked during the night of 10/22/21. The two NAs that were suspended did not work the night of 10/22/21. Since they fit the description stated by the resident, NA #1 and NA #2 were suspended on 10/24/21. The interim Administrator stated both NAs were suspended to protect the residents. She was not able to state why both NA #1 and NA #2 were not suspended immediately after becoming aware of the allegation. The interim Administrator confirmed she did not notify Adult Protective Services after the allegation was made as she was traveling and not in the facility. An interview with Charge Nurse #1 on 3/4/22 at 6:00pm revealed she was one of the nurses working in the facility on 10/23/21 and the afternoon of 10/24/21. On 10/23/21, she was notified by the Administrator via text to fill out the 24-hour report. The information on the report was provided by the interim Administrator. Charge Nurse #1 stated she was not instructed to do anything else nor was she instructed to report the allegation to Adult Protective Services. She stated the interim Administrator was going to notify Adult Protective Services. She stated NA #1 and NA #2 were suspended on 10/24/21 and she was unsure why they were not suspended immediately after the allegation was made. She confirmed she did not call Adult Protective Services about the allegation. An interview with the Administrator on 3/4/22 at 4:23pm revealed she was out of the state on 10/23/21 and 10/24/21. An interim Administrator was covering in her absence. Upon the Administrator's return to the facility, she completed and signed the 5 day report, dated 10/29/21. The Administrator stated she could not speak to why NA #1 and NA #2 were allowed to work until noon on 10/24/21 since she was not involved in the investigation at the time they were suspended. She confirmed that it was the facility's policy to immediately suspend employees accused of abuse pending the outcome of the investigation.

Based on record review and staff interviews, the facility failed to develop comprehensive, individualized care plans that addressed the areas of antidepressant and diuretic medications for 1 of 12 sampled residents reviewed (Resident #8). Findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's active care plans, initiated on 11/29/21 and last reviewed/revised 02/18/22, revealed no care plans that addressed antidepressant or diuretic medication use. The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #8 received antidepressant and diuretic medications 7 of 7 days during the MDS assessment period. Review of Resident #8's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] · [MEDICATION(S)] (antidepressant) 50 mg at bedtime for sleep. · [MEDICATION(S)] (antidepressant) 20 milligrams (mg) once a day for depression. · [MEDICATION(S)] (diuretic) 20 mg once a day for fluid retention. During an interview on 03/02/22 at 10:14 AM, the MDS Nurse explained she typically care planned any medications a resident was taking such as anticoagulants, antidepressants, pain, and diuretics that included interventions to monitor for side effects and notify the physician as needed. The MDS Nurse confirmed Resident #8 received antidepressant and diuretic medications during the 7-day MDS assessment period for the assessment dated [DATE]. She added both should have been included in her comprehensive care plan. The MDS Nurse stated it was an oversight and explained she had only been in the position for approximately 2 months and was still learning the process. During an interview on 03/03/22 at 10:31 AM, the Director of Nursing (DON) revealed prior to the MDS Nurse starting employment at the facility, floor nurses were completing care plans and they have since revised the process so that the MDS Nurse would be responsible for ensuring care plans were developed. The DON confirmed Resident #8 received antidepressant and diuretic medications during the MDS assessment period of 12/20/21 and care plans should have been developed and included in her comprehensive care plan. During an interview 03/03/22 at 3:24 PM, the Administrator stated she would expect for care plans to be comprehensive, and plans developed for each resident as indicated. The Administrator added the MDS Nurse was new in her position and was being trained by the Regional MDS Consultant.

