Every finding on record at The Nichols Center

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a stage two pressure ulcer for one (1) of (1) residents reviewed for care planning. Resident #38. Findings Include:Record review of the facility's Care Plan policy updated 2/20/20 revealed Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care .7. The care plan will be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS assessments (quarterly), significant change, annual and with changes in residents' condition as needed .On 03/26/2026 12:54 PM, in an interview with Registered Nurse (RN) #2/ Minimum Data Set (MDS) nurse stated that care plans are supposed to be updated by nurses on the floor when they receive a new physician order. She stated they discuss care plans in clinical and if it is not updated then she updates it. She stated the comprehensive care plan is used by nurses, Certified Nurse Assistants (CNAs) and physicians. She confirmed the care plan was not updated and should have been updated.On 03/26/2026 1:14 PM, in an interview with the Director of Nursing (DON) stated the area was put in the system as a skin tear. She stated the care plan should have been updated after the physician orders diagnosis as a stage two pressure wound. She stated the care plan is used by all staff to give care. She stated the nurses are responsible for updating the care plan as well as the nurse that takes the order off. She stated her expectations for all staff is to do what they are supposed to do.Record review of the Face Sheet for Resident #38 revealed an admission date of 9/20/24 with diagnoses that included Pressure ulcer of right ankle, Stage 2 with an onset date of 3/16/26.Record review of Resident #38 Order Summary Report' revealed an order dated 3/17/26 Clean Stage 2 pressure ulcer to right ankle with wound cleanser. Pat dry. Apply calcium alginate to wound bed. Cover with bordered foam. every day shift related to PRESSURE ULCER OF RIGHT ANKLE, STAGE 2. Record review of Resident #38's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 12/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident has severe cognitive impairment. Record review of Resident #38 comprehensive care plans revealed there were no goals or interventions related to the stage 2 pressure area on Resident #38's right ankle.

Based on observation, interview, record review, and facility policy review, the facility failed to provide psychiatric services in accordance with professional standards of practice for one (1) of three (3) residents reviewed for unnecessary medications, Resident #53. Findings Include: Record review of the facility policy Behavioral Health Services dated 4/01/18 revealed, It is the policy of this facility that all residents receive care and services to assist him or her to reach and maintain the highest level of mental and psychosocial functioning. Record review of the Progress Notes dated 2/3/26 through 3/12/26 revealed no psychiatric follow up notes were available and a behavior was marked YES on the progress notes indicating behaviors had been present. During an interview on 3/26/26 at 10:45 AM, the Director of Nursing (DON), stated Resident #53 was not being followed by psychiatric services despite receiving an antipsychotic medication. She stated the facility manages short term residents differently and does not automatically initiate psychiatric consultations based on antipsychotic use. She stated a consult is only initiated if behaviors are observed and warrant evaluation. She confirmed Resident #53 had not been referred to psychiatric services. She further stated the facility does not have a policy specifying when psychiatric consultation should be obtained. During a follow up record review and interview on 3/26/26 at 11:21 AM, the DON confirmed the documented behavior entries but stated no descriptive notes were included. She stated the entries were made in error and attributed them to the nurse selecting options in the electronic record without supporting documentation.During an interview on 3/26/26 at 11:26 AM, Licensed Practical Nurse (LPN) # 2 stated that although no recent behaviors were observed, upon admission Resident #53 exhibited confusion, restlessness, and cursing toward staff during care. The nurse also reported current concerns including poor oral intake, with the resident often refusing facility meals and waiting for food from his wife.During an interview on 3/26/26 at 11:31 AM, Certified Nurse Aide (CNA) #1 stated Resident #53 does not typically exhibit inappropriate behaviors toward staff but has cursed at his wife when she attempted to assist with movement of his affected right side following a prior stroke.During an interview on 3/26/26 at 12:04 PM, LPN # 2 stated Resident #53 had not exhibited recent behaviors but demonstrated confusion, aggression, and cursing during the first week following admission. The nurse reported the resident's wife indicated he had been off his antipsychotic medication prior to admission.During a follow up interview on 3/26/26 at 12:38 PM, the DON stated psychiatric follow up is important for residents receiving antipsychotic medications to monitor for adverse effects such as changes in mental status, weight loss, mood changes, or behavioral changes. She stated when behaviors are identified, nursing staff should notify a practitioner, and a psychiatric evaluation would be appropriate. She also stated newly admitted rehabilitation residents may require closer monitoring due to recent transitions from acute care settings.Record review of the Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 3/7/26 revealed a Brief Interview for Mental Status score (BIMS) of 11 which indicated moderate cognitive impairment.Record review of the Face Sheet revealed Resident #58 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease.Record review of the Order Summary Report revealed an order dated 1/30/26 for an antipsychotic drug Seroquel (Quetiapine) 100 milligrams (mg) by mouth at bedtime. There were no orders for a psychiatric consultation or follow up.

