Every finding on record at Summerford Health and Rehab, LLC

Based on record reviews, interviews, document reviews, and policy review, the facility failed to ensure sufficient staff were available to provide supervision for residents on the facility's secured unit during the night shift. On 01/09/2023 at approximately 2:30 AM, staff left residents on the [NAME] Haven Unit (a locked, secured unit where 24 residents resided) unsupervised to take care of residents on other units because there was an insufficient number of staff. While the locked/secured unit was unsupervised, Resident #404 struck their roommate, Resident #403, with a cane which resulted in a facial laceration, facial bruising and swelling, and multiple other injuries to the resident's body. This failure affected one of nine units in the facility. Findings included: A review of the facility's Staffing policy revised October 2017 revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care . A review of the facility's 2023 Facility Assessment updated 08/10/2023, indicated in Section 3.1 . Our general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time . Per the Facility Assessment, the direct care staff (licensed and certified) were . 1:6 resident ratio days (total licensed or certified) 1:8 resident ratio evenings 1:10 resident ratio nights This includes RN [Registered Nurse] Supervisors, Restorative Nurse, LPNs [Licensed Practical Nurses] and CNAs [Certified Nursing Assistants] providing direct care . A review of Section 3.2 titled Staffing plan, indicated . Our staffing plan to meet the needs of the resident population. Staff needed for care for our resident census/population: Licensed or Registered Nurses providing direct care . 3-5 on nights . Nurses Aides . 7-9 on nights . Section 3.3 Individual staff assignment, revealed . How we determine and review individual staff assignments for coordination and continuity of care for residents within and across staff assignment. We compare our overall census and/or resident acuity needs to determine if we need to adjust staffing. Acuity needs change often, so we may adjust schedule assignments each shift. Charge Nurse or Registered Nurses on call may adapt staffing based on our internal communication tools, such as our verbal shift change report, or team talks . A review of the facility schedule for Sunday 01/08/2023 for the 11:00 PM to 7:00 AM shift, revealed LPN #15 was scheduled to work the 1st North Unit and the [NAME] Haven Unit. The schedule indicated one CNA (CNA #32) was scheduled to work the [NAME] Haven Unit, one CNA was scheduled on the 1st North Unit, one CNA was scheduled for the Far North Unit, and the word split was written on the schedule for the Northeast (NE) Unit. According to the schedule, there were nine total staff members (three LPNs and five CNAs) for the 11:00 PM to 7:00 AM shift that began on 01/08/2023. A review of an undated, unlabeled, handwritten note provided by the Administrator indicated on 01/08/2023, during the 11:00 PM to 7:00 AM shift, there were nine total staff that worked in the facility and not 10 to 14 staff as required per the 2023 Facility Assessment. A review of the facility's Daily Census report dated 01/08/2023, indicated the [NAME] Haven Unit/secured unit had a census of 24 residents, resulting in a resident to staff ratio of 1:12, not 1:10 per the 2023 Facility Assessment for the evening shift. A review of Resident #403's Admission Record revealed the facility admitted the resident on 10/22/2022 with diagnoses that included dementia, generalized anxiety, adjustment disorder with depressed mood, and sleep disorder. A review of Resident #403's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 10/26/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. A review of Resident #404's Admission Record revealed the facility admitted the resident on 03/25/2021. Per the Admission Record, Resident #404's diagnoses included vascular dementia with agitation, anxiety disorder, and insomnia. A review of Resident #404's annual MDS, with an ARD of 02/01/2023 revealed the resident had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. A review of the facility's Investigation Template dated 01/16/2023 revealed on 01/09/2023 at approximately 3:45 AM, when CNA #32 entered Resident #403 and Resident #404's room she observed blood all over Resident #403 and Resident #404 sat on their bed facing Resident #403's bed. CNA #32 observed the top of Resident #404's walking cane on the floor next to Resident #403's bed by the nightstand. CNA #32 asked Resident #404 whether the resident knew what happened and whether the resident had hit Resident #403. Per the Investigation Template, Resident #404 denied hitting the resident. The CNA reported the incident to LPN #15. When LPN #15 got to the room, she noted Resident #403's lips were swollen, there was blood in the resident's mouth, a skin tear and bleeding to the left ear, a skin tear to the left hand between the first and second digits, a skin tear with a hematoma on the left side of the forehead, a skin tear to the left forearm, a skin tear to the right forearm, the left knee was bruised, [NAME] (a raised area caused by a blow) marks to the upper and outer left thigh and right upper thigh, several dark purple bruises to the left forearm, and the left pupil was pinpoint and not as reactive (indicative of possible neurological injury). LPN #15 reported she saw the handle of Resident #404's walking cane on the floor at the head of Resident #403's bed on the left side between the bed and the nightstand. The LPN reported when she asked Resident #404 what happened, the resident stated they did not know. According to the facility's Investigation Template, Resident #403 reported Yeah, someone hurt me from behind. They beat the fire out of me. They took a stick and just come in and beat the fire out of me when I was trying to sleep. That is one reason I am afraid to go to sleep. Continued review of the Investigative Template revealed the facility determined Resident #403 was physically abused. Resident #403's recount of the incident described the alleged offender, stated the alleged offender shared a room with them, and they were beaten with a stick. By reason of deduction the cane that belonged to Resident #404 was found broken in the resident's bed under the covers. The facility determined Resident #404 had the means and the ability to commit this offense and due to evidence, the facility had reason to believe Resident #404 committed the offense. A review of Resident #403's Emergency Department [ED]-Physician Documentation dated 01/09/2023 revealed the resident reported to the ED after being assaulted by their roommate (Resident #404). Per the report, the resident was hit in their face with a cane multiple times. The ED report revealed the resident had ecchymosis (bruises) to the left side of the face, a laceration to the left eyebrow, soft tissue swelling over the right upper lip, and soft tissue contusion of the superior left forehead. The laceration to the left eyebrow was described as 2.5 (two and one-half) centimeters in length and the depth as superficial, which required approximation with Steri-strips. During an interview on 09/12/2023 at 10:45 AM, CNA #32 stated on the night of 01/08/2023 to 01/09/2023 she was assigned to the secured unit with one LPN. She stated at approximately 2:30 AM, she left the secured unit to help on the NE unit. CNA #32 stated there was no CNA assigned to cover the NE unit; subsequently, all the CNAs covered that unit in addition to their assigned units. CNA #32 stated when she returned to the secured unit, she observed blood on Resident #403. CNA #32 stated she did not remember how long she was off the unit. According to CNA #32, part of Resident #404's cane was observed on the floor beside Resident #403's bed and the rest of the cane was in Resident #404's bed. In a follow-up interview on 09/14/2023 at 8:38 AM, CNA #32 stated the night of 01/08/2023 was the first time she had been assigned to the secured unit and she was also assigned to provide care for two residents on the NE unit. She stated the NE charge nurse (LPN #34) instructed her to do rounds on the NE unit at 2:30 AM and 4:30 AM. She stated she was aware she was expected to arrange coverage when she left the secured unit; however, there were not enough CNAs to cover the unit. The CNA stated she could not remember whether she contacted the charge nurse when she left to go to the NE unit. She stated there was no other staff member on the unit when she left the unit. CNA #32 said she was off the secured unit about 25 to 30 minutes. According to CNA #32, when she left the unit to notify LPN #15 of Resident #403's injuries, the nurse was in the medication room on the North unit, just outside the doors to the secured unit. During an interview on 09/12/2023 at 6:45 AM, LPN #15 reported she was assigned to work the night shift that started on 01/08/2023. LPN #15 stated she was assigned to cover two units, one of which was the secured unit, and during the shift she was back and forth between the two units. She stated it was normal for staff to be assigned to float between two floors. She stated she was not present on the secured unit when the incident occurred between Resident #403 and Resident #404 because she floated between two units. LPN #15 stated as she assessed Resident #403's injuries she observed part of Resident #404's cane on the floor beside Resident #403's bed and the cane had red spots on it. Per LPN #15, the rest of the cane was found broken in Resident #404's bed. She stated she interviewed both residents, but no information was provided. During an interview on 09/14/2023 at 10:00 AM, CNA #33 stated she had gone to the secured unit during the night shift on the morning of 01/09/2023 to get CNA #32 to help her lift a resident. She stated when she entered the secured unit, there were no other staff members present. She stated the NE Unit did not have a CNA assigned for the night shift so all CNAs in the building were assigned to care for residents on that unit. During an interview on 09/14/2023 at 10:30 AM, LPN #34 stated CNA #32 had three or four residents on the NE unit assigned to her during the night shift of 01/08/2023. According to the LPN, CNA #32 would have spent 25 to 30 minutes caring for the assigned residents on the NE Unit. She stated there was no CNA for the NE Unit so all CNAs in the building were assigned residents on that unit. She stated it was common for all CNAs to help cover the entire building. According to LPN #34, the CNA was expected to come to the NE Unit every two hours to check on their assigned residents. LPN #34 stated most of the units could be viewed/supervised from the nurses' station. However, the secured unit could not be visualized from the nurses' station because of the locked/solid doors. LPN #34 stated the locked unit should not be left unsupervised. In an interview on 09/13/2023 at 3:16 PM, the Director of Nursing (DON) stated the facility had trouble staffing at times. Per the DON, her expectation was that the residents on the secured unit should never be left without a staff member present on the unit and there should be enough staff to adequately supervise and care for the residents. The DON added that if only one CNA and one nurse were assigned to the secured unit, and they were both covering another hall, they should switch out so that one of them would always be on the secured unit. She stated normally they would schedule staff so that the CNA assigned to the locked unit would not be required to help on the other units. She stated she did not remember whether the residents had been left alone while the CNA assigned to the locked unit helped on another unit. She stated she would expect for the CNA and the LPN to trade places, so someone supervised the residents. According to the DON, she did not know whether the residents had been left alone. During an interview on 09/13/2023 at 5:07 PM, the Administrator stated it was common for the CNAs to leave the secured unit and assist on another unit. The administrator stated they did not have a policy for floating and she did not know how the CNAs decided when to leave their units to float another hall. There was no policy for staffing for the locked unit. In a follow-up interview on 09/14/2023 at 9:38 AM, the Administrator stated sometimes the facility had trouble getting enough staff. She stated she could not say the secured unit was supervised or unsupervised at all times. According to the Administrator, no one had reported to her the secured unit had been left unsupervised. This deficient practice was cited as a result of the investigation of complaint/report #AL00042935.

Based on record reviews, interviews, the facility's incident report, the facility's investigation titled, INVESTIGATION TEMPLATE, and the facility's policy titled, Abuse Prevention Program, the facility failed to protect Resident #403's right to be free from physical abuse by having inadequate staff to supervise residents. On 01/09/2023 at approximately 3:45 AM, Certified Nurse Assistant (CNA) #32 responded to Resident #403's room and observed him/her lying in bed with blood coming from a laceration to the face. Upon investigation, it was determined that residents were left unsupervised on the secured (locked) unit and staff failed to prevent Resident #404 from repeatedly striking Resident #403 with his/her cane. This resulted in actual harm to Resident #403, who sustained laceration to left forehead with hematoma, laceration to right forehead, skin tear to left ear, [NAME]/redness to left cheek, top right side mouth swollen with laceration and chipped front tooth, [NAME] to right outer thigh, bruising to left and upper arm, welps to left upper and lower arm, skin tear with bring to left thumb, bruises on top of bilateral hands, [NAME] on right side of mid back, welps on right shoulder and upper arm, and left knee swollen with discoloration that required transport to a local hospital for evaluation and treatment. This affected Resident #403, one of five residents sampled for abuse. Findings included: Cross Reference F 725 The facility's policy titled, Abuse Prevention Program dated 10/27/2022, documented: Policy Statement Our residents have the right to be free from abuse . This includes . physical abuse . Definitions 1. Abuse, is defined at S483.5 as the willful infliction of injury, deliberate act . with resulting physical harm, pain or mental anguish . It includes . physical abuse . Abusers can be . residents . A review of an Admission Sheet indicated Resident #403 was admitted on [DATE], and readmitted on [DATE], with diagnoses that included Dementia and Sleep Disorder. The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #403 had a Brief Interview for Mental Status (BIMS) score of three of 15, which indicated the resident had severe cognitive impairment. The resident required total assistance with all Activities of Daily Living (ADLs). The MDS indicated Resident #403 did not have any behaviors directed at others. A review of Resident #403's care plan, developed on 01/13/2023, after being struck several times by Resident #404, indicated that the resident had a risk of decreasing psychosocial well-being related to recent trauma as evidenced by voicing remembrance of the event. A review of an Admission Sheet indicated the facility admitted Resident #404 on 03/25/2021, with diagnoses that included Vascular Dementia with Agitation and Insomnia. Resident #404's MDS dated [DATE], indicated he/she had a BIMS score of 11 of 15, which indicated the resident had moderate cognitive impairment. The resident required limited assistance with all Activities of Daily Living and exhibited no behaviors toward others. On 01/09/2023, the facility reported an incident to the Alabama Department of Public Health (ADPH) Online Incident Reporting System regarding an incident that occurred 01/09/2023. The facility's initial report documented that at 3:45 AM a Certified Nurse Assistant (CNA) heard someone talking and upon entering Resident #403's room she observed Resident #403 lying in bed with injuries. The report revealed the resident had been transported to a local hospital at approximately 5:10 AM for evaluation and treatment. The report indicated it was undetermined at that time how the injuries occurred. Resident #403's Emergency Department (ED) Physician Documentation, dated 01/09/2023, revealed Resident #403 presented to the ED after being assaulted by a demented roommate. The resident was struck in the face multiple times with a cane. The ED report revealed the resident had ecchymosis (bruises) to the left side of the face, a laceration to the left eyebrow, soft tissue swelling over the right upper lip, and soft tissue contusion of the superior left forehead. The laceration to the left eyebrow was described as 2.5 centimeters in length and the depth as superficial, which required approximation with steri-strips. A review of the facility's investigation titled, INVESTIGATION TEMPLATE dated 01/16/2023, revealed the details of the facility's investigation related to the injuries inflicted upon Resident #403 on 01/09/2023. The report documented: . Description of the Allegation: On 1/9/2023 (CNA #32) heard someone talking and entered (Resident #403's) . room she (CNA #32) noted patient to be lying bed with injuries to (his/her) head, face, arms and legs. (CNA #32) noted another resident to be in the room sitting in a chair talking to (Resident #403). Resident was immediately assessed . Bruising and redness noted to forearms and legs. Lacerations noted to forehead and left arm. Bleeding was not to mouth upon initial assessment . Resident (#403) was discharged to the hospital at approximately 5:10 AM . Description of any assessment and injury. Initial assessment completed 1/9/23 prior to d/c (discharge) to hospital: Bruising and redness noted to forearms and legs. Lacerations noted to forehead and left arm. Bleeding noted to mouth. Assessment done 1/9/23 upon return from hospital: Laceration to left forehead with hematoma, laceration to right forehead, skin tear to left ear, [NAME]/redness to left cheek, top right side mouth swollen with laceration and chipped front tooth, [NAME] to right outer thigh, bruising to left and upper arm, welps to left upper and lower arm, skin tear with bring to left thumb, bruises on top of bilateral hands, [NAME] on right side of mid back, welps on right shoulder and upper arm, left knee swollen with discoloration . Investigation Summary . (LPN #15) stated at approximately 3:45 AM, (CNA #32) came to get me and told me that (Resident #403) had blood on the bed, pillow, mouth, arm and leg. (LPN #15) stated when she (LPN #15) got into the room . (Resident #403's) lips were swollen, (he/she) had blood in (his/her) mouth, (his/her) left ear was bleeding . skin tear with hematoma on left side of (his/her) forehead, skin tear to left forearm, skin tear to right forearm, left knee was bruised, [NAME] marks on upper and outer left and right . thigh . (LPN #15) noted (Resident #404) to be sitting on the side of the bed . and the handle of (Resident #404's) cane . between the bed and night stand . (Resident #403) was re-interviewed on 1/12/23 . When asked if anyone had hurt him/her (Resident #403) stated Yeah, someone hurt me from behind. They beat the fire out of me. They took a stick and just come in and beat the fire out of me when I was trying to sleep . When asked to describe the person (Resident #403) stated (He/She) shared a room with me. (He/She) was white. (He/She) was rough looking. Several staff reported (Resident #404) would at time use (his/her) cane to tap ground in front of another resident or on another resident's wheelchair as a means to get their attention to get them out of (his/her way). One staff member reported they observed (Resident #404) to raise (his/her) cane at another resident, however, would not say anything threatening to the other patient just for them to move . Upon completing of the investigation, it remains evident that (Resident #403) was physically abused. the cane belonged to (Resident #404) .was found broken by (Resident #404) in (his/her) bed under the covers upon initial assessment of the resident room. (Resident #404) revealed the cane when asked by staff where (his/her) cane was. (Resident #404) had the means and ability to commit this offense and due to evidence, we have reason to believe (Resident #404) to have committed the offense. On 09/14/2023 at 4:56 PM, an interview was conducted with CNA #32. The CNA stated that on 01/09/2024 around 8:00 PM Resident #403 was in bed rolling around in bed and calling out. She stated she heard Resident #404 tell Resident #403 to shut the hell up. She stated Resident #404 had not seemed aggressive or agitated. She stated after the resident told the other resident to shut up; she did not tell anyone, but she should have told someone. She stated she left the unit to go help on another hall and no additional staff were on the secured unit. She stated they were low staffed always and it was her first time working on the unit. On 09/12/2023 at 10:45 AM, CNA #32 stated that on 01/09/2023 there was one CNA assigned to the secured unit and one LPN. She stated Resident #403 would yell out a lot. She stated that around 2:30 AM she left the secured unit to work on another unit because she had been assigned some residents on another unit. The CNA stated that when she returned to the locked unit, she observed that blood was on Resident #403. She stated part of Resident #404's cane was on the floor beside Resident #403's bed and the rest of the cane was in Resident #404's bed. She stated Resident #47 was in the residents' room, but the resident was not cognitively intact and was not able to provide any information. CNA #32 said that Resident #47 stated there was singing in the room, and he/she had come to join them. On 09/11/2023 at 6:45 AM, LPN #15 stated on 01/09/2023 she was assigned to two halls and was back and forth between them. She stated the resident would make moaning noises and yell out. She indicated she was not on the unit when the incident occurred; she was floating between the two units. She stated the handle of Resident #404's cane was found on the floor near the head of Resident #403's bed; it had some red spots on it. The rest of the cane was broken and was found in Resident #404's bed. The LPN stated Resident #47 was in the resident's room but was not cognitively intact. LPN #15 interviewed Resident #47 who stated there was singing in the room, so he/she came in to join them. The LPN stated she interviewed both residents, but Resident #403 did not say anything and Resident #404 stated they did not know anything. She stated Resident #403 was transferred to a local hospital and later that day Resident #404 was transferred to a local psychiatric hospital. On 09/13/2023 at 3:16 PM, the Director of Nurses (DON) stated her expectation was that the residents on the locked unit should never be left without a staff member present on the unit and there should be enough staff to adequately supervise the residents. The DON stated that the victim Resident #403 had been placed on another unit when he/she returned from the hospital. Resident #404 was placed in a private room on the unit when he/she returned from the local psychiatric hospital. On 09/13/2023 at 5:07 PM, the Administrator (ADM) stated CNA #32 began to suspect that Resident #404 had assaulted the roommate, Resident #403, when the broken cane was discovered on the floor next to the bed. She stated Resident #404 was able to transfer and ambulate without staff assistance, but Resident #403 was totally dependent on staff for all ADLs. She stated Resident #47 was not cognitively intact and was not able to provide any information. This was cited as a result of complaint/report # AL00042935.

Based on record reviews, interviews, document reviews, and policy review, the facility failed to ensure sufficient staff were available to provide supervision for residents on the facility's secured unit during the night shift. On 01/09/2023 at approximately 2:30 AM, staff left residents on the [NAME] Haven Unit (a locked, secured unit where 24 residents resided) unsupervised to take care of residents on other units because there was an insufficient number of staff. While the locked/secured unit was unsupervised, Resident #404 struck their roommate, Resident #403, with a cane which resulted in a facial laceration, facial bruising and swelling, and multiple other injuries to the resident's body. This failure affected one of nine units in the facility. Findings included: A review of the facility's Staffing policy revised October 2017 revealed .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care . A review of the facility's 2023 Facility Assessment updated 08/10/2023, indicated in Section 3.1 . Our general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time . Per the Facility Assessment, the direct care staff (licensed and certified) were . 1:6 resident ratio days (total licensed or certified) 1:8 resident ratio evenings 1:10 resident ratio nights This includes RN [Registered Nurse] Supervisors, Restorative Nurse, LPNs [Licensed Practical Nurses] and CNAs [Certified Nursing Assistants] providing direct care . A review of Section 3.2 titled Staffing plan, indicated . Our staffing plan to meet the needs of the resident population. Staff needed for care for our resident census/population: Licensed or Registered Nurses providing direct care . 3-5 on nights . Nurses Aides . 7-9 on nights . Section 3.3 Individual staff assignment, revealed . How we determine and review individual staff assignments for coordination and continuity of care for residents within and across staff assignment. We compare our overall census and/or resident acuity needs to determine if we need to adjust staffing. Acuity needs change often, so we may adjust schedule assignments each shift. Charge Nurse or Registered Nurses on call may adapt staffing based on our internal communication tools, such as our verbal shift change report, or team talks . A review of the facility schedule for Sunday 01/08/2023 for the 11:00 PM to 7:00 AM shift, revealed LPN #15 was scheduled to work the 1st North Unit and the [NAME] Haven Unit. The schedule indicated one CNA (CNA #32) was scheduled to work the [NAME] Haven Unit, one CNA was scheduled on the 1st North Unit, one CNA was scheduled for the Far North Unit, and the word split was written on the schedule for the Northeast (NE) Unit. According to the schedule, there were nine total staff members (three LPNs and five CNAs) for the 11:00 PM to 7:00 AM shift that began on 01/08/2023. A review of an undated, unlabeled, handwritten note provided by the Administrator indicated on 01/08/2023, during the 11:00 PM to 7:00 AM shift, there were nine total staff that worked in the facility and not 10 to 14 staff as required per the 2023 Facility Assessment. A review of the facility's Daily Census report dated 01/08/2023, indicated the [NAME] Haven Unit/secured unit had a census of 24 residents, resulting in a resident to staff ratio of 1:12, not 1:10 per the 2023 Facility Assessment for the evening shift. A review of Resident #403's Admission Record revealed the facility admitted the resident on 10/22/2022 with diagnoses that included dementia, generalized anxiety, adjustment disorder with depressed mood, and sleep disorder. A review of Resident #403's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 10/26/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. A review of Resident #404's Admission Record revealed the facility admitted the resident on 03/25/2021. Per the Admission Record, Resident #404's diagnoses included vascular dementia with agitation, anxiety disorder, and insomnia. A review of Resident #404's annual MDS, with an ARD of 02/01/2023 revealed the resident had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. A review of the facility's Investigation Template dated 01/16/2023 revealed on 01/09/2023 at approximately 3:45 AM, when CNA #32 entered Resident #403 and Resident #404's room she observed blood all over Resident #403 and Resident #404 sat on their bed facing Resident #403's bed. CNA #32 observed the top of Resident #404's walking cane on the floor next to Resident #403's bed by the nightstand. CNA #32 asked Resident #404 whether the resident knew what happened and whether the resident had hit Resident #403. Per the Investigation Template, Resident #404 denied hitting the resident. The CNA reported the incident to LPN #15. When LPN #15 got to the room, she noted Resident #403's lips were swollen, there was blood in the resident's mouth, a skin tear and bleeding to the left ear, a skin tear to the left hand between the first and second digits, a skin tear with a hematoma on the left side of the forehead, a skin tear to the left forearm, a skin tear to the right forearm, the left knee was bruised, [NAME] (a raised area caused by a blow) marks to the upper and outer left thigh and right upper thigh, several dark purple bruises to the left forearm, and the left pupil was pinpoint and not as reactive (indicative of possible neurological injury). LPN #15 reported she saw the handle of Resident #404's walking cane on the floor at the head of Resident #403's bed on the left side between the bed and the nightstand. The LPN reported when she asked Resident #404 what happened, the resident stated they did not know. According to the facility's Investigation Template, Resident #404 initially reported they did nothing illegal, then stated he/she hit Resident #403 with the stick but there weren't any marks on the resident. Per the Investigation Template, Resident #403 reported Yeah, someone hurt me from behind. They beat the fire out of me. They took a stick and just come in and beat the fire out of me when I was trying to sleep. That is one reason I am afraid to go to sleep. Continued review of the Investigative Template revealed the facility determined Resident #403 was physically abused. Resident #403's recount of the incident described the alleged offender, stated the alleged offender shared a room with them, and they were beaten with a stick. By reason of deduction the cane that belonged to Resident #404 was found broken in the resident's bed under the covers. The facility determined Resident #404 had the means and the ability to commit this offense and due to evidence, the facility had reason to believe Resident #404 committed the offense. A review of Resident #403's Emergency Department [ED]-Physician Documentation dated 01/09/2023 revealed the resident reported to the ED after being assaulted by their roommate (Resident #404). Per the report, the resident was hit in their face with a cane multiple times. The ED report revealed the resident had ecchymosis (bruises) to the left side of the face, a laceration to the left eyebrow, soft tissue swelling over the right upper lip, and soft tissue contusion of the superior left forehead. The laceration to the left eyebrow was described as 2.5 (two and one-half) centimeters in length and the depth as superficial, which required approximation with Steri-strips. During an interview on 09/12/2023 at 10:45 AM, CNA #32 stated on the night of 01/08/2023 to 01/09/2023 she was assigned to the secured unit with one LPN. She stated at approximately 2:30 AM, she left the secured unit to help on the NE unit. CNA #32 stated there was no CNA assigned to cover the NE unit; subsequently, all the CNAs covered that unit in addition to their assigned units. CNA #32 stated when she returned to the secured unit, she observed blood on Resident #403. CNA #32 stated she did not remember how long she was off the unit. According to CNA #32, part of Resident #404's cane was observed on the floor beside Resident #403's bed and the rest of the cane was in Resident #404's bed. In a follow-up interview on 09/14/2023 at 8:38 AM, CNA #32 stated the night of 01/08/2023 was the first time she had been assigned to the secured unit and she was also assigned to provide care for two residents on the NE unit. She stated the NE charge nurse (LPN #34) instructed her to do rounds on the NE unit at 2:30 AM and 4:30 AM. She stated she was aware she was expected to arrange coverage when she left the secured unit; however, there were not enough CNAs to cover the unit. The CNA stated she could not remember whether she contacted the charge nurse when she left to go to the NE unit. She stated there was no other staff member on the unit when she left the unit. CNA #32 said she was off the secured unit about 25 to 30 minutes. According to CNA #32, when she left the unit to notify LPN #15 of Resident #403's injuries, the nurse was in the medication room on the North unit, just outside the doors to the secured unit. During an interview on 09/12/2023 at 6:45 AM, LPN #15 reported she was assigned to work the night shift that started on 01/08/2023. LPN #15 stated she was assigned to cover two units, one of which was the secured unit, and during the shift she was back and forth between the two units. She stated it was normal for staff to be assigned to float between two floors. She stated she was not present on the secured unit when the incident occurred between Resident #403 and Resident #404 because she floated between two units. LPN #15 stated as she assessed Resident #403's injuries she observed part of Resident #404's cane on the floor beside Resident #403's bed and the cane had red spots on it. Per LPN #15, the rest of the cane was found broken in Resident #404's bed. She stated she interviewed both residents, but no information was provided. During an interview on 09/14/2023 at 10:00 AM, CNA #33 stated she had gone to the secured unit during the night shift on the morning of 01/09/2023 to get CNA #32 to help her lift a resident. She stated when she entered the secured unit, there were no other staff members present. She stated the NE Unit did not have a CNA assigned for the night shift so all CNAs in the building were assigned to care for residents on that unit. During an interview on 09/14/2023 at 10:30 AM, LPN #34 stated CNA #32 had three or four residents on the NE unit assigned to her during the night shift of 01/08/2023. According to the LPN, CNA #32 would have spent 25 to 30 minutes caring for the assigned residents on the NE Unit. She stated there was no CNA for the NE Unit so all CNAs in the building were assigned residents on that unit. She stated it was common for all CNAs to help cover the entire building. According to LPN #34, the CNA was expected to come to the NE Unit every two hours to check on their assigned residents. LPN #34 stated most of the units could be viewed/supervised from the nurses' station. However, the secured unit could not be visualized from the nurses' station because of the locked/solid doors. LPN #34 stated the locked unit should not be left unsupervised. In an interview on 09/13/2023 at 3:16 PM, the Director of Nursing (DON) stated the facility had trouble staffing at times. Per the DON, her expectation was that the residents on the secured unit should never be left without a staff member present on the unit and there should be enough staff to adequately supervise and care for the residents. The DON added that if only one CNA and one nurse were assigned to the secured unit, and they were both covering another hall, they should switch out so that one of them would always be on the secured unit. She stated normally they would schedule staff so that the CNA assigned to the locked unit would not be required to help on the other units. She stated she did not remember whether the residents had been left alone while the CNA assigned to the locked unit helped on another unit. She stated she would expect for the CNA and the LPN to trade places, so someone supervised the residents. According to the DON, she did not know whether the residents had been left alone. During an interview on 09/13/2023 at 5:07 PM, the Administrator stated it was common for the CNAs to leave the secured unit and assist on another unit. The administrator stated they did not have a policy for floating and she did not know how the CNAs decided when to leave their units to float another hall. There was no policy for staffing for the locked unit. In a follow-up interview on 09/14/2023 at 9:38 AM, the Administrator stated sometimes the facility had trouble getting enough staff. She stated she could not say the secured unit was supervised or unsupervised at all times. According to the Administrator, no one had reported to her the secured unit had been left unsupervised. This deficient practice was cited as a result of the investigation of complaint/report #AL00042935.

Based on observation, interview, and facility policy and document review, the facility failed to ensure staff appropriately used and discarded personal protective equipment (PPE) for three (Residents #308, #38, and #47) of three residents reviewed who had transmission-based precautions implemented. These residents lived on three of six halls where residents resided. Resident #308 tested positive for coronavirus disease 2019 (COVID-19) and required contact and droplet precautions. Resident #38 and Resident #47 were identified as requiring enhanced barrier precautions. Findings included: A review of the facility policy titled, Infection Prevention and Control Program Policy, with a revision date of 01/20/2023, indicated, . All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . Review of the facility policy titled, Isolation - Categories of Transmission-Based Precautions, revised in 10/2018, indicated, . Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents . The policy indicated, . 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . and . 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . The policy further indicated, .Droplet Precautions 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger than 5 (five) microns in size] that can be generated by the individual coughing, sneezing, talking or by performance of procedures such as suctioning.) . 3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is a risk of spraying respiratory secretions . 1. Resident #308's Point of Care Testing Results, dated 09/11/2023, revealed the resident had a positive COVID-19 test that day. A review of Resident #308's Order Summary Report revealed a physician's order, dated 09/11/2023, that indicated contact/droplet precautions were to be implemented every shift until 09/21/2023 due to the resident testing positive for COVID-19. A review of Resident #308's care plan focus statement, with an initiation date of 09/11/2023, indicated the resident tested positive for COVID-19 and staff were to implement contact and droplet precautions. During an observation on 09/13/2023 at 9:14 AM Certified Nursing Assistant (CNA) #11 entered Resident #308's private room after donning gloves, a gown, and goggles. CNA #11 was already wearing an N-95 mask when she approached the resident's room, and she wore the same mask when she entered the room. At 9:18 AM, CNA #11 was observed exiting the room wearing only the N-95 mask; all other PPE had been removed. Resident #308's room had a sign posted on the door that indicated, Contact Precautions. The sign did not indicate which PPE staff were to use. Another sign posted on the door indicated, Droplet Precautions and directed staff to perform hand hygiene and don a surgical mask before entering the room and on leaving the room the sign indicated to dispose of the mask and perform hand hygiene. PPE supplies were hung on the door to the resident's room and included N-95 masks, goggles, face shields, gowns, and gloves. During an interview on 09/13/2023 at 9:20 AM, CNA #11 stated she entered Resident #308's room wearing a gown, goggles, gloves, and the N-95 mask she had been wearing during her shift. She stated she was unsure about what to do with the goggles and left them in the room. CNA #11 stated she did not leave the N-95 mask in the room because it was the only one she had, and she did not think she should be out in the hall without the mask. CNA #11 stated the signage on the door was confusing about which PPE to use so she put everything on that was available. She stated if a visitor came to Resident #308's room they would probably be confused because the signs did not list what PPE they should wear or inform them to throw away the PPE before leaving the room. During an observation on 09/13/2023 at 9:28 AM, Nursing Assistant in Training (NAT) #3 exited Resident #308's room wearing a KN-95 mask. During an interview at that time, NAT #3 stated she recently completed CNA training courses and knew she should wear the PPE that was listed on the door. She stated she wore all the PPE available, including the KN-95 mask she was wearing earlier in her shift and a face shield, goggles, gloves, and a gown that were donned before entering the resident's room. NAT #3 stated she discarded all the PPE except the mask because she was confused about discarding the mask. She stated if a visitor to Resident #308's room would be confused, and they may not wear the proper PPE. During an interview on 09/13/2023 at 2:15 PM, Registered Nurse (RN) #18 stated she was the RW Unit Manager for the hall that included Resident #308's room. She stated the resident tested positive for COVID-19 on 09/11/2023. RN #18 stated staff should wear the PPE listed on the door outside the resident's room and remove all PPE before exiting the room. She stated the risk of exiting the room while wearing the same mask worn during Resident #308's care would be contamination of the mask and possible transmission to others. She stated the N-95 mask should be discarded in the resident's room and then a new mask should be donned outside of the room. During an interview on 09/14/2023 at 1:21 PM, the Infection Control Preventionist (ICP) stated the staff should not have come out of Resident #308's room wearing any PPE, including the mask worn in the room. She said staff should stop at the door to remove the PPE and staff could not wear the masks worn in the room outside of the room. The ICP stated the risk of wearing a potentially contaminated mask may be transmission of COVID-19. During an interview on 09/15/2023 at 11:23 AM, the Director of Nursing (DON) stated that for a resident who tested positive for COVID-19, staff should dispose of their mask before exiting the room and don a new mask after they exited the room. During an interview on 09/15/2023 at 1:21 PM, the Administrator stated that for a room housing a resident with COVID-19, she expected staff to put on a new mask when leaving the room according to Center for Disease Control (CDC) guidance. 2. Resident #47's Order Summary Report revealed a physician's order, dated 01/18/2023, which indicated enhanced barrier precautions (EBP) were to be implemented every shift due to a history of ESBL (extended spectrum beta-lactamase) in the resident's urine. A review of Resident #47's care plan focus statement, with an initiation date of 01/18/2023, indicated there was a potential for transmission of microorganisms from the resident to another resident or staff related to ESBL resistance. Interventions directed staff to implement EBP, perform hand hygiene before and after resident care, remove PPE and discard in the trash before leaving the resident's room, and wear PPE for high contact activities including assisting the resident with bathing, showering, dressing, transferring, changing linens, personal hygiene, toileting, and incontinence care. During an observation on 09/13/2023 at 9:04 AM Resident #47's room had an EBP sign posted on the door and PPE hanging on the outside of the door. The EBP sign indicated staff should wear gloves and a gown when assisting the resident with dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or toileting. Certified Nursing Assistant (CNA) #8 was observed to exit the room with Resident #47 who was in a wheelchair. Observation of Resident #47's room revealed no gown had been discarded in the room. During an interview on 09/13/2023 at 9:06 AM, Licensed Practical Nurse (LPN) #12 stated Resident #47 had ESBL in their urine. LPN #12 stated staff should wear a gown, gloves, and a mask when providing care for the resident. For PPE disposal, LPN #12 stated staff should discard the PPE in the resident's room. During an interview on 09/13/2023 at 9:12 AM, CNA #8 stated she did not use a gown when assisting the resident and only used a mask and gloves. She stated she assisted Resident #47 with dressing, transfers to the toilet, and transfers to the wheelchair. CNA #8 stated she was aware the resident was on EBP, and she should have worn a gown. During an interview on 09/13/2023 at 2:05 PM, Registered Nurse (RN) #16 stated when providing direct resident care for a resident with ESBL, staff should wear gloves, a gown, and a mask, and CNA #8 did not wear the appropriate PPE when assisting Resident #47. During an interview on 09/14/2023 at 1:11 PM, the Infection Control Preventionist (ICP) stated EBP was an extra precaution. She stated that for care of a resident with ESBL, staff should wear a mask, gloves, and a gown. The ICP stated the risk was transmission to another resident from the staff's clothing. During an interview on 09/15/2023 at 11:23 AM, the Director of Nursing (DON) stated it was a recommendation from the Centers for Disease Control (CDC) that EBP be put in place for certain higher risk microorganisms or residents with wounds or catheters. She stated she expected staff to follow the protocols for PPE in a room where EBP were implemented. During an interview on 09/15/2023 at 1:21 PM, the Administrator stated EBP were an extra way to protect the residents, and she expected staff to follow the directions related to PPE that was listed on the sign on the door. The Administrator acknowledged that Resident #47 had physician orders for the EBP. 3. A review of an Order Summary Report revealed a physician's order with a start date of 08/14/2023 that indicated enhanced barrier precautions (EBP) were to be implemented every shift for Resident #38 due to a history of ESBL (extended spectrum beta-lactamase). A review of a care plan focus statement, with an initiation date of 06/07/2023, indicated EBP were to be implemented for Resident #38 due to a history of ESBL in the urine. An observation was made on 09/11/2023 at 3:10 PM of the Hospice Nurse (HN) and Registered Nurse (RN) #21 entering Resident #38's room. There was a sign on the door to the resident's room that indicated EBP were to be implemented. Hanging on the door was a container that was filled with PPE. Both the HN and RN #21 conducted hand hygiene and donned gloves, but not gowns, before removing the resident's adult brief and inspecting the resident's skin. An observation was made on 09/12/2023 at 10:05 AM of Certified Nursing Assistant (CNA) #9 and CNA #10 in Resident #38's room providing morning care. The CNAs did not don gowns prior to providing morning care. An interview was held with CNA #9 on 09/12/2023 at 10:25 AM. CNA #9 stated she knew the sign on the resident's door was for EBP, which meant when she provided care, she should don PPE. CNA #9 stated she did not wear a gown when providing the resident's morning care and stated she was in a rush and had forgotten. An interview was held on 09/12/2023 at 10:56 AM with Licensed Practical Nurse (LPN) #14. LPN #14 stated EBP meant using more precautions due to a condition the resident had. She stated that when providing care, gloves should be worn and depending on the type of care given, a gown should be worn. LPN #14 stated if a CNA provided a bed bath, a gown should be worn. The LPN said if a nurse conducted a skin inspection or pressure ulcer care the nurse was expected to wear gloves, but wearing a gown would depend on the size of the pressure ulcer. She clarified the statement by adding if a resident had a massive wound the nurse wore a gown, but a gown was not required when providing care for a skin tear. An interview was held with RN #21 on 09/15/2023 at 11:02 AM. She stated Resident #38 had a sign on the door for EBP, which meant she should have worn a gown when she assessed the resident's skin. RN #21 stated she just forgot. RN #21 stated gowns should be worn by CNAs when providing baths when a resident required EBP. An interview was held with the Infection Control Preventionist (ICP) on 09/14/2023 at 1:11 PM. The ICP stated EBP created confusion for the staff, and residents had told her they did not like the EBP sign on the door because they felt the signage singled them out. The ICP stated the EBP signage found on Resident #38's door was for a bacterium in the urine that was difficult to treat. She stated the risk of not following EBP would be transmission of ESBL to another resident. The ICP stated EBP was an extra precaution but was not used if a resident was actively sick and required transmission-based precautions such as contact or droplet precautions. The ICP stated the CNAs knew they should have worn gowns when caring for Resident #38, they just did not wear them. An interview was held with the Director of Nursing (DON) on 09/15/2023 at 11:23 AM. The DON stated the recommendations for EBP were from the Centers for Disease Control (CDC) and stated EBP provided an extra layer of protection. The DON stated she expected staff to follow the protocols for EBP that were listed on the door and included a mask, a gown, and gloves. The DON stated the risk of not following EBP could be transmission to the staff themselves or to other residents if the staff spread whatever the resident had. An interview was conducted with the Administrator on 09/15/2023 at 1:21 PM. The Administrator stated EBP was an extra way to protect the resident and added if staff were providing direct care, they should wear the PPE listed on the door to the resident's room. The Administrator acknowledged that Resident #38 had a physician order for EBP. 22445

Based on record review, interviews, and facility policy review, the facility failed to ensure medical records were complete and accurate for one (Resident #253) of 15 residents reviewed for activities of daily living (ADL) documentation. Findings included: A review of a facility policy titled, Charting and Documentation, revised in 07/2017, indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . 2. The following information is to be documented in the resident medical record: a. Objective observations, b. Medication administered; c. Treatments or services performed; d. Changes in residents' condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. A review of Resident #253's Admission Record revealed the facility admitted the resident on 12/07/2021 with diagnoses that included dementia, anxiety disorder, Alzheimer's disease, venous insufficiency, and encounter for palliative care. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/18/2022, revealed Resident #253 had a Brief Interview for Mental Status (BIMS) score of 6 (six), indicating the resident was severely cognitively impaired. The resident required extensive assistance from staff with bed mobility and toilet use, limited assistance from staff with dressing and personal hygiene, and was totally dependent on staff for bathing. Resident #253 was always incontinent of bladder and bowel. Resident #253 had no weight loss and ate a mechanically altered diet. Review of a Documentation Survey Report v2 form for Resident #253 for the month of July 2022, revealed the following: - There was no documented evidence staff assisted the resident with bladder/bladder elimination care on 13 days on the 7:00 AM to 3:00 PM shift, 22 days on the 3:00 PM to 11:00 PM shift, and 11 days on the 11:00 PM to 7:00 AM shift. - There was no documented evidence staff assisted the resident with activities of daily living (ADL) and toilet use on 10 days on the 7:00 AM to 3:00 PM shift, 21 days on the 3:00 PM to 11:00 PM shift, and 12 days on the 11:00 PM to 7:00 AM shift. - There was no documented evidence staff assisted the resident with bed mobility, dressing, locomotion on the unit, personal hygiene, transferring, nor walking in the corridor/room on 12 days on the 7:00 AM to 3:00 PM shift and 21 days on the 3:00 PM to 11:00 PM shift. In addition, there was no documented evidence staff assisted the resident with bed mobility for 12 days on the 11:00 PM to 7:00 AM shift. During an interview on 09/13/2023 at 1:17 PM, Certified Nursing Assistant (CNA) #9 stated incomplete ADL documentation for Resident #253 did not mean care was not provided. She stated she just did not have time to document. During an interview on 09/13/2023 at 2:29 PM, CNA #43 stated the lack of ADL documentation in July 2022 was because staffing was lower, and she was too busy to document. During an interview on 09/14/2023 at 2:06 PM, CNA #44 stated the blanks in documentation in July 2022 were probably because they were short staffed and not able to complete documentation; however, she stated care was provided. A telephone interview was held with Licensed Practical Nurse (LPN) #20 on 09/14/2023 at 10:35 AM. LPN #20 stated she had been unable to complete needed documentation due to being understaffed and too busy. During an interview on 09/14/2023 at 9:16 AM, the Director of Nursing (DON) stated Resident #253's ADL documentation looked incomplete. She indicated staff were required to document every shift and after they performed a task. She stated she expected complete and accurate documentation. During an interview on 09/15/2023 at 10:32 AM, the Administrator stated staff should document timely and accurately. She stated she expected staff to document ADL care every shift. She stated even though there were blanks in the documentation, she believed care was provided. She stated the blanks meant they did not document or forgot to document. This deficient practice was cited as a result of the investigation of complaint/report #AL00041921.

Based on observations, interviews, record review, and facility policy review, the facility failed to provide physician ordered nutritional supplements Resident #76, one of two residents reviewed who had weight loss and physician orders for nutritional supplements. Findings included: A review of the undated facility policy titled, Supplements, indicated, . Residents receiving supplements may include those who are underweight, who are on therapeutic diets and those with poor intake (50%), weight loss, skin problems, and other problems addressed on care plans . Consumption of these supplements is recorded in the resident's medical record by nursing services . A review of the Admission Record for Resident #76 revealed the facility admitted the resident on 05/31/2023 with diagnoses that included fracture of the left femur, generalized muscle weakness, anemia, unspecified dementia, and adjustment disorder with depressed mood. A review of a quarterly Minimum Data Set (MDS) for Resident #76, with an Assessment Reference Date (ARD) of 08/21/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 (three), which indicated Resident #76 was severely cognitively impaired. The MDS indicated Resident #76 was able to eat independently. The MDS did not indicate the resident lost weight. A review of a care plan focus statement, with a start date of 06/08/2023, indicated that Resident #76 had a potential nutritional problem related to dementia, transient ischemic attacks, anemia, and anxiety, with a goal of maintaining adequate nutritional status as evidenced by maintaining weight. The care plan included interventions with an initiation date of 07/19/2023 that directed staff to provide health shakes three times a day. A review of the Dietitian Nutritional Assessment, dated 06/06/2023, indicated Resident #76's weight on 06/02/2023 was recorded as 180 pounds. The assessment indicated Resident #76 was able to eat independently after set-up assistance. The assessment indicated the estimated nutritional needs for Resident #76 were 25 to 30 kilocalories (kcal) per kilogram (kg) or 2045 to 2454 kcal per day. The assessment indicated the resident's intake was good and likely adequate to meet needs. A review of the Weight Summary for Resident #76 revealed that on 06/30/2023 the resident's weight had gone down to 159 pounds, indicating a 21-pound weight loss (11.6% weight loss in 28 days). Further review of the Weight Summary revealed that on 08/11/2023 the weight for Resident #76 was recorded as 161.6 pounds, an 18.4-pound weight loss (7.5% weight loss in 60 days). A review of Resident #76's Order Summary Report revealed that on 07/03/2023 health shakes (a milk-shake type nutritional supplement that is high in calories) were ordered to be served three times a day with meals. A review of Resident #76's July 2023 and August 2023 Medication Administration Record [MAR] revealed no transcription of the order for health shakes or staff documentation indicating the health shakes were provided. A review of Resident #76's Health Supplement log (used to indicate if a nutritional supplement/health shake was offered by staff), for the timeframe from 08/16/2023 to 09/13/2023, revealed there were nine entries indicating the health supplement was not applicable, fifty entries indicating the health supplement was not provided, one entry indicating the resident refused, and four entries indicating the health supplement was provided. The amount of health supplement consumed was not recorded in this log. An observation was made on 09/12/2023 at 12:15 PM of the lunch meal. Resident #76 had no health shake on their meal tray. On 09/13/2023 at 8:15 AM, Resident #76's breakfast tray was observed, and there was no health shake on the meal tray. An observation was made of Resident #76's lunch meal tray on 09/13/2023 at 12:12 PM. Certified Nursing Assistant (CNA) #9 delivered the resident's tray, set the tray up, and opened items for the resident. CNA #9 stated Resident #76 was independent with eating. The resident was served cabbage, a bowl of beans, ground meat, a piece of cornbread, and fruit cobbler. There was no health shake on the resident's meal tray. CNA #9 was interviewed on 09/13/2023 at 12:15 PM and stated that on the days she worked, she was assigned to provide care for Resident #76 and that included set-up assistance for all three meals. CNA #9 said Resident #76 received no health shake or other nutritional supplement but added the resident's family provided snacks for the resident. An interview was held with CNA #10 on 09/13/2023 at 12:30 PM. The CNA stated she previously served Resident #76's meal trays and stated the resident had not received a nutritional supplement such as a health shake. The CNA stated if any resident received a nutritional supplement, the information would be located on the tray card. The CNA viewed a tray card and pointed out where the information about a nutritional supplement/health shake would be located. On review of Resident #76's tray card, there was no nutritional supplement listed. An interview was conducted with CNA #36 on 09/14/2023 at 8:58 AM. CNA #36 stated she had served Resident #76 their breakfast and added there had been no nutritional supplement such as a health shake on the resident's meal tray. An interview was held with CNA #29 on 09/14/2023 at 8:58 AM. CNA #29 stated she worked with Resident #76 at times and had not seen any nutritional supplement such as a health shake on the resident's meal trays. The Assistant Director of Nursing (ADON) was interviewed on 09/14/2023 at 12:27 PM and stated that when the weight committee (a meeting attended by the unit managers, Director of Nursing [DON], ADON, Dietary Manager [DM] and Administrator) made a recommendation to add health shakes or nutritional supplements to increase a resident's weight or maintain a resident's weight, an order was obtained from the physician. The ADON stated she expected the dietary department to send the nutritional supplements/health shakes to Resident #76 as ordered. A telephone interview was held with the Registered Dietitian (RD) on 09/14/2023 at 2:10 PM. The RD confirmed Resident #76 had experienced significant weight loss and added it was not good that the resident had not received the ordered nutritional supplements. The RD stated the nutritional supplement added 600 to 840 calories per day depending on the exact type of nutritional supplement the resident received. The RD stated that at this time Resident #76's weight was stable, and the resident had gained a few pounds. The RD added that not receiving the nutritional supplement could have resulted in Resident #76 having additional weight loss. A review of Resident #76's September 2023 MAR revealed transcription of an order for health shakes three times daily with meals with a start date of 09/13/2023. The MAR indicated the resident was provided a health shake with breakfast on 09/14/2023 and staff documented the resident consumed 50%. An interview was held with the Dietary Manager (DM) on 09/15/2023 at 8:22 AM. The DM stated dietary audits were completed prior to every quality assurance and performance improvement (QAPI) meeting. The DM said she compared provider orders for each resident with what was listed on the tray ticket. The DM stated she had no clue as to how the nutritional supplement/health shake for Resident #76 was missed. The DM stated there was documentation in the weight meeting notes that indicated there was a recommendation that Resident #76 receive nutritional shakes, but the dietary department had not received a dietary communication slip from the nursing department. The DM stated Resident #76's appetite had improved, and the resident had gained weight. The DM added a negative outcome from the resident not receiving the health shakes as ordered could have been continued weight loss for Resident #76. The DON was interviewed on 09/15/2023 at 5:36 PM and stated she expected staff to follow physician's orders and was unsure why Resident #76 had not received the ordered health shakes. An interview was held with the Administrator on 09/15/2023 at 6:38 PM and she stated she expected staff to follow physician's orders including providing nutritional supplements as ordered.

Based on observations, record review, interviews, and facility document and policy review, the facility failed to consider all causal factors related to falls when determining appropriate interventions to prevent further falls Resident #38. In addition, the facility failed to ensure staff implemented care planned interventions, including a fall mat and non-skid strips, on 07/17/2023 when the resident sustained a fall without injury. During the survey, Resident #38 was observed with no fall mat by their bed and no non-skid strips on the floor as specified by their care plan. This was observed on three of six days of survey. This affected one of three sampled residents reviewed for falls. Findings included: A review of a facility policy titled, Falls and Fall Risk, Managing, revised March 2018, revealed, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . The policy also indicated, . Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . A review of an Admission Record revealed the facility admitted Resident #38 on 05/31/2023 with diagnoses that included Alzheimer's disease, hypertension, weakness, and restlessness and agitation. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance of one person for bed mobility. According to the MDS, transfers only occurred one to two times during the assessment period, while walking and ambulation did not occur. A review of an admission Morse Fall Scale, dated 05/31/2023, indicated Resident #38 scored 75.0, indicating the resident was at High Risk for Falling. The scale indicated Resident #38 had a history of falls, had impaired gait, and overestimated or forgot their limits in relation to their ability to ambulate. A review of Resident #38's comprehensive care plans revealed a Focus, with a start date of 05/31/2023, that indicated the resident was at risk for falls related to deconditioning. Interventions added on 05/31/2023 directed staff to ensure the resident's call light was within reach, encourage the resident to use the call light, and anticipate the resident's needs. Another Focus, initiated on 05/31/2023, indicated Resident #38 had an activities of daily living self-care deficit related to impaired balance. This focus included an intervention, initiated on 05/31/2023 and revised on 06/07/2023, that indicated the resident required quarter-length siderails during the provision of care to assist with bed mobility. On 06/08/2023 the care plan Focus was updated to include interventions that directed staff to keep the resident's bed in the lowest position and to place a fall mat beside the bed. A review of Progress Notes revealed a Post Fall Note, dated 06/12/2023 at 4:30 PM, that indicated Resident #38 was found sitting on the floor at the foot of the bed. The note indicated the resident had bowel movement (BM) all over their hands, bottom, down their legs, and all over the floor and bed. The note indicated the resident was placed back in bed, bathed, and changed. According to the note, Resident #38 sustained skin tears to the left elbow and left knee. The note indicated staff would continue to monitor the resident. The note did not include reference to any immediate interventions to prevent Resident #38 from falling again. A review of an incident report, dated 06/12/2023 at 4:30 PM, revealed Resident #38 sustained an unwitnessed fall in their room. The resident was found on the floor at the end of the bed with BM all over them. The Immediate Action Taken was to assist the resident back to bed and clean the resident, bed, and floor. There was no indication staff had been interviewed to determine the last time the resident was seen or the condition of the resident on last observation. The incident report indicated there were no predisposing environmental factors, and physiological factors included confusion, incontinence, gait imbalance, and impaired memory. Situational factors included ambulation without assistance. There was no information included about the height of the resident's bed or whether fall mats were in place at the time of the fall. A review of a Monthly Incident/Accident QA [quality assurance] Log revealed Resident #38 sustained a fall in their room on 06/12/2023. The log indicated the resident did not sustain any injuries. The Root Cause was listed as, Resident unable to recall cause of fall. Resident found sitting on floor at end of the bed, barefoot, and had bm [BM] all over [his/her] bottom, hands, down legs, on feet, all over floor and on bed. The log indicated Resident #38's care plan was updated but did not indicate what updates had been made and/or recommended. A review of Resident #38's care plan Focus, addressing fall risk (initiated on 05/31/2023 and last revised on 06/08/2023) revealed no interventions had been added related to the resident's 06/12/2023 fall. On 06/15/2023, an additional Focus area was added that indicated Resident #38 had recurrent falls related to poor safety awareness and cognitive deficit. On 06/15/2023, planned interventions directed staff to obtain a urinalysis with culture and sensitivity if indicated, and to conduct neurological checks (neurological checks include level of consciousness, movement, hand grasp, speech, vital signs, pupil reaction and pupil size) per facility policy. On 06/21/2023, an intervention was added that directed staff to Continue interventions on the at-risk plan. A review of Progress Notes revealed a Health Status Note, dated 07/04/2023 at 6:38 AM, that indicated the nurse was called to the room by Resident #38's roommate. Resident #38 was found sitting on the floor, leaning against the bed. The roommate reported the resident was sitting on the side of the bed and scooted off the bed. The note did not include reference to any immediate interventions to prevent Resident #38 from falling again. A review of a Monthly Incident/Accident QA Log revealed Resident #38 sustained a fall in their room on 07/04/2023. The log indicated the resident did not sustain any injuries. The Root Cause was listed as, Resident unable to recall cause of fall resident found sitting on floor leaning against [his/her] bed with [his/her] feet pointed at roommates' [sic] bed, sitting on [his/her] covers and [his/her] pillows, roommate stated [he/she] sat up on the side of the bed and was talking to me but when I asked [him/her] what [he/she] said [he/she] scooted [his/her] self off the bed. The Monthly Incident/Accident QA Log did not specify the height of the resident's bed or if fall mats were in place at the time of the fall. The log indicated Resident #38's care plan was updated but did not indicate what updates had been made and/or recommended. A review of Resident #38's care plan Focus, addressing recurrent falls (initiated on 06/15/2023), revealed on 07/05/2023 the care plan was updated to include an intervention for non-skid strips to the floor by the bed, despite a witness to the fall reporting the resident scooted off the side of the bed. A review of a Progress Notes revealed a Health Status Note, dated 07/17/2023 at 5:45 PM, that indicated the nurse walked into Resident #38's room to give medication and noted the resident was not in the bed. The note indicated the nurse walked to the other side of the room and found the resident lying on the floor. A review of a Post Fall Observation, dated 07/17/2023 at 3:34 PM and completed by Licensed Practical Nurse (LPN) #20, revealed Resident #38 was last seen in bed before the fall, the resident was barefoot, and no restraints or adaptive equipment were in use at the time of the fall. According to the report, the nurse reviewed and determined the resident was receiving nine or more medications, including antihypertensives, the resident had a history of multiple falls, in which the resident attempted to get out of bed but could not walk or stand. Potential factors that could have contributed to the fall were listed as NA [not applicable], and measures taken to prevent further falls were listed as unknown at this time due to residents' mental status. The Post Fall Observation did not specify the height of the resident's bed, if fall mats were in place at the time of the fall, or if non-skid strips had been applied to the floor per the 07/05/2023 care plan update. A review of a Monthly Incident/Accident QA Log revealed Resident #38 sustained a fall in their room on 07/17/2023. The log indicated the resident did not sustain any injuries. The Root Cause was listed as, Resident unable to recall cause of fall. The nurse states she walked into the resident's room and found resident lying on left side of bed on [his/her] right side. The Monthly Incident/Accident QA Log did not specify the height of the resident's bed, if fall mats were in place at the time of the fall, or if non-skid strips had been applied to the floor per the 07/05/2023 care plan update. A telephone interview was held with LPN #20 on 09/14/2023 at 10:35 AM. LPN #20 stated there were no non-skid strips or fall mat being used at the time of Resident #38's fall on 07/17/2023. LPN #20 stated that on 07/17/2023 she had gone into Resident #38's room to give the resident medications, and the resident was not in bed. LPN #20 stated she found the resident between the bed and the wall, under the bed. LPN #20 stated she had not put an immediate intervention in place after the fall to prevent reoccurrence of falls. An observation was made of Resident #38 on 09/11/2023 at 3:10 PM. Resident #38 was found in bed. A sign was noted over the head of Resident #38's bed that indicated a fall mat should be on the floor at all times when the resident was in bed. No fall mat was on the floor, and no fall mat was seen in the resident's room. An observation was made on 09/12/2023 at 10:05 AM. Certified Nursing Assistant (CNA) #9 and CNA #10 were providing care to Resident #38. There was no fall mat on the floor. During the care observation, the Housekeeping Supervisor (HS) brought in two fall mats. CNA #9 and CNA #10 both stated they had not seen any fall mats by Resident #38's bedside since the resident arrived on the unit about a month ago. An interview was held with LPN #14 on 09/12/2023 at 10:56 AM. The LPN stated she was unable to recall Resident #38 having a fall mat on the floor. On 09/13/2022 at 11:40 AM, an interview was held with Registered Nurse (RN) #19. RN #19 stated she had worked in the facility for about a month and was familiar with Resident #38. RN #19 stated she had seen fall mats in Resident #38's room and indicated if the fall mats were not in place, they may have been taken out for cleaning. RN #19 stated that before taking dirty fall mats for cleaning, new fall mats should have been placed. The HS was interviewed on 09/13/2023 at 1:46 PM. The HS stated that prior to her delivering fall mats to Resident #38's room on 09/12/2023, there had been no fall mats in the resident's room. The HS stated RN #21 told her to take the fall mats to the resident's room. An observation was made of Resident #38's room on 09/14/2023 at 8:53 AM. There were no non-skid strips applied to the floor in the resident's room. An interview was conducted with CNA #29 on 09/14/2023 at 9:21 AM. CNA #29 stated that prior to the week of survey, she had no memory of seeing any fall mats by Resident #38's bed and indicated she did not recall seeing any non-skid strips on the resident's floor. The Assistant Director of Nursing (ADON) was interviewed on 09/14/2023 at 12:27 PM. The ADON stated nurses were expected to place immediate interventions to prevent further falls by the resident. The ADON stated finding the root cause of a resident's fall was not the responsibility of one person. The ADON reviewed Resident #38's 06/12/2023 fall and acknowledged no interventions were added at the time of the fall. She stated there should have been interventions added. The ADON reviewed the information for Resident #38's 07/04/2023 fall and stated that without the knowledge of what footwear the resident wore, the resident's level of continence, the height of the bed, or if the fall mat was in place, the investigation was incomplete. The ADON then reviewed the fall information for Resident #38's 07/17/2023 fall and stated she saw no intervention that was added at the time of the fall. The ADON stated a thorough investigation meant to evaluate all pieces of the fall, including what caused the resident to fall and determining whether all interventions were in place to prevent falls. The ADON said care plans should be re-evaluated after each incident. The ADON stated each unit manager was responsible for making sure fall prevention interventions were in place. The ADON said she expected all care plan interventions to be used. The ADON stated it upset her that Resident #38's fall interventions were not in place. An interview was held with RN #21, a unit manager, on 09/15/2023 at 10:04 AM. RN #21 stated that when a resident fell , staff were expected to assess the resident, determine the reason for the fall, and implement an intervention at the time of the fall. RN #21 stated factors for consideration when adding interventions included the resident's continence, vision, hearing, and physical abilities. RN #21 said the purpose of adding interventions was to prevent additional falls. RN #21 stated a complete fall investigation included interviews with staff, making sure interventions had been placed, continence status, the type of footwear worn by the resident, the height of the bed, and the last time care was provided. RN #21 reviewed the fall reports for Resident #38 and stated information was missing. She said she did not consider the fall reports thorough investigations, and the root cause of Resident #38's falls had not been determined. RN #21 reviewed the Monthly Incident/Accident QA Logs and stated there was still no investigation or root cause and indicated the logs only stated what happened. RN #21 stated that when she reviewed the care plan for Resident #38, she realized the resident should have had fall mats by the bed and thought perhaps the mats had not been transferred when Resident #38's room was changed. An interview was held with RN #16, a unit manager, on 09/15/2023 at 12:27 PM. RN #16 stated Resident #38 had lived on her unit from 06/26/2023 until 08/11/2023. On the resident's admission to the unit, RN #16 stated she had been told Resident #38 had previous falls but was unsure what interventions were in place at the time of transfer to her unit. RN #16 stated she expected the nurses to try to figure out why each fall occurred, such as trying to determine what was going on and describe what was found, including describing any environmental obstacles and footwear. RN #16 reviewed the fall reports for Resident #38 and stated details and immediate interventions were missing. RN #16 stated thorough fall investigations were important to prevent other falls. An interview was held with RN #17, the staff educator, on 09/15/2023 at 1:00 PM. RN #17 stated she taught nurses that when a resident experienced a fall, they were to paint a picture of what happened and to include interventions such as low bed, non-skid socks, continence, or other factors that may have caused the resident to fall. RN #17 said nurses were also taught to place interventions at the time of the fall to prevent the resident from experiencing further falls. RN #17 reviewed the Monthly Incident/Accident QA Logs for Resident #38's falls and stated she did not consider the QA notes a thorough investigation. RN #17 added a thorough investigation was needed to determine the root cause of why Resident #38 fell and to identify any other factors that may have influenced the fall, so appropriate actions could be taken to prevent other falls. An interview was held with the MDS Director (MDS-D) on 09/15/2023 at 5:16 PM, and she stated non-skid strips on the floor would help when staff was standing the resident to keep the resident's feet from slipping. The MDS-D stated she expected staff to follow the interventions on the care plan and added the unit managers were responsible to make sure the fall prevention interventions were being used as directed by the care plan. The MDS-D stated weekly at-risk meetings were held to discuss falls, but only the falls were discussed and not necessarily the interventions. An interview was held with the Director of Nursing (DON) on 09/15/2023 at 5:36 PM. The DON stated staff were expected to complete incident reports and the proper documentation according to the facility's policy. The DON stated she expected an immediate intervention to be placed for falls. The DON stated she had reviewed the incident reports for Resident #38's falls and agreed there could have been more investigation done. The DON added unit managers were expected to review incident reports for a complete investigation, and residents' falls were reviewed daily in a clinical meeting attended by unit managers, the ADON, and the DON. The DON stated she expected the care plan to be followed and revised after falls. The DON added it was the responsibility of the unit manager and the assigned nurse to make sure interventions were used as indicated by the care plan. An interview was held with the Administrator on 09/15/2023 at 6:28 PM. The Administrator stated she expected staff to follow the care plan interventions. The Administrator stated she expected staff to investigate how and why the resident fell . The Administrator stated interventions were expected to be placed at the time of any fall to prevent further falls.

Based on observations, interviews, record review, and facility document and policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) that were necessary to maintain good grooming and personal hygiene for Resident #39. Specifically, Resident #39 had fingernails that were long and dirty. This failure affected one of 11 sampled residents reviewed for ADL care. Findings included: A review of a facility policy titled Activities of Daily Living, revised in March 2018, indicated, . Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Additionally, . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks) . A review of Resident #39's Admission Record revealed the facility admitted the resident on 12/26/2016 with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. On 01/26/2018, Resident #39 was diagnosed with vascular dementia, and on 11/27/2020, the resident was diagnosed with Parkinson's disease. A review of Resident #39's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2023, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for personal hygiene and bathing. A review of Resident #39's care plan, initiated on 01/18/2022, revealed the resident had an ADL self-care performance deficit. Interventions initiated on 01/18/2022 directed staff to check the resident's nail length and trim and clean them on bath days and as necessary. During an observation on 09/10/2023 at 1:36 PM, Resident #39 was observed lying in bed with fingernails on both hands that extended over the tip of the fingers approximately 1/4 to 1/2 inch in length, with brown substances underneath the nails. During an interview at that time, Resident #39 stated they did not remember the last time their fingernails had been cut and cleaned, but they needed to be cut and cleaned. During an interview on 09/10/2023 at 1:41 PM, Registered Nurse (RN) #17 stated Resident #39's fingernails were long and dirty and needed to be trimmed and cleaned. She indicated that Licensed Practical Nurse (LPN) #39 normally cut residents' fingernails and toenails, and certified nursing assistants (CNAs) were not allowed to cut the residents' nails. She stated she expected Resident #39's fingernails to be cleaned and trimmed. During an interview on 09/12/2023 at 6:07 AM, CNA #37 indicated Resident #39 was dependent on staff for nail care and did not refuse nail care. She stated Resident #39's nails should be trimmed and cleaned. During an interview on 09/12/2023 at 6:11 AM, LPN #38 indicated Resident #39 did not refuse care and was dependent on staff for nail care. During an interview on 09/13/2023 at 8:44 AM, the Director of Nursing (DON) stated Resident #39 was dependent on staff for nail care. She stated the facility's policy on nail care should be followed. She stated fingernails should be trimmed and cleaned as needed. The DON stated that CNAs, nurses, and LPN #39 should be checking nail length, and if nails were long and dirty, they should be trimmed and cleaned. She stated she expected residents' fingernails to be cleaned and trimmed. During an interview on 09/13/2023 at 8:54 AM, LPN #39 stated she cut Resident #39's fingernails about three weeks ago. She indicated Resident #39 did not refuse nail care. She stated she expected residents' nails to be trimmed and cleaned. During an interview on 09/13/2023 at 9:01 AM, the Administrator stated she expected a resident's fingernails to be trimmed and cleaned without substances underneath the nails. She stated that the CNAs and nurses were responsible for ensuring nails were cleaned and trimmed.

Based on interviews, record review, and facility policy review, the facility failed to update the care plan to include interventions related to Resident #116's refusal of insulin administration. This failure affected one of 30 residents whose care plans were reviewed. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised in December 2016, indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Further review of the policy indicated, .The Interdisciplinary Team must review and update the care plan: . b. When the desired outcome is not met . d. At least quarterly, in conjunction with the required quarterly MDS assessment . A review of Resident #116's Admission Record revealed the facility admitted the resident on 11/25/2022 with diagnoses that included type 2 diabetes mellitus and long term (current) use of insulin. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/2023, revealed Resident #116 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident received insulin injections daily during the seven-day review period. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/28/2023, revealed Resident #116 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident received insulin injections daily during the seven-day review period. A review of Resident #116's care plan focus statement, with an initiation date of 01/24/2022 and last revised on 02/20/2023, indicated the resident was at risk for unstable blood glucose related to diabetes mellitus and required supplemental insulin. Further review of the care plan revealed it did not address the resident's refusal of insulin. A review of Resident #116's Orders-Administration Note, dated 03/29/2023, revealed the resident was to receive NovoLog insulin injections according to a sliding scale before meals and at bedtime. The sliding scale documented in the Orders-Administration Note indicated if the resident blood glucose (sugar) was 151-200 (mg/dL), the resident was to receive 2 units of insulin; 201-250 mg/dL, 4 units; 251-300 mg/dL, 6 units; 301-350 mg/dL, 8 units; 351-400 mg/dL, 10 units; and [PHONE NUMBER] mg/dL, 10 units. A review of Resident #116's nursing Progress Notes for the timeframe from 06/01/2023 to 09/13/2023 revealed the resident refused to allow staff to administer sliding scale NovoLog insulin as prescribed by the physician on the following dates: 06/06/2023, 06/10/2023, 06/12/2023, 06/23/2023, 06/26/2023, 06/27/2023, 06/28/2023, 07/03/2023, 07/05/2023, 07/06/2023, 07/10/2023, 07/14/2023, 07/16/2023, 07/18/2023, 08/02/2023, 08/11/2023, 08/28/2023, 09/10/2023, and 09/11/2023. During an interview on 09/12/2023 at 1:59 PM, Resident #116's stated that they sometimes refused their medications especially their insulin. During an interview on 09/13/2023 at 9:35 AM with Licensed Practical Nurse (LPN) #25, she stated that if a resident refused medications, it should be addressed in their care plan. During an interview on 09/13/2023 at 12:06 PM with Registered Nurse (RN) #19, she stated if a resident refused medication their care plan should be updated to include the refusal. During an interview on 09/13/2023 at 3:31 PM with RN #28, she stated that Resident #116 sometimes refused the administration of insulin, and the resident's care plan should have been updated to reflect those refusals. During an interview on 09/15/2023 at 10:29 AM with LPN #26, she stated that if a resident refused their medications their care plan should be updated. During an interview on 09/15/2023 at 12:13 PM with RN #21, she said that if a resident refused to take medications it should be in their care plan. During an interview on 09/15/2023 at 6:55 PM with the Administrator, she stated that she expected her staff to revise and update the care plans timely. She said that if a resident was refusing a medication, staff should investigate why the resident did not want the medication and come up with a good intervention.

Based on interviews, record reviews, facility policy and document review, the facility failed to ensure a Certified Nursing Assistant (CNA) reported an allegation of abuse to administration immediately, or within two hours. On 02/23/2023, CNA #2 allegedly observed CNA #1 being rough and verbally inappropriate while providing care but did not report the allegation to the Administrator until 02/27/2023 at 1:15 PM, four days later. This failure affected three (Residents #40, #114, and #139) of five sampled residents reviewed for abuse. Findings included: A review of a facility policy titled, Abuse Investigation and Reporting, revised April 2019, revealed, . Abuse or Neglect is to be reported immediately to the supervisor, who then will report to the Administrator. Abuse of any kind is to be reported to the appropriate State agency, within two (2) hours, by the facility as well as serious injury (which could fall under neglect or injury of unknown origin) . A review of Resident #40's Admission Record revealed the facility most recently admitted the resident on 08/31/2021 with diagnoses of Alzheimer's disease, major depressive disorder, and generalized anxiety disorder. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/2022, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 9 (nine), which indicated the resident had moderate cognitive impairment. According to the MDS, the resident required extensive assistance of one person for bed mobility. A review of Resident #114's Admission Record revealed the facility admitted the resident on 01/13/2021 with diagnoses that included dementia, Alzheimer's disease, delirium, anxiety disorder, adjustment disorder with depressed mood, and metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). A review of an annual MDS, with an ARD of 03/29/2023, revealed a Staff Assessment for Mental Status (SAMS) identified Resident #114 as having a short- and long-term memory problem and moderately impaired cognitive skills for daily decision making. According to the MDS, the resident required extensive assistance of one person for bed mobility. A review of Resident #139's Admission Record revealed the facility most recently admitted the resident on 10/22/2022 with diagnoses that included muscle weakness and encephalopathy. A review of a quarterly MDS, with an ARD of 03/07/2023, revealed Resident #139 had a BIMS score of 3 (three), which indicated the resident had severe cognitive impairment. According to the MDS, the resident required extensive assistance of one person for bed mobility. A review of the Alabama Department of Public Health Online Incident Reporting System revealed a Confirmation of Receipt of Online Incident Report, dated 02/27/2023, that indicated the facility submitted a report of alleged physical abuse to the state survey agency on 02/27/2023 at 2:42 PM. The report indicated CNA #2 reported the allegation to the Administrator on 02/27/2023 at 1:15 PM. CNA #2 indicated that on 02/23/2023 she observed CNA #1 being rough by shoving residents into the rails and verbally inappropriate with residents while providing care to them during the shift. The report identified Residents #40, #114, and #139 as the affected residents. A review of a statement, dated 02/27/2023 and signed by CNA #2, revealed, I did not report these concerns to anyone until today, 2/27/23 [02/27/2023]. A review of a Disciplinary Action Record, signed by CNA #2 and the Administrator on 03/01/2023, revealed CNA #2 received an Initial Written Warning due to a violation of the facility's abuse prevention policy as evidenced by the failure to timely report a suspicion of abuse on 02/23/2023. During an interview on 09/12/2023 at 6:42 AM, Licensed Practical Nurse (LPN) #15 stated she was the charge nurse on the night of 02/23/2023, and CNA #2 did not report abuse or mistreatment during the shift. LPN #15 indicated CNA #2 should have reported it at that moment, if she thought something was going on. During an interview on 09/12/2023 at 7:33 AM, LPN #13 stated if staff had abuse concerns, they should report it immediately. During an interview on 09/13/2023 at 3:04 PM, CNA #2 stated she was in training when the incident occurred. She indicated she had abuse training in her CNA class and knew she should have reported her concern immediately. CNA #2 stated she called Registered Nurse (RN) #17 to report it the next day because she was one of the trainers in the CNA classes. CNA #2 stated RN #17 told her to report her concern to the Administrator, which she did. CNA #2 stated she was written up by the Administrator for not reporting immediately. CNA #2 stated, No, I did not report it right away, but it was less than 24 hours, and then I got in trouble for it. CNA #2 also stated, I did know I should have reported it immediately, and that's [that is] on me. During an interview on 09/13/2023 at 3:28 PM, RN #17 stated CNA #2 sent her a text message and provided a few details of her concerns. RN #17 said she sent a text message back to CNA #2 and instructed her to report the concerns to the Administrator, who was the Abuse Coordinator. RN #17 was unable to retrieve the text messages to verify the date and time CNA #2 reported to her, but indicated since she was a mandatory reporter, she had also notified the Administrator. RN #17 recalled when CNA #2 reported the concerns to her, she indicated it had occurred a few days prior. RN #17 said if staff suspected abuse, they should report it immediately to protect the residents from the alleged abuser. During an interview on 09/15/2023 at 11:29 AM, the Director of Nursing (DON) stated she expected everyone to report abuse immediately, for resident safety. The DON stated the immediacy of reporting was because of the need to remove the abusing staff member to keep the residents safe. During an interview on 09/15/2023 at 1:26 PM, the Administrator stated CNA #2 should have reported the incident immediately, and CNA #2 knew that. The Administrator stated she expected any incident to be immediately reported to make sure the residents were safe, and so facility management could intervene right away. This deficient practice was cited as a result of the investigation of complaint/report #AL00043481.

Based on observations, interviews, and review of the facility's policy titled, Procedure for Administration of Pharmaceutical Service, the facility failed to ensure expiration dates were on the label of eleven medications on four of the five medication carts in the facility on [DATE] and [DATE]. This deficient practice affected four of the five medication carts observed. Findings Include: A review of the facility's policy titled, Procedure for Administration of Pharmaceutical Service, with a review date of (MONTH) 3, 2019, revealed, .The label of each patient's individual medications indicates .expiration date . On [DATE] at 3:29 p.m. the Surveyor with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN ), observed a Medication Cart that contained the following: 1. [MEDICATION NAME] Sodium 100 mg (milligram) capsules without an expiration date on the container label. 2. [MEDICATION NAME] Mag DR 40 mg tablets without an expiration date on the container label. 3. [MEDICATION NAME] 5 mg tablet without an expiration date on the container label. On [DATE] at 3:48 p.m. the Surveyor with EI #3, LPN, observed North East Medication Cart that contained the following: 1. [MEDICATION NAME] 1 GM (gram) tablets without an expiration date on the container label. 2. [MEDICATION NAME] 4 mg tablets without an expiration date on the container label. 3. [MEDICATION NAME] 40 mg tablets without an expiration date on the container label. On [DATE] at 4:21 p.m., the Surveyor observed the Far North Medication Cart that contained the following: 1. [MEDICATION NAME] 120 mg tablets without an expiration date on the container label. 2. Thera tablets without an expiration date on the container label. 3. [MEDICATION NAME] 25mg /100 mg tablets without an expiration date on the container label. On [DATE] at 11:27 a.m., the Surveyor with EI #8, LPN, observed the Rehab Medication Cart that contained the following: 1. [MEDICATION NAME] without an expiration date on the medication label. 2. Osteo Bi Flex tablets without an expiration date on the label. On [DATE] at 4:31 p.m., the Surveyor interviewed EI #6, LPN. EI #6 was asked, what was observed on the medication labels in the medication cart. EI #6 replied, there were medication labels/containers that did not have an expiration date. EI #6 was asked, why was there not an expiration date on some of the residents' medication containers. EI #6 said she did not know. EI #6 was asked, what staff were responsible for ensuring the medications were not expired. EI #6 replied, the responsibility was hers. EI #6 was asked, what was the potential harm with not having an expiration date on the residents' medications containers. EI #6 replied, the resident may not get the full effect of the medications. EI #6 was asked, who was responsible for stocking the medications on the medication cart. EI #6 replied, the nurse. On [DATE] at 9:42 a.m., the Surveyor interviewed EI #7, Pharmacist. EI #7 was asked, what was the facility's policy regarding the expiration date on the residents' medication labels. EI #7 replied, the date of issue and expiration date should be on the residents' medication label. EI #7 was asked why some of the labels on the medications on the medication carts did not contain an expiration date. EI #7 replied, they changed labels recently. EI #7 was asked, who was responsible for ensuring the medications were labeled correctly and with an expiration date. EI #7 replied, she guessed her. EI #7 was asked, what was the potential harm with the label not containing an expiration date. EI #7 replied, the possibility that a resident could have received an expired medication. On [DATE] at 10:21 a.m., the Surveyor interviewed EI #4, Director of Nursing. EI #4 was asked, what important dates should be included on the residents' medication labels according to the facility policy. EI #4 replied, date of issue and expiration date of one year or earlier which ever was applicable. EI #4 was asked, why should the expiration date be included on the residents' medication labels. EI #4 replied, so the nurses did not give any expired medication. EI #4 was asked, who was responsible for ensuring the labels contained an expiration date. EI #4 replied, the pharmacy and the nurse. EI #4 was asked, what was the potential harm with the residents' medication labels not containing an expiration date. EI #4 replied, the residents could have received expired medication.

Based on observation, interviews and review of the facility's policy titled, INSTILLATION OF EYE DROPS AND APPLICATION OF EYE OINTMENT, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN), provided privacy for Resident Identifier (RI) #190 while administering eye drops in the dining area with twelve other residents present on 11/6/2019. The deficient practice affected one of one resident receiving eye drops during medication administration observations. Findings include: Review of the facility's policy titled, INSTILLATION OF EYE DROPS AND APPLICATION OF EYE OINTMENT, with an effective date of 11/2010, revealed, . PR[NAME]EDURE: INSTILLATION OF EYE DROPS .2. Position patient/provide privacy . RI #190 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #190's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 10/18/19, documented RI #190 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 11/06/19 at 3:06 p.m., the Surveyor observed EI #5, LPN, administering eye drops to RI #190 in the dining area with twelve other residents present. EI #5 did not provide privacy for RI #190 while administering eye drops. On 11/07/19 at 10:21 a.m., the Surveyor interviewed EI #4, Director of Nursing. EI #4 was asked, what was the facility's policy regarding instilling eye drops and privacy. EI #4 replied, the nurse should always provide privacy for the resident. [NAME] I#4 was asked why. EI #4 replied, for the dignity of the resident. EI #4 was asked, would the facility's dining area containing over ten residents be considered a private area or a non private area. EI #4 replied, a non private area to receive eye drops. EI #4 was asked, what would be the potential harm with the nurse administering eye drops in a dining area with over ten other residents present. EI #4 replied, administration of eye drops in the dining area with over ten other residents could cause embarrassment for the resident. On 11/07/19 at 1:58 p.m., the Surveyor conducted an interview with EI #5. EI #5 was asked, what was the facility's policy regarding administering eye drops to a resident and privacy. EI #5 replied, the nurses should provide privacy while administering eye drops. EI #5 was asked, what did she do to provide privacy for RI #190 while administering eye drops on 11/6/19. EI #5 replied, she did not provide privacy for R I#190 while administering eye drops. EI #5 was asked, where was RI #190 when she administered the eye drops. EI #5 replied, sitting in the dining room. EI #5 was asked was RI #190 alone, sitting in the dining room. EI #5 replied, no there were other residents walking around in the dining room. EI #5 was asked, how should the nurse administer the eye drops to ensure privacy. EI #5 replied, take the resident to their room or the office which was private. EI #5 was asked, what was the potential harm with administering eye drops without providing privacy. EI #5 replied, it was a dignity issue for the residents. EI #5 was asked, what was RI #190's response when she asked if RI #190 did not want privacy when the eye drops were administered. EI #5 replied, she did not ask RI #190 about privacy before administering the eye drops.

Based on interview, record review and review of a facility policy titled Grievance, the facility failed to ensure that Resident Identifier (RI) #32's grievance, filed on 10/16/19, was resolved in a timely manner and per facility policy. This affected one of one resident on the sample reviewed for filing a grievance. Findings Include: Review of the facility policy titled Grievance, effective (MONTH) 2009, revealed the following: . 6. The resident . will be informed of the findings of the investigation and the plan to correct the identified problems . within three (3) working days of the filing of the grievance . 7. Social Services will contact the grieving person approximately two (2) weeks after the plan is established to ensure that it is working properly . During the Resident Council meeting on 11/6/2019 at 2:36 p.m., RI #32 stated he/she was upset because he/she reported several missing items to the facility weeks ago and was told they would be replaced; however, the items had still not been replaced. The missing items consisted of: - one set of twin sheets, including one fitted sheet and one top sheet - one set of green satin pajamas RI#32 stated he/she had told housekeeping and filed a grievance about the missing items. RI#32 stated he/she was very upset about not having the belongings returned or replaced. On 11/06/2019 at 3:53 p.m., RI #32's grievance form, dated 10/16/19, was reviewed. The form identified the missing items as a top and bottom sheet, one set of pajamas, and a pajama top. Under Follow Up there was documentation indicating Housekeeping and Laundry had searched rooms, but the missing items had not been found. On 10/30/2019, Social Services updated the form to indicate staff were continuing to look for the items and if not found, they would be replaced. On 11/07/2019 at 9:45 a.m., Employee Identifier (EI) #1, Social Worker, stated RI #32 had filed a grievance about some missing sheets and pajamas. EI #1 stated the date the grievance began is the date it was received by Social Services. EI #1 was asked to review RI# 32's grievance, dated 10/16/2019. EI #1 was asked if the facility would be in compliance with their grievance policy if the items had not yet been found or replaced, and EI #1 said no. When asked what concerns the unresolved grievance could cause RI #32, EI #1 said it could cause RI #32 concern that the facility does not understand or have any sympathy for his/her concerns and that they may not be taking him/her seriously and cause undo stress and anxiety. On 11/07/2019 at 10:06 a.m., EI#2, Housekeeping/Laundry Supervisor, stated RI #32 had filed a grievance about three weeks prior regarding missing sheets and pajamas. EI #2 said she filled out a grievance form and turned it in to Social Services. EI #2 was provided a copy of the grievance form for RI #32's missing items and asked if it was the one she had completed. EI #2 stated it was. When asked if the grievance had been resolved, EI #2 said no, not to her knowledge. EI #2 said she had gone to RI #32's room several times to reassure him/her that they were still looking for the items. EI#2 said RI #32 was upset and nearly tearful over the missing items. After reviewing the facility's Grievance Policy, EI #2 said she interpreted the policy to mean the facility had two weeks to resolve the grievance. When asked if RI #32's grievance had been resolved, EI #2 said no, because RI #32 was not happy and to be resolved both parties must be in agreement .

Based on observation, interview, record review and review of a facility policies titled MDS (Minimum Data Set) 3.0 & Care Plans and Fall Prevention Policy, the facility failed to implement Resident Identifier (RI) #86's care plan approach for non slip strips in the bathroom to prevent falls. This affected 1 of 35 sampled residents for whom care plans reviewed. Findings Include: A facility policy titled MDS 3.0 & Care Plans, with a revised date of 7/24/14, documented .Purpose: to gather definitive information on a resident's strengths and needs in order to develop an individualized care plan . An undated facility policy titled Falls Prevention Policy documented: . based on individual situations . Interventions are noted on the care plan . RI #86 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 86's care plans revealed: . Problem Onset: 03/19/2019 . High risk for falls r/t (related to) GENERALIZED WEAKNESS . Approaches . PLACE NON SLIP STRIPS ON THE BATHROOM FLOOR FOR SAFETY . On 11/6/19 at 5:30 p.m. no non slip strips were observed on RI # 86's bathroom floor. On 11/7/19 at 8:52 a.m. no non slip strips were observed on RI # 86's bathroom floor. On 11/7/19 at 10:29 a.m. an interview was completed with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN)/Charge Nurse. EI #3 was asked if RI #86 was supposed to have non slip strips in his/her bathroom. EI #3 stated yes, according to the care plan. EI #3 was asked if RI #86 had non slip strips in his/her bathroom. After observing the bathroom with the surveyor, EI #3 stated no. EI #3 was asked why RI #86 should have non slip strips in the bathroom. EI #3 stated to keep him/her from slipping in the bathroom. EI #3 was asked when the non slip strips in the bathroom were put in place. EI #3 stated 12/5/18 for safety. EI #3 was asked if the fall care plan was followed if the non slip strips were not in the bathroom. EI #3 stated no. EI #3 was asked why the care plan was not followed. EI #3 stated the strips may have come up and not been replaced. EI #3 was asked what was the importance of following the care plan. EI #3 stated to promote safety.

Based on observation, interview and review of a facility policy titled Falls Prevention Policy, the facility failed to ensure non-skid strips were placed on Resident Identifier (RI) #86's bathroom floor. This affected 1 of 5 sampled residents reviewed for falls. Findings Include: A review of an undated facility policy titled Falls Prevention Policy revealed: .Residents will be assessed upon admission for the risk of falls . If a score of 10 or above is obtained, the following interventions will be put into place, based on individual situations . Interventions are noted on the care plan . RI # 86 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #86's Physician order [REDACTED].PLACE NON SLIP STRIPS ON THE BATHROOM FLOOR FOR SAFETY . A review of RI #86's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/19 documented RI #86 had a history of [REDACTED]. A review of a document titled Fall Risk assessment dated [DATE] documented RI #86 was a fall risk. RI # 86's fall care plan, last reviewed 9/11/19, documented: . High risk for falls r/t (related to) GENERALIZED WEAKNESS . Approaches . PLACE NON SLIP STRIPS ON THE BATHROOM FLOOR FOR SAFETY . On 11/6/19 at 5:30 p.m. no non slip strips were observed on RI # 86's bathroom floor. On 11/7/19 at 8:52 a.m. no non slip strips were observed on RI # 86's bathroom floor. On 11/7/19 at 10:29 a.m. an interview was completed with Employee Identifier (EI) #3, Licensed Practical Nurse (LPN)/Charge Nurse. EI #3 stated she was familiar with RI #86 and that he/she was a fall risk. EI #3 stated RI #86's last fall was (MONTH) of 2019. EI #3 was asked if RI #86 ever got out of bed. EI #3 stated he/she was gotten up daily to the wheel chair. EI #3 was asked if RI #86 ever tried to get out of the wheel chair. EI #3 stated yes, at times. EI #3 was asked if RI #86 was supposed to have non slip strips in his/her bathroom. EI #3 stated yes, according to the care plan. EI #3 was asked if RI #86 had non slip strips in his/her bathroom. After observing the bathroom with the surveyor, EI #3 stated no. EI #3 was asked why RI #86 should have non slip strips in the bathroom. EI #3 stated to keep him/her from slipping in the bathroom. EI #3 was asked when the non slip strips in the bathroom were put in place. EI #3 stated 12/5/18 for safety. EI #3 was asked why the strips were not in bathroom. EI #3 stated they may have come up and not been replaced. EI #3 was asked what was the potential negative outcome of not having the non slip strips in the bathroom. EI # 3 replied if RI #86 were to go in the bathroom he/she could fall if he/she tried to get out of the wheelchair

Based on observation, interviews with staff, and review of a facility policy titled Operation of Dishwasher, and regulations from the 2013 Food and Drug Administration FOOD CODE, facility staff failed to ensure effective cleaning and sanitizing of equipment and utensils as evidenced by: 1) dishmachine wash temperatures were not maintained at or above 120 degrees Fahrenheit (F) throughout the dishwashing process; 2) a coffee pot was not clean and air dried prior to storage; and 3) utensils were not effectively sanitized to destroy potential food borne pathogens in the 3-compartment final rinse sink at temperatures at or above 171 degrees F. This had the potential to affect all 198 residents for whom meals were prepared and served at the time of this survey. Findings include: 1) The facility procedure related to Operation of Dishwasher (dated May 2016), directs staff as follows: . 3.The dishwasher must have an operation temperature of 120 degrees at all times . If the temperature falls below the required temperature do not wash dishes or silverware until the proper temperature has been obtained . The 2013 Food Code, 4-501.110(B) specifies: The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 degrees F. During the initial kitchen tour on 09/26/17 at 11:20 a.m., the surveyor observed staff in the process of washing breakfast dishes in the dishroom. The low temperature/chemical sanitizing machine was observed during two cycles with a wash water temperature of 115 degrees F during each of the cycles. Staff continued processing dishes. On 09/27/17 at 10:10 a.m., the surveyor again checked the wash and rinse temperatures of the dishmachine. Although the wash water temperature of the first observed cycle was adequate (122 degrees F), the temperature of the second wash cycle registered only 116 degrees F. Eight to ten racks of various dishes and utensils had already been processed. At 10:29 a.m., the surveyor observed an additional cycle of dish processing (two racks of metal plate lids). The wash water registered 117 degrees F. 2) The 2013 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils specifies: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. The facility policy related to Operation of Dishwasher (dated May 2016), indicated .all dishes are to be are to be . pre-rinsed . before entering the dishwasher . On 09/27/17 at 10:10 a.m., one of three short metal coffee pots was stored in the clean utensil room. Inside the pot was one to two teaspoons of clear, brown liquid. EI #1, dishroom staff, confirmed the observation, and removed the pot from the shelf. EI #1 returned to the Dishroom with the coffee pot. EI #1 stated she would pour out the remaining coffee (which she demonstrated), then ran the coffee pot through the dishmachine. EI #1 did not rinse the coffee pot prior to processing through the dishmachine. EI #1 commented she had no idea why residue had been found in the previously cleaned pot. 3) The facility procedure titled: Operation for Three Compartment Sink (Pots and Pans), dated April 2016, directs staff as follows: . 3. Compartment #3, the far right hand sink, is the sanitizing sink and minimum is 171 degrees and each item must be soaked for a minimum of 30 seconds. The 2013 Food Code mandates under 4-501.111 Manual Warewashing Equipment, Hot Water Sanitization Temperatures the following: If immersion in hot water is used for sanitizing in a manual operation, the temperature of the water shall be maintained at 171 degrees F or above. On 09/27/17 at 9:45 a.m., the surveyor observed a variety of utensils soaking in the final rinse sink of the 3-compartment pot and pan sinks. The water temperature registered 147 degrees F when tested with a facility thermometer. At 10:01 a.m. (16 minutes later), the utensils were out of the sink and draining on the counter. The final rinse water temperature was again checked with the facility's thermometer and found to be 155 degrees F. The water temperature had not reached the specified 171 degrees F before removal. On 09/28/17 at 8:50 a.m., the Dietary Director (EI #6) and Assistant Dietary Manager (EI #7)were interviewed by the surveyor in regard to the above findings. Neither EI #6 or EI #7 were aware of the low wash water temperatures of the dishmachine. EI #6 stated the staff had been instructed to monitor the water temperatures as they wash the dishes, but the temperature gauge was difficult to read. In regard to the soiled stored coffee pot, EI #6 explained after pouring out the remaining coffee, staff should have soaked the pot in a tub of sanitizing water (with soap and chlorine), then washed the inside with hand or brush, and sprayed the inside with water before processing the pot on a rack through the dishmachine.

Based on an anonymous complaint received by the State Agency, the facility's abuse policy and Employee Identifier (EI) #1's Application for Employment and Background Verification Report and staff interviews, the facility allowed EI #1, a Registered Sex Offender, to be hired by the facility on 4/26/2016. EI #1's criminal background check dated 4/20/2016 indicated EI #1 had a conviction of rape in the 2nd degree. This deficient practice had the potential to affect all 206 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 2/22/2017 indicated the facility had a total of 206 residents. On 2/23/2017 at 9:35 AM, EI #2, the Administrator; EI #3, the Assistant Administrator; EI #4, the Director of Nursing and EI #5, the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy in the area of Resident Rights, F 225. Findings include: On 2/17/2017, the State Agency received an anonymous complaint, which alleged EI #1, a Registered Sex Offender, was working in the facility. The facility's policy titled ABUSE updated 11/28/2016, documented . I. Screening Procedures: 1. Administrator or his designee will review personal and past employment references during the pre-employment process. 2. Summerford Nursing Home, Inc. will conduct on all employees prior to employment: . B. Background check . 3. The application will be given to the Human Resource department with department, shift, and date of hire documented in the upper right hand corner of the application. This documentation from the Administrator or his designee will indicate to all departments, the potential employee has successfully passed all pre-employment screening and that personal and past employment references are satisfactory . Employee Identifier (EI) #1's Application for Employment indicated on 4/19/2016, EI #1 applied for the position of maintenance. On EI #1's application, he indicated he had been convicted of a crime other than a minor traffic violation. The application listed the crime as sex offender. The Background Verification Report located within EI #1's personnel file and dated 4/20/2016, revealed EI #1 had a guilty plea of felony rape 2nd degree. There was a handwritten note on the report that documented OK (initials of EI #2, the facility's administrator) Statutory Rape Consenting Teenager not a violent crime. The report further revealed EI #1 was a Registered Sex Offender in Alabama. The upper right corner of the application listed EI #1's date of hire as 4/26/2016. During an interview on 2/22/2017 at 2:34 PM, EI #1 was asked what department did he work in. EI #1 replied that he worked in maintenance, outside gardening. When asked how long he had been employed with the facility, EI #1 stated since April 2016. EI #1 was asked, if he ever worked inside the facility and he replied, if they needed him to work inside like for plumbing and changing out light bulbs. When asked if he had ever gone inside a resident's room, EI #1 replied if needed to change out light bulbs. In an interview on 2/22/2017 at 4:40 PM, EI #2, the facility's administrator stated he was the person that made the decision to hire EI #1. When asked if he was within the regulatory guidelines when he hired a person with a criminal background, EI #2 stated yes. EI #2 was asked why he hired EI #1 and he replied, EI #1 works hard and does a good job. In a follow-up interview on 2/22/2017 at 5:50 PM, EI #2 was asked if anyone monitored EI #1 while he worked. EI #2 said no. When asked if EI #1 was a convicted sexual offender, EI #2 said yes. EI #2 was asked if EI #1 was convicted of 2nd degree rape and he said yes. When asked if he had that knowledge prior to hiring EI #1, EI #2 said of course, it was in the paperwork. During another interview with EI #2 on 2/23/2017 at 4:00 PM, he was asked if he knowingly and intentionally hired EI #1, a known sex offender convicted of 2nd degree rape to work at Summerford Nursing Home. EI #2 replied, yes. When asked if the facility was in compliance with F 225, EI #2 said at the time he thought he was but now he has been shown he was not. EI #2 was asked, why he hired EI #1. EI #2 replied, under the circumstances he didn't think it applied to that tag because it was not a violent crime. When asked what was the potential harm in hiring someone to work in a long-term care facility that has been convicted and found guilty of abuse, EI #2 said possible could abuse residents. In an interview on 2/23/2017 at 4:55 PM, EI #3, the Assistant Administrator was asked if he had seen EI #1's background check. EI #3 answered, No, My dad (EI #2) ran his (EI #1) background check. When asked if he was aware EI #1's background check revealed he had been charged with rape, EI #3 replied, I had heard about it. EI #3 was asked if EI #2 had consulted with him (EI #3) about hiring EI #1. EI #3 said, No, he (EI #2) made the decision. When asked if EI #1 should have been hired, EI #3 said no. ************************* On 2/23/2017 at 6:05 PM, the facility submitted an acceptable Allegation of Compliance (AOC) which documented F225 EI #1's employment was terminated 9:55 AM 2-23-2017. A review of all current employees' background checks will be completed 2-23-2017. Any employee found to have been guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, will have their employment terminated effective immediately. All current Employee Files were checked for, and none were found guilty of: abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Completed 2-23-2017. We will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. The Abuse Registry will be checked to insure all current employees do not have a negative status. The check was completed on all current employees on 2-23-17, and none were found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. ************************* After reviewing the facility's information provided in their AOC,background checks, nurse aide registry checks and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a F level. This deficiency was cited as a result of the investigation of complaint/report number AL 008.

Based on an anonymous complaint received by the State Agency, the facility's administrator's job description, Employee Identifier (EI) #1's Application for Employment and Background Verification Report and staff interviews, the facility's Administrator responsible for the overall management of the facility, and who is responsible for the final approval of all potential hires, approved the hiring of a convicted sex offender to work at the facility. This deficient practice had the potential to affect all 206 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 2/22/2017 indicated the facility had a total of 206 residents. On 2/23/2017 at 9:35 AM, Employee Identifier (EI) #2, the Administrator; EI #3, the Assistant Administrator; EI #4, the Director of Nursing and EI #5, the Assistant Director of Nursing were notified of the findings of Immediate Jeopardy in the area of Administration, F 490. Findings include: On 2/17/2017, the State Agency received an anonymous complaint, which alleged EI #1, a Registered Sex Offender, was working in the facility. The Summerford Nursing Home, Inc. ADMINISTRATOR Job Description documented POSITION PURPOSE Directs operations of Summerford Nursing Home Inc. a 216-bed facility which provides skilled and intermediate care. NATURE AND SCOPE . Hires, . PRINCIPAL ACCOUNTABILITIES *Directs operations of Summerford Nursing Home Inc. to meet State, Federal regulations and avoid violations or licensure decertification . Employee Identifier (EI) #1's Application for Employment indicated on 4/19/2016, EI #1 applied for the position of maintenance. On EI #1's application, he indicated he had been convicted of a crime other than a minor traffic violation. The application listed the crime as sex offender. The Background Verification Report located within EI #1's personnel file and dated 4/20/2016, revealed EI #1 had a guilty plea of felony rape 2nd degree. There was a handwritten note on the report that documented OK (initials of EI #2, the facility's administrator) Statutory Rape Consenting Teenager not a violent crime. The report further revealed EI #1 was a Registered Sex Offender in Alabama. The upper right corner of the application listed EI #1's date of hire as 4/26/2016. In an interview on 2/22/2017 at 4:40 PM, EI #2, the Administrator stated he was the person that made the decision to hire EI #1. When asked if he was within the regulatory guidelines when he hired a person with a criminal background, EI #2 stated yes. EI #2 was asked why he hired EI #1 and he replied, EI #1 works hard and does a good job. In a follow-up interview on 2/22/2017 at 5:50 PM, EI #2 was asked if EI #1 was a convicted sexual offender, EI #2 said yes. EI #2 was asked if EI #1 was convicted of 2nd degree rape and he said yes. When asked if he had that knowledge prior to hiring EI #1, EI #2 said of course, it was in the paperwork. During another interview with EI #2 on 2/23/2017 at 4:00 PM, he was asked if he knowingly and intentionally hired EI #1, a known sex offender convicted of 2nd degree rape to work at Summerford Nursing Home. EI #2 replied, yes. When asked what was the potential harm in hiring someone to work in a long-term care facility that has been convicted and found guilty of abuse, EI #2 said possible could abuse residents. In an interview on 2/23/2017 at 4:55 PM, EI #3, the Assistant Administrator was asked if he had seen EI #1's background check. EI #3 answered, No, My dad (EI #2) ran his (EI #1) background check. When asked if he was aware EI #1's background check revealed he had been charged with rape, EI #3 replied, I had heard about it. EI #3 was asked if EI #2 had consulted with him (EI #3) about hiring EI #1. EI #3 said, No, he (EI #2) made the decision. When asked if EI #1 should have been hired, EI #3 said no. ************************* On 2/23/2017 at 6:05 PM, the facility submitted an acceptable Allegation of Compliance (AOC) which documented F490 Beginning 2-23-17 at 11:00AM, the administrator as well as an assistant administrator will review background checks for abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. In the absences of the administrator, the assistant administrator and an administrative assistant will review the background check. We will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. DON provided reeducation regarding federal regulation tags F225 and F490 to the administrator, assistant administrator, and human resources on 2/23/2017. Medical director will oversee the implementation of the allegation of compliance. ************************* After reviewing the facility's information provided in their AOC,background checks, nurse aide registry checks and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a F level. This deficiency was cited as a result of the investigation of complaint/report number AL 008.

Based on observations, interviews and record review, the facility failed to ensure the planned menus for 09/13/16, 09/14/16, and 09/15/16, met the menu planning requirements for achieving nutritional adequacy. This had the potential to affect 194 residents receiving meal trays from the kitchen. Findings Include: The Diet and Nutrition Care Manual, approved by the facility on 07/05/2016, was received on 09/13/16, from Employee Identifier (EI) #9, the Certified Dietary Manager (CDM). The Diet and Nutrition Care Manual included the following under the Menu Planning Requirements section: . Menu Nutritional and Regulatory Requirements Checklist . Fruit: 2 cups per day . Vegetable: 2 1/2 cups per day . On 09/15/16 at 10:00 a.m., the facility's menus for 09/13/16, 09/14/16, and 09/15/16, as approved and signed by EI #10, the Registered Dietitian (RD)/Licensed Dietitian (LD) were reviewed. The menu for 09/13/16, showed only one cup of fruit was served; cup orange juice and 1/2 cup pears. On 09/13/16, only two cups of vegetable were served; 1/2 cup fried squash, 1/2 cup slaw, approximately 1/2 cup of vegetable in the 6 ounces of chicken stew, and 1/2 cup baked okra. On 09/14/16, only 1 1/2 cups of fruit were served; 1/2 cup apple juice, approximately 1/2 cup fruit in a 2 inch by 2 inch piece of Million Dollar Pie, and 1/2 cup fruit salad. On 09/14/16, only 2 cups of vegetables were served; 1/2 cup beans, 1/2 cup tossed salad, 1/2 cup scalloped potatoes, and 1/2 cup English peas. On 09/15/16, only 2 cups of vegetable were served; 1/2 cup broccoli, 1/2 cauliflower, approximately 1/2 cup vegetable in 6 ounces vegetable soup, and 1/2 cup spinach casserole. On 09/15/16 at 11:00 a.m., the menus for 09/13/16, 09/14/16, and 09/15/16, were reviewed with EI #9. After reviewing the serving sizes and total number of fruits and vegetables as listed on the menus and the shortages, EI #9 said, I see. I can fix that. EI #9 also verified that the Menu Planning Requirements in the facility diet manual were to be used for planning the facility's menus and to ensure nutritional adequacy. During a phone interview on 09/15/16 at 1:35 p.m., EI #10 stated she understood the problem with the nutritional adequacy guideline for fruits and vegetables not being met. EI #10 further said she was in agreement that the serving sizes were short.

Based on observations, interviews and record review, the facility failed to ensure air gaps existed between eight kitchen sink equipment drains and four of six kitchen floor sink drains to prevent back flow and cross-contamination. This had the potential to affect 194 residents receiving meal trays from the kitchen. The 2013 Food Code by the United States (U. S.) Public Health Service and the Food and Drug Administration (FDA) included: . 5-202.13 Back Flow Prevention, Air Gap. An air gap between the water supply inlet and the floor level rim of the PLUMBING FIXTURE, EQUIPMENT, . may not be less than 25 mm (millimeters) (1 inch). On 09/14/16 at 10:20 a.m., one drain pipe was observed coming from the three-compartment food preparation sink, with an extender piece of pipe attached to the end of the drain pipe, which extended into a grate-topped floor sink drain. There was no air gap between the top floor level of the floor sink drain and the end of the drain pipe. On 09/14/16 at 10:25 a.m., the dishmachine was observed with one drain pipe extending from the dishmachine into the floor drain without an air gap. There were two additional drain pipes from sinks in the dishwashing area that extended into the floor sink drain also. There was no air gap for either of these three pipes. On 09/14/16 at 10:45 a.m., Employee Identifier (EI) #8, a Certified Dietary Manager (CDM) was interviewed while making an observation of a floor sink drain. When asked what would happen if there was a backup of water in the floor sink drain, EI #8 said there would be a problem. When asked if there was an air gap, EI #8 said there is suppose to be. On 09/14/16 at 10:58 a.m., EI #11, a Maintenance Worker, was interviewed while making an observation of the three-compartment food preparation sink's drain pipe going into the floor sink drain. EI #11 said he knew about air gaps. When asked if he saw an air gap between the drain pipe and the floor sink drain, EI #11 said we are right there at a fine line. When asked how the pipe got into the floor sink drain, EI #11 said he did not know who put it (the extension) on. EI #11 said he thought someone put it on to slow the drain down. EI #11 said he would fix it and take care of it. EI #11 said he would get it to an inch. On 09/14/16 at 12:30 p.m., there was an observation of a two-compartment food preparation sink with one drain pipe extending into a floor sink drain with no air gap. There was also a three-compartment pot/pan sink with one drain pipe extending into the same floor sink drain with no air gap. An additional observation was made of a potato peeling machine with a drain pipe extending into a floor sink drain and the drain pipe from a food scrap sink extending into the same floor sink drain without a one inch air gap for either. On 09/14/16 at 12:41 p.m., EI #9, a CDM, was asked if there was an air gap for the three compartment pot/pan sink. EI #9 said no. When asked about the food scrap sink, potato machine, and the two-compartment food preparation sink drains, EI #9 said no. EI #9 said there were no air gaps. On 09/15/16 at 11:35 a.m., EI #8 said the problem with the lack of air gaps came about because the lines (drain pipes) had dropped down and they just needed to raise them. EI #8 said there were three lines that needed to be cut off at the ends to create air gaps.