Based on observations and interviews with staff the facility failed to perform hand hygiene before meal tray setup and after contact with objects in the resident's environment during the delivery and service of meals for 1 of 3 staff observed for infection control (Medication Aide #1). The findings included: Review of the facility's Infection Control Manual dated 03/10/20 read in part: The most effective single method for the prevention of infection is hand hygiene. Handwashing Procedure of when should you wash your hands included before and after contact with a resident. The use of an alcohol-based hand sanitizer (hand sanitizer that contains at least 60% alcohol) may be used unless the hands are visibly soiled. A continuous observation of meal tray delivery and setup was conducted on 02/28/22 at 12:39 PM through 02/28/22 at 12:45 PM. Medication Aide (MA) #1 was not observed to perform hand hygiene before he removed a meal tray from the food cart. MA #1 entered Resident #21's room and placed the meal tray on the bedside table then unwrapped the napkin and removed the silverware. MA #1 grabbed the fork by the handle and placed it in a food item then removed the lid from a cup of coffee. MA #1 then left the room and without performing hand hygiene retrieved a second meal tray from the food cart. MA #1 entered Resident #387's room and placed the meal tray on the bedside table. MA #1 grabbed Resident #387's walker and wheelchair by the handles and moved those items out of his way. MA #1 unwrapped the napkin and removed the fork and knife and placed those items beside the plate of food. MA #1 grabbed the bedside table and repositioned closer to the resident. Without performing hand hygiene MA #1 left room and retrieved a third meal tray from the food cart. MA #1 entered Resident #15's room and placed the meal tray on bedside table. Resident #15 requested to leave the tray as is and MA #1 left the room. MA #1 located a dispenser of alcohol-based hand sanitizer attached to the wall on the hallway where meals were being served and sanitized his hands. An interview was conducted with MA #1 on 02/28/22 at 12:59 PM. MA #1 stated he was not sure about when to perform hand hygiene when serving meal trays to residents. MA #1 revealed he had always been told to do hand hygiene every third room when serving meal trays and that's what he did. MA #1 was unsure what the facility's policy was about meal trays service between resident rooms but stated if he touched a resident or their personal items such as handles on a wheelchair or walker, he should've performed hand hygiene. An interview was conducted on 03/03/22 at 4:36 PM with the Administrator. The concerns of meal tray delivery and setup were shared. The Administrator stated the Director of Nursing (DON) was responsible for infection control and deferred questions related to hand hygiene during meal tray service to her. During an interview on 03/03/22 at 5:51 PM the observation of meal tray delivery and setup for residents was shared with the DON. The DON stated she expected facility staff to perform hand hygiene or at least use an alcohol-based hand sanitizer after the handles of a resident's wheelchair and walker were touched.

Based on record review and staff interviews the facility failed to complete a recapitulation of stay for 1 of 2 closed records reviewed for planned discharge (Resident #88). Findings included: Resident #88 was admitted to the facility 03/05/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data set (MDS) dated [DATE] revealed Resident #88 was cognitively intact, discharge planning was in place, and he expected to be discharged to the community. Review of the medical record revealed Resident #88 was discharged to the community 04/16/21. Review of Resident #88's electronic medical record (EMR) revealed no discharge summary that included all the components of a recapitulation of stay. An interview with the Social Worker (SW) on 03/02/22 at 5:22 PM revealed the Administrator had a check-off form/audit tool that was completed after a resident was discharged . She stated the form included the resident's disposition and if any social services, dietary information, clinical information, or post discharge instructions were provided. She stated that served as a recapitulation of a resident's stay and this form was completed for Resident #88. An interview with the Administrator on 03/03/22 at 03:07 PM revealed discharge documentation included a d/c summary, a nurse's note, a SW's note, an order summary, discharge instructions and plan of care that were completed at or near the time of discharge and were each a separate document. She explained a Discharge Item Checklist/Audit was completed after discharge. The Administrator confirmed there was not a comprehensive document that served as recapitulation of stay. A follow-up interview with the Administrator on 03/03/22 at 04:35 PM revealed she was familiar with the elements that needed to be included in a recapitulation of stay due to her previous work as an Administrator in another state. She explained the facility was following the discharge documentation requirements from the corporation but she was going to talk with the company to see if modifications could be made to discharge documentation procedures to meet the regulation requirements.

Based on record review, observations, and staff interviews the facility failed to serve the correct amount of salad and omitted vegetable sticks from the planned menu as recommended by the Registered Dietician. An observation on 11/18/19 at 4:26 PM revealed the Cook was instructed by the Dietary Manager (DM) to serve 1/2 cup of salad. There were no veggie sticks observed on the tray service line. The DM instructed the Cook to only serve breaded veggies to the resident who received a mechanically altered diet. The Cook served the salad as directed and omitted the vegetable sticks from regular diet plates. At 4:51 PM approximately 10 meals were plated with a 1/2 cup of salad and no vegetable sticks. The plates were covered, and ready to leave the kitchen. A review of the menu guide with DM on 11/18/19 at 4:51 PM revealed 1 cup of salad and vegetable sticks were to be served to residents receiving a regular diet and a breaded veggie to residents on a mechanically altered diet. During an interview on 11/18/19 at 4:51 PM the DM explained she had misread and/or misunderstood and incorrectly instructed the Cook to serve 1/2 cup of salad instead of a 1 cup per the menu guidelines. She also confirmed the vegetable sticks were omitted for residents who received a regular diet. A telephone interview conducted on 11/20/19 at 8:20 AM with the Registered Dietician revealed the menu guide provided portions amounts of food items served for each meal. The RD explained the guide was in place to be followed by the dietary staff to ensure residents received the correct amount and items listed for each meal. During an interview on 11/20/19 at 12:58 PM the Interim Administrator Consultant revealed it was her expectation the menu and RD guidelines were followed. She expected residents were served the correct portions and food items.

Based on resident and staff interviews and record reviews, the facility failed to transcribe an order to increase oxygen during exertion for 2 days which resulted in this not being communicated to staff and failed to provide a medication list to the requesting physician for 1 of 2 residents sampled for oxygen therapy (Resident #95). The findings included: 1. a. Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and able to make his needs known. The MDS also noted he received oxygen therapy. Resident #95 was discharged home on[DATE]. Review of the care plan, dated 5/1/19, revealed Resident #95 was care planned for ineffective breathing with interventions including oxygen continuously at 4 to 5 l/min to keep oxygen saturations 90% or higher. The care plan, revised on 5/14/19, revealed Resident #95 was to be on oxygen therapy 4 l/min via nasal cannula at rest; 6 l/min with exertion. Review of a physician order [REDACTED].#95 to have oxygen at 4-5 liters per minute (l/min) to keep oxygen saturations (O2 sats) 90% or higher. Another order, dated 5/14/19 written by the pulmonologist, stated Resident #95 was to receive oxygen 4 l/min at rest; 6 l/min with exertion. This order was signed off by the Director of Nursing on 5/16/19. Review of the Medication Administration Record (MAR) revealed: -5/1/19 an order for [REDACTED]. O2 sats were to be documented q shift. -5/14/19 an oxygen order for 4 l/min per nasal cannula at rest and 6 l/min per nasal cannula with exertion was added to the MAR and dated 5/14/19. -Review of O2 sats from 05/01/19 through 5/22/19 revealed all were at 90% or higher except one reading on 5/17/19. An interview, conducted with the Director of Nursing (DON) on 11/19/19 at 4:49 PM, revealed Resident #95 went to see the pulmonologist on 5/14/19. Nurse #1, who was caring for the resident, was responsible for reviewing the consult report and transcribing the new order. The DON stated she found the pulmonologist Consultation Report dated 5/14/19 in the doctor's book on 5/16/19, with recommendations to give the resident 4 l/min of O2 continuous at rest, or 6 l/min O2 continuous with exertion. After finding the Consultation Report with the new orders, she then transcribed the order to the Medication Administration Record and dated it 5/14/19. The order was faxed to the pharmacy and added to the Medication Administration Record (MAR) on 5/16/19 at 1:00 PM. She stated she did not think to communicate the new order to therapy since it was not a designated order for therapy. Nurse #1, who was caring for Resident #95 on 5/17/19 should have been aware that he was to be on 6 liters while therapy was working with him. After PT#1 asked Nurse #1 if the resident was to be on 6 l/min while exercising, she should have checked the orders. The DON stated when the Consultation Report was returned from the pulmonologist, Nurse #1 should have transcribed the order for 6 liters of oxygen with exertion and put the new order on the MAR. However, the DON stated she would not have expected the nurse to communicate with therapy because she had not thought to notify them either. New orders were communicated to the care team in the morning meetings. The DON was not sure if she shared the new order in morning meeting on 5/17/19. Review of a physical therapy progress note, dated 5/17/19, revealed physical therapist (PT) #1 entered Resident #95's room to begin therapy. Resident #95 was on 4 liters of oxygen and his oxygen saturation was 85%. After some breathing exercises, his oxygen saturation increased to 92% within 10 seconds. Resident #95's family member reported his oxygen was supposed to be on 6 liters anytime he was up and on his feet. The therapist spoke to Resident #95's nurse who responded that she had never been told that he was supposed to be on 6 liters and there were no orders to increase his oxygen. An interview, conducted with the Rehab Program Director on 11/19/19 at 9:19 AM, revealed PT #1 was unavailable for interview. She stated if an order is received after the resident has been in the facility for a while, therapy finds out about the order in the morning meeting when all new orders are reviewed and shared with therapy. An interview conducted with the Rehab Manager (RM) on 11/19/19 at 2:58 PM revealed the therapists were not aware of the new order for Resident #95 to be on oxygen at 6 liters per minute during exertion. She stated when a new order comes in, she finds out about it in the morning meeting and follows up to make sure the primary therapist is aware. All new orders are usually reviewed in the morning management meetings. She further stated she was not sure how or why the order for oxygen at 6 liters with exertion was not communicated or a copy given to the therapy department. RM knew he had an appointment with the [MEDICAL CONDITION] physician on 5/14/19 but stated they don't check the chart for new orders if the appointment was not orthopedic or therapy related. Nurse #1 was not available for interview. An interview conducted with the Assistant Director of Nursing (ADON) on 11/20/19 at 11:30 AM revealed she received a copy of the new order for oxygen at 6 l/min with exertion sometime on 5/17/19. She stated she added a note on the communication board dated 5/17/19 and timed 3:01pm which stated, FYI: Each shift Resident #95 adjust his O2 to 6 l/min when he transfers/toilets-otherwise he's on 4 liters. Please make a note to indicate this each shift. This is a doctor order. The ADON confirmed that the nurse who worked first shift on 5/17/19 would not have seen the communication note. An interview, conducted with the Interim Administrator on 11/20/19 at 11:38 AM, revealed the nurse who was caring for Resident #95 on 5/14/19 should have processed the orders when she received them from the pulmonologist office on 5/14/19. b. An interview with Resident 95's family member on 11/17/19 at 7:45 PM revealed the facility never sent the resident's medication list requested by the cardiologist on 5/16/19. The family member explained the cardiologist requested the medication list because he needed to know what antibiotic Resident #95 was taking for [MEDICAL CONDITION]. She stated that when she checked with the cardiologist office on 5/17/19, the facility still had not faxed the medication list. An interview with Nursing Assistant (NA) #1 on 11/18/19 at 2:04 PM revealed she accompanied Resident #95 to a cardiology appointment on 5/16/19. She stated[NAME] Clerk #1 made copies of his medical records and put the copies in an envelope and she gave the envelope to an employee at the cardiology office when Resident #95 was checked in for his appointment. NA #1 stated she did not open the envelope, so she did not know which medical records were in the envelope and sent to the cardiology office. [NAME] Clerk #1 was no longer employed by the facility and was not available for interview. Review of the Consultation report sheet, dated 5/16/19 and signed by the cardiologist, revealed an order for [REDACTED]. The order was noted by Nurse #2 and dated 5/16/19. An interview with Nurse #2 on 11/19/19 at 4:31 PM revealed she noted the order to fax Resident #95's medication list to the cardiology office on the Consultation form on 5/16/19 but failed to follow through with asking anyone to fax the Medication Administration Record (MAR). Nurse #2 could not find a fax confirmation that the medication list was faxed. An interview with the Director of Nursing (DON) on 11/18/19 at 2:30 PM revealed when a resident goes to a physician appointment, the[NAME] Clerk makes a copy of the resident's demographic sheet, the MAR and a blank consultation report sheet. The DON indicated no one knew for sure if the MAR was sent with Resident #95 to his appointment with the cardiologist on 5/14/19. After the resident is seen by the physician, the physician writes any new orders on the blank consultation report sheet. The consultation report sheet with the new orders is brought back to the facility and given to facility staff. The interview further revealed Nurse #2 should have sent Resident #95's MAR by fax to the cardiologist's office on 5/16/19. An interview with the Interim Administrator on 11/20/19 at 11:38 AM revealed that the facility staff should follow-up on orders the same day they are received. The medication list requested by the cardiologist should have been faxed to them on 5/16/19.

Based on record review and staff interviews, the facility failed to complete a significant change Minimum Data Set (MDS) for a resident with two areas of change, a Stage 4 pressure ulcer and suspected Deep Tissue Injury (sDTI), for 1 of 2 residents reviewed for pressure ulcers. Findings included: Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The following secondary [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #3's cognition was moderately impaired, needed extensive assistance with two (2) plus person physical assistance for bed mobility and dressing, total dependence with 2 plus person physical assistance for transfers and toileting, and extensive assistance with one (1) person physical assistance for eating. The MDS further indicated Resident #3 was frequently incontinent of bowel and bladder and was at risk of developing pressure ulcers but was not coded for having any pressure ulcers or opioids (pain medications). The MDS revealed the resident was coded for a pressure reducing device for a chair and bed. A review of the Pressure Ulcer Care Area Assessment (CAA), dated 04/29/18, revealed Resident #3 received a pureed diet with nectar thickened liquids with an average meal intake between 50 -100% and the staff fed her. The CAA further revealed she was non-ambulatory. The CAA indicated she was at risk for pressure ulcer development but had no skin breakdown or pressure areas. The MDS further indicated that Resident #3 needed extensive assistance with bed mobility and other activities of daily living (ADL's) and that therapy was working with the resident to reduce right sided weakness. A review of a Skin Referral Form, dated 05/06/18, indicated Resident #3 had broken skin on her coccyx. A review of a Skin Referral Form, dated 05/14/18, indicated Resident #3 was evaluated by the Treatment Nurse and she determined the resident had a Stage 3 pressure ulcer on the cleft of her buttock. The Skin Referral Form further indicated that treatment orders were initiated. A review of a Wound Ulcer Flowsheet, dated 05/17/18, indicated there was a Stage 3 pressure ulcer on the left inner buttock that measured 3.5-centimeter (cm) (length) x 2 cm (width) x 1 cm (depth). A review of a Wound Ulcer Flowsheet, dated 05/23/18, indicated that the pressure ulcer on the left inner buttock was re-classified as an Unstageable pressure ulcer that measured 3.5 cm x 2 cm x 1.4 cm with an increased depth. A review of a Wound Ulcer Flowsheet, dated 05/30/18, indicated that the Unstageable pressure ulcer on Resident #3's left inner buttock measured 3.5 cm x 2 cm x 3 cm. The flowsheet further indicated that the wound had purulent (pus-like) drainage and an odor. The flowsheet revealed that a wound culture was ordered, and the wound was infected. A review of a Wound Ulcer Flowsheet, dated 06/08/18, indicated the pressure ulcer on the left inner buttock was re-classified as a Stage 4 pressure ulcer and measured as 3 cm x 1.3 cm x 2.2 cm. A review of a Wound Ulcer Flowsheet, dated 07/06/18, indicated Resident #3 developed a Suspected Deep Tissue Injury (sDTI) on the left heel which measured 3 cm x 2 cm x 0 cm. A review of a Wound Ulcer Flowsheet, dated 07/18/18, indicated the Stage 4 pressure ulcer site was named as a Sacral wound instead of left inner buttock that measured 3.5 cm x 2 cm x 2 cm. The flowsheet further indicated no infection was present in the wound. A review of the Quarterly MDS, dated [DATE], revealed Resident #3 had short and long-term memory problems and was severely impaired regarding daily decision making. The MDS further revealed Resident #3 needed total dependence with 2 plus person physical assistance for bed mobility, transfers, dressing, and toileting and total dependence with 1-person physical assistance for eating. The MDS indicated Resident #3 was always incontinent of bowel and had an indwelling Foley catheter. The MDS further indicated the resident was coded for a Stage 4 pressure ulcer, a Suspected Deep tissue injury (sDTI), a pressure reducing device for a chair and bed, nutrition interventions, pressure ulcer care and 1 day of opioids within 7 days. A review of Resident #3's medical record, from (MONTH) (YEAR) to (MONTH) (YEAR), indicated that a Significant Change MDS was not implemented following the discovery of the Stage 4 Sacral pressure ulcer and sDTI of the left heel. A review of a Wound Ulcer Flowsheet, dated 08/20/18, indicated the left heel pressure ulcer was re-classified as Unstageable and measured 1 cm x 2 cm x 0 cm. A review of a Wound Ulcer Flowsheet, dated 09/21/18, indicated the left heel wound was re-classified as an Arterial Ulcer that measured 1 cm x 1.4 cm x 0.3 cm. The flowsheet further indicated that specialized boots were put implemented as an intervention. A review of a Wound Ulcer Flowsheet, dated 10/30/18, indicated the Stage 4 Sacral pressure ulcer measured 1 cm x 1.3 cm x 1 cm and no infection was present. The flowsheet further indicated that the left heel arterial ulcer measured 0.8 cm x 0.6 cm x 0.5 cm and no infection was present. On 11/02/18 at 10:28 AM, an interview was conducted with the MDS nurse. She indicated that the 2 areas of change related to the pressure ulcers that developed should have warranted a Significant Change MDS prior to the Quarterly MDS, dated [DATE]. On 11/02/18 at 01:18 PM, an interview was conducted with the Administrator. She indicated that her expectation was that there should have been a Significant Change MDS for Resident #3 with the development of the 2 pressure ulcers prior to the Quarterly MDS, dated [DATE].

Based on record review and staff interviews, the facility failed to develop a baseline care plan in the areas of surgical incision and infection within 48 hours of admission to the facility for 1 of 2 newly admitted residents reviewed for baseline care plan (Resident #92). The findings included: Resident #92 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the hospital discharge orders, dated 09/10/18, revealed an order for [REDACTED]. A review of a physician order, dated 09/14/18, revealed an order for [REDACTED]. A review of the nursing admission assessment, dated 09/10/18 at 6:22 PM, revealed Resident #92 was alert and oriented to person, place, and time. The admission assessment further revealed there was a mid to lower back surgical incision which measured 4.5 inches long with thick black stitches that were intact. The assessment indicated the dressing had a small amount of serosanguinous drainage noted to the base of the dressing and that the dressing was changed on 09/10/18 at the hospital prior to the resident transferring to the facility. A review of the skilled/post-acute nursing note, dated 09/11/18 at 4:57 AM, indicated Resident #92's skin was intact and the dressing to her back was intact. The skilled/post-acute nursing note further indicated that the resident was receiving an antibiotic for infection. A review of the Admission Minimum Data Set (MDS), dated [DATE], indicated Resident #92 was cognitively intact, needed limited assistance with two (2) plus person physical assistance for bed mobility, limited assistance with one (1) person physical assistance for transfers and extensive assistance with 1-person physical assistance for dressing and toileting. The MDS revealed that the resident had the following areas coded: an infection following a procedure, a surgical wound with surgical wound care and received 7 days of antibiotics since admission. A review of the Resident #92's baseline care plan, dated 09/21/18, revealed there was no Focus or Problem related to the surgical incision or the surgical infection. An interview was conducted with the Treatment Nurse on 11/01/18 at 10:58 AM. She indicated that she oversaw Resident #92's dressing changes. She further indicated the resident's surgical incision had healed well. An interview was conducted with the MDS nurse on 11/02/18 at 10:40 AM. She stated that the Baseline Care Plan should have addressed the surgical Incision and the infection. An interview was conducted with the Director of Nursing (DON) on 11/02/18 at 12: 53 PM. She did not address the issue of the baseline care plan but did state when the facility had the new admission on 09/10/18, Nurse #2 completed the admission assessment on Resident #92. The DON further stated that Nurse #2 checked the resident's dressing, performed a head-to-toe assessment, and sent a skin referral to the treatment nurse. An interview was conducted with the Administrator on 11/02/18 at 01:18 PM. She indicated that her expectation was that the baseline care plan should have addressed the surgical incision and the wound infection.

Based on medical record review, observations, staff interviews and physician interview the facility failed to implement measures to prevent falls for two (2) of six (6) sampled residents with a history of falls. (Residents #7 and #8) The findings are: 1. Resident #8 had [DIAGNOSES REDACTED]. Review of a 12/08/11 "Falls committee" note revealed Resident #8 experienced multiple falls over last several months and she refused to use the call bell to request assistance. Staff were to "round frequently" to assess for resident needs. A significant change Minimum Data Set (MDS) of 12/12/11 specified Resident #8 had moderately impaired cognitive skills and required extensive assistance with transfers and toileting. The resident's "Falls" Care Area Assessment (CAA) dated 12/15/11 read, "Long term resident of facility that has history of falls. Resident is able to call for assistance as needed. Will address in care plan". Review of Resident #8's care plan, that was in place on 12/15/11, included the problem area, "Risk for falls characterized by history of falls/multiple risk factors related to: disease process (Parkinsonism); unsteady gait." The goal to this problem area included: "Resident will remain free of injury as evidenced by no injuries from falls or accidents thru review period." Approaches to address the problem area included: assist during transfer and mobility, encourage resident to take rest periods as needed, observe for decline or change in mobility and refer to therapy as indicated, have commonly used articles within easy reach, provide frequent reminders to resident to call for assistance before getting up, resident to wear proper and non slip footwear and encourage use of wheelchair when out of bed for mobility. Review of Resident #8's medical record revealed that from 12/17/11 to 04/17/12 she experienced a total of eleven (11) unsupervised falls which occurred on the following dates; 12/17/11, 12/19/11, 12/27/11, 01/12/12, 01/14/12, 01/19/12, 03/11/12, 03/27/12, 04/01/12, 04/11/12 and 04/17/12. Further medical record review revealed Resident #8 was injured during five (5) of these unsupervised falls on the following dates: 12/27/11: Found on floor on her back with right knee bent up against wall with her right foot rotated outward. A radiology report of 12/29/11 revealed Resident #8 experienced a fractured right toe. 01/12/12: Found in room on floor with her wheel chair resting on top of her. Resident had small amount of bleeding from right side of head and sent to emergency room for evaluation. Hospital records of 01/12/12 revealed Resident #8 had a laceration above her right temple which was closed with sutures. 01/14/12: Found in room on floor in a small puddle of blood. Hospital records of 01/14/12 revealed Resident #8 had a skin tear with hematoma to her forehead as well as pain to her left shoulder. 03/11/12: Found in bathroom on floor with head against the wall with a quarter sized knot and redness across shoulder blades. Hospital records of 03/11/12 specified that Resident #8 experienced an acute cervical strain and contusion to her right shoulder. 04/11/12: Found in room on floor lying face down with her wheelchair on top of her and bloody drainage noted from left hand. Hospital records of 04/11/12 specified that Resident #8 experienced multiple abrasions to right knee and left hand and with multiple contusions with soft tissue hematoma to head, right knee and left hand. Observations of Resident #8 on 04/16/12 at 7:25 AM revealed she had a dark purple bruise on her forehead, around a significant portion of her right eye and bridge of her nose which covered approximately a 16 cm by 7 cm wide area. When questioned, Resident #8 stated that a couple days ago she fell . On 04/18/12 at 10:30 AM Resident #8's physician (MD) was interviewed. The physician stated that Resident #8 was predisposed to falls due to Parkinson's disease. The MD stated physical therapy had been tried to improve functional ability but because of Parkinson's disease Resident #8 did not have the ability to self-correct if she got off balance. The MD stated after Resident #8 worked with physical therapy she thought she could do more than she is capable of doing and attempts to transfer herself and falls. The MD stated staff try to keep Resident #8 in her wheelchair because she could not ambulate safely noting most of her falls occurred when she attempted to self-transfer. On 04/20/12 at 9:10 AM the occupational therapist (OTR) reported Resident #8 was a difficult resident due to memory problems, no attention to task and control issues related to the Parkinson's. The OTR stated Resident #8 had no desire to be safe and that staff had to stay with her when toileting and transferring because Resident #8 would move impulsively. The OTR stated in the past changes had been made for Resident #8 which included placing her in a lower wheelchair with antitippers and a wedge cushion. The OTR stated Resident #8 was currently being assessed for interventions to prevent future falls. On 04/20/12 at 12:35 PM the Director of Nursing (DON), Assistant Director of Nursing (ADON) and MDS Coordinators #1 and #2 were interviewed regarding Resident #8's eleven (11) unsupervised falls experienced from 12/17/11 to 04/17/12. Staff confirmed that during this time period five (5) of these falls resulted in Resident #8 being injured. During this interview staff provided the following information regarding the eleven (11) unsupervised falls experienced by Resident #8 since 12/17/11 and the facility's response to each of these falls: 12/17/11- The DON confirmed that the nurse should not have left Resident #8 unattended in bathroom. MDS Coordinator #2 stated that no other interventions were implemented to prevent further falls. 12/19/11- The DON confirmed that Resident #8 was unsupervised during this fall and she experienced bruised buttocks. MDS Coordinator #2 specified the only change made to the resident's care plan was to remove the use of bed and chair alarms. 12/27/11- The DON confirmed that Resident #8 was unsupervised during this fall and experienced a fractured toe. The DON stated that nursing assistants were educated on the importance of staying with residents. MDS coordinator #2 confirmed that no changes were made to Resident #8's care plan. 1/12/12- The DON confirmed the resident was unsupervised during this fall and experienced a laceration to her right temple which required sutures. The DON stated in response to this fall the physician ordered anti tippers to the resident's wheel chair on 1/13/12. 1/14/12- The DON confirmed the resident was unsupervised during this fall and experienced skin tear with hematoma to her forehead. The ADON stated that the falls committee's response, to the resident's falls which occurred on 1/12/12 and 1/14/12, was to place anti tippers on the resident's wheel chair. 1/19/12- The DON confirmed that Resident #8 was unsupervised during this fall. The ADON stated that in response to this fall the facility placed a one way non skid cushion in Resident #8's wheel chair to keep her from getting out of her wheel chair unassisted. 03/11/12- The DON confirmed that Resident #8 was unsupervised during this fall and experienced an acute cervical strain and contusion to her right shoulder. ADON confirmed that although the resident was injured from this fall no other interventions were implemented to prevent further falls. 03/27/12- The DON confirmed that Resident #8 was unsupervised during this fall. The ADON and MDS Coordinator #2 confirmed no other interventions were implemented to prevent further falls. 04/01/12- The DON confirmed that Resident #8 was unsupervised during this fall. Resident #8 was seen by a psychiatrist on 04/03/12 to evaluate for "cognition and mood", but no recommendations were made regarding the resident's falls. 04/11/12- The DON confirmed that Resident #8 was unsupervised during this fall which resulted in injuries. In response to this fall the social worker was to discuss the resident's noncompliance with falls interventions. 04/17/12- The DON confirmed that Resident #8 was unsupervised during this fall. The facility's response to this fall was to implement a rock and go wheel chair with self release alarm belt. On 04/20/12 at 3:05 PM Nursing Assistant (NA) #1, who regularly worked with Resident #8, was interviewed. NA #1 stated that she had worked with Resident #8 for a couple years and despite telling the resident to call for assistance she would attempt to care for herself independently. NA #1 stated that she tried to check on Resident #8 every one to two hours, but Resident #8 would not consistently allow staff to assist with toileting. 2. Resident #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] revealed she was assessed to be moderately impaired for making daily care decisions, required limited assistance with walking, and required extensive assistance for transferring, bed mobility, dressing. Resident #7 had a history of [REDACTED]. Resident #7's quarterly MDS dated 02/03/12 specified she had experienced falls; she was assessed to be severely impaired for making daily decisions, and required extensive assistance of one person for transfer, bathing, bed mobility and hygiene. The Care Area Assessment (CAA) dated 08/04/11 revealed Resident #7 was at risk for falls and had impaired balance. A review of the care plan dated 08/04/11 and updated on 02/09/12 identified the resident at "Risk for falls." The care plan's goal specified, "Resident will remain free of injury as evidenced by no injuries from falls or accidents thru this review." The care plan specified interventions for falls including: "provide personal alarm and bed alarm; assist during transfer; rehabilitation therapy referral as needed; provide frequent reminders for resident to call for assistance before getting up; provide frequent staff observation of resident; resident to wear proper and non-slip footwear; and assist with toileting resident as needed." Review of a Licensed Nurse (LN) progress note dated 08/16/11 revealed Resident #7 attempted to get out of bed without assistance and sat on the floor. Nurse's notes dated 08/16/11 at 11:19 PM stated the bed alarm was in place and that Resident #7 received a six (6) centimeter skin tear to her lower outer leg. A Falls Committee note signed by the Assistant Director of Nursing (ADON) dated 08/17/11 revealed, "Resident encouraged to use call bell for assistance with transfer, staff instructed to round frequently to anticipate resident needs." Review of a LN progress note dated 09/09/11 at 9:20 PM Resident #7 fell forward from her wheelchair, hit the floor, and developed a large hematoma to her left forehead. The resident was sent to the emergency department after consultation with the physician and discharged back to the facility on [DATE] early in the morning. No information on facility review of this incident could be located. There was no documentation of alarms being in use. No new interventions were documented as being implemented. Review of a LN progress note dated 10/16/11 at 9:45 PM revealed the resident was observed by three facility staff members as she attempted to get out of bed without assistance. Resident #7 fell backwards across bed striking the over bed table slightly with the top right side of her head. No information on facility review of this incident could be located. No new interventions were documented as being implemented. A Falls Committee note signed by the ADON dated 11/14/11 indicated the personal alarms were removed for Resident #7 due to no attempts to self-transfer in several months. Review of a Licensed Nurse (LN) progress note dated 01/11/12 at 8:51 PM stated Resident #7 was "found in floor next to her bed resting her back against the bed." No injures were reported. A Falls Committee note signed by the ADON dated 01/12/12 stated the resident was reviewed for the unobserved fall and staff was educated on the importance of placing the resident in non-skid footwear. Review of a LN progress note dated 01/19/12 at 7:10 PM revealed Resident #7 was found on the floor with her back against her bed with a half inch skin tear to her right shin. The resident stated that she slid out of her wheelchair onto the floor while trying to get into her bed. A Falls Committee note signed by the ADON dated 01/23/12 indicated a one-way slide mat (non-skid) was implemented for Resident #7's wheelchair and staff was to continue to round frequently. Review of a LN progress note dated 04/15/12 at 8:25 PM revealed Resident #7 was found by the nursing assistant in floor of her room sitting in front of her wheelchair. Resident #7 was assessed to have "scrape marks on both shoulder blades and below right shoulder blade." The resident denied injury to her head. The nurse's note indicated Resident #7's wheelchair brake was off and Resident #7 was reminded to call for assistance. An interview with the ADON on 4/20/12 at 3:40 PM revealed she reviewed and did a root cause analysis on each incident. The ADON stated she was aware that Resident #7 had experienced previous falls. She stated she was not informed of the falls Resident #7 experienced on 09/09/11 and 10/16/11. The ADON explained that since she was unaware of both of these falls, no follow up or evaluation was conducted to determine why the resident had fallen and no interventions were attempted to prevent future falls. The ADON indicated when reviewing the fall on 01/11/12 she could not locate any records from the investigation, but from review of the nurse's notes and Falls Committee note, absence of non-skid socks must have been a contributing factor. The ADON further indicated that the fall on 04/15/12 had not been fully investigated. An interview on 04/20/12 at 4:12 PM with the Director of Nursing (DON) revealed the ADON collected all of the information for the investigation then presented her findings at the daily meeting. The DON confirmed no documentation or Falls Committee note could be located for the falls on 10/16/11 and 04/15/12. The DON specified she expected the ADON to implement pertinent interventions discovered from the fall investigations and reeducate staff as needed on items such as placing call bell close to resident, placing non-skid socks on residents and monitoring.