Based on record review, staff and responsible party (RP) interview and facility policy review, the facility failed to ensure a resident was treated with dignity and respect for one (1) of four (4) residents reviewed for resident rights. Resident #1. Findings included:Record review of facility policy Resident Rights, dated 10/24/25, revealed Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility.Record review of the facility investigation dated 10/06/25, revealed Resident #1 reported on 10/3/25 at 2:00 AM, that he called for assistance and Certified Nursing Assistant (CNA) #1 told him to use his brief for his incontinence and that she would return to change him. The resident waited an hour and a half before CNA #1 returned. CNA #1 told the resident, You are in rehab and should be walking. CNA #1 was placed on investigative leave on 10/6/25 and terminated on 10/8/25.Record review of an additional facility investigation revealed that on 10/6/25, Resident #1's RP reported that on 10/5/25, CNA #2 had entered Resident #1's room to assist him to the bathroom and never spoke to him during the entire interaction. The RP reported CNA #2 threw the covers over the resident and threw the bed remote onto the bed. Resident #1 confirmed this and described CNA #2 as rude and nasty. CNA #2 was placed on investigative leave on 10/6/25 and terminated on 10/8/25.Interview with the Administrator on 11/24/25 at 2:02 PM verified CNA #1 and CNA #2 did not treat Resident #1 with dignity and respect.Interview with the Director of Nursing (DON) on 11/25/25 at 9:02 AM revealed the resident initially did not know the names of the CNAs involved. The DON reviewed video footage to obtain photos of the CNAs on duty, and the resident identified both CNAs.Telephone interview with Resident #1's RP on 11/24/25 at 4:25 PM revealed she was present and witnessed CNA #2 not speaking to the resident during care, throwing the covers over him, throwing the remote onto the bed, and slamming the door.Record review of the admission Record revealed that the facility admitted Resident #1 on 9/23/25 with diagnosis of Difficulty in Walking.Record review Brief Interview for Mental Status (BIMS) Evaluation dated, 9/23/25 revealed a BIMS score of 14, which indicated Resident #1 is cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure resident safety during mechanical lift transfers by failing to assess and use the appropriate sling, and by failing to inspect the sling for signs of wear or damage prior to use for one (1) of three (3) residents reviewed for accidents and hazards (Resident #1). Findings include: Review of the facility policy titled Modified Lifting Policy, last updated 2/3/23, revealed:Policy: The facility will provide a safe work environment for patient care by providing and requiring the use of safety materials and equipment designed to prevent patient injury. Review of the [proper name] lift manufacturer guidelines under Safety Information revealed: Before each patient transfer, the sling must be inspected for signs of damage . that might cause it to fail. Under Transfer Criteria, it revealed: Before using the lift, patients must be assessed by the facility's professional nursing staff . to determine which patients are suitable for transfer with the lift, which sling size is appropriate, and the number of staff necessary to transfer each patient Record review of the facility investigation revealed that Resident #1fell approximately three (3) feet to the floor while being lifted with a total lift using a sling. The fall resulted in a skin abrasion to the residents right elbow and an L1 (lumbar) compression fracture. This investigation determined that the resident was not assessed for the use of a lift, an incorrect sling was used, and the lift had not been inspected. During an interview with the Administrator (ADM) on 10/22/25 at 8:16 AM, she confirmed that staff failed to use the correct sling and failed to assess the sling that was used, resulting in Resident #1 falling and sustaining a lumbar fracture with associated skin abrasion. She stated staff are educated to always assess the sling and use the appropriate sling for each resident. She confirmed that monthly audits are conducted on slings; however, the sling used was not on the August 2025 audit list and was not a sling provided by the facility's lift company. She stated, It must have come from the hospital or something. She confirmed the sling was in poor condition and was immediately removed from use. She stated that all staff involved in the incident were terminated for failing to inspect and use the proper sling during the transfer. She further stated, If staff had inspected the sling properly, the accident would likely not have occurred. An interview with Resident #1 on 10/22/25 at 9:00 AM confirmed that she fell from the total lift when the straps broke on the sling, causing her to fall to the floor on her buttocks and lower back. She stated she experienced soreness and increased pain and later learned she had a lumbar fracture. The resident stated that prior to the transfer, staff were commenting that the sling was not the correct one, but the nurse told them it would be okay to use this time. Record review of an orthopedic note dated 10/6/25 revealed: Patient is status post fall from a Hoyer lift chair. Now with L1 compression fracture. A phone interview with Certified Nursing Assistant (CNA) #1 on 10/22/25 at 10:14 AM revealed she assisted with the transfer when the sling broke, and Resident #1 fell. She stated she obtained the sling from laundry, and it was the only one available. She stated CNA #2 told her, We can't use a shower sling for a transfer, and that she then asked Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #2 who stated it would be okay to use this time, but not again because it's technically not the right sling. CNA #1 stated the sling appeared old and faded like it had been washed a lot. She confirmed that she had been educated and checked off on proper sling use. A phone interview with RN #1 on 10/22/25 at 10:48 AM revealed she did not recognize the sling as a shower sling and did not assess the sling for proper size or condition. She confirmed she should have assessed the resident and sling for appropriateness and stated the resident was a new admission with no lift assessment completed at that time. Record review of a written statement by CNA#2 revealed she told CNA #1, No, we can't use that sling, and advised her to ask the nurse. She confirmed both nurses said it was okay this time but not next time. CNA #2 stated that she, RN #1, and CNA #1 attached the sling to the lift, and it broke during the transfer, causing the resident to fall. During an interview with the Staff Development Coordinator on 10/22/25 at 10:55 AM, she stated all residents should be assessed prior to mechanical lift use to ensure proper sling size and that slings should be inspected for wear and tear before each use. She confirmed she observed the sling after the incident and noted it was in poor condition with fraying on the straps. She stated that if a proper sling was unavailable, staff should have waited or sanitized another sling rather than use one not approved for transfer. A phone interview with the Loss Control Representative for the [proper name] lift company on 10/22/25 at 11:00 AM revealed the sling used was not one provided by their company. She inspected the sling and confirmed it was frayed, old in appearance, and manufactured in 2019, and stated it should not have been used. An interview with CNA #3 on 10/22/25 at 11:10 AM revealed she had completed lift skills checkoffs and was trained to inspect slings before use to ensure they were in good condition. She stated she was taught that shower slings are only to be used for bathing, not for transfers. An interview with RN#2 on 10/22/25 at 11:15 AM revealed that all residents must be assessed for proper equipment, sling size, and sling condition before each transfer. Record review of the mechanical lift skills check-off for CNA #1 dated 8/13/25 and CNA #2 dated 8/14/25 confirmed that both employees were observed for selecting the correct size sling and inspecting it for damage. Record review of the admission Record revealed the facility admitted Resident #1 on 9/3/25 with medical diagnosis that included anxiety disorder. Record review of the Brief Interview for Mental Status (BIMS) dated 9/9/25 revealed a score of 15, indicating the resident was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to implement a care plan for monitoring for side effects and behavior monitoring with the use of psychotropic medications for (1) one of 16 resident care plans reviewed. Resident #38 Findings include: Review of the policy titled, Care Plans, updated 2/20/20, revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strength that will identify how the interdisciplinary team will provide care . Record review of the March 2024 Medication Administration Record for Resident #38 revealed no monitoring for side effects or targeted behaviors related to antipsychotic, antianxiety, and antidepressant medications. Record review of the care plan titled, Antipsychotic drug use: at risk for side effects, with start date 5/1/23 revealed, Interventions: Monitor patterns of targeted behaviors .Assess for adverse side effects, document, and report . Record review of the care plan titled, Antianxiety drug use: at risk for side effects, with a start date of 5/1/23 revealed, .Interventions Monitor patterns of targeted behaviors .Assess for adverse side effects, document, and report . Record review of the care plan titled, Antidepressant drug use: at risk for side effects, with a start date of 5/1/23 revealed, .Interventions: Monitor patterns of targeted behaviors .Assess for adverse side effects, document, and report . In an interview with the Medical Records/ Licensed Practical Nurse (LPN) on 3/13/24 at 3:00 PM, revealed after review of the psychotropic care plans for Resident #38, staff were not following the care plans. In an interview with the Director of Nursing (DON) on 3/13/24 at 3:07 PM, confirmed after review of the care-plans for Resident #38 staff were not following her care plans for behavior/side effect monitoring because there was no documentation of the monitoring and stated the purpose of the care plan is to ensure the resident receives the resident specific care they need. Record review of the Face Sheet revealed that the facility admitted Resident #38 to the facility on [DATE] with a diagnosis of Unspecified Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. Depression, and Anxiety disorder.

Based on staff interview, record review, and policy review the facility failed to provide services or care that accepted standards of quality dictate should have been provided when staff administered an as needed (prn) antipsychotic medication every 12 hours scheduled for (1) one of (9) nine residents whose medication regimen was reviewed. (Resident #104) Finding include: Review of the policy titled, Medication Administration General Guidelines revealed, .Procedure: . 2. Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice .18. Prior to administration, the medication and dosage schedule on the resident MAR (Medication Administration Record) is compared with the medication label, this information should be checked at least three times during the medication preparation process. If the the label and the MAR are different, the physician's orders are checked for the correct dosage schedule prior to administering . Record review of the Physician Order List dated 3/8/24 for Resident #104, revealed Olanzapine 2.5 mg (milligram) 1 tablet by mouth every 12 hours as needed times 14 days with time code of Q12 hours (every 12 hours). Record review of the Physician Orders List for Resident #104 dated 3/12/24, revealed Olanzapine 2.5 mg one tablet by mouth every 12 hours as needed times 14 days with time code of PRN Q12 (as needed every 12 hours). Record review of the March 2024 MAR for Resident #104 revealed Olanzapine 2.5 mg tablet by mouth every 12 hours as needed for 14 days scheduled to be administered at 8:00 AM and 8:00 PM. During an interview with Registered Nurse (RN) #1 on 03/13/24 at 1:24 PM, revealed she cares for Resident #104 and has not seen the resident have any behaviors and has not received any reports from other staff about any behaviors. During an interview with the Medical Records/Licensed Practical Nurse (LPN) on 3/13/24 at 3:00 PM, revealed she recognized yesterday that the physician's orders for Olanzapine 2.5 mg for Resident #104 was incorrectly put in the computer and was triggering to be signed off every twelve hours scheduled, but the order was to be every 12 hours as needed, so she contacted the provider and obtained an order correction. She then revealed that she was unable to find any documentation of behaviors for the need to administer the Olanzapine and confirmed the resident should not have received the Olanzapine every 12 hours because that is not what the provider ordered. She then revealed possible negative outcomes from receiving the Olanzapine is that the resident could have become over sedated, have loss of appetite, or Tardive Dyskinesia. During an interview with Certified Nurse Assistant (CNA) #1 and CNA #2 on 3/13/24 at 3:10 PM, they both revealed they have not seen or heard of Resident #104 having any behaviors. During an interview with the Director of Nursing (DON) on 03/13/24 at 3:40 PM, confirmed that Resident #104 should not have been given the medication ordered as needed Olanzapine without documentation of behaviors requiring the use of the medication . She also confirmed staff did not follow the physician's order when they gave the Olanzapine medication every 12 hours scheduled when the order read every 12 hours as needed. She then revealed the nurses should have recognized the order and the MAR needed to be clarified before administering the Antipsychotic medication, when they checked the five (5) rights of administration. Record review of the Face Sheet revealed that the facility admitted Resident #104 to the facility on [DATE] with diagnoses including Depression and Unspecified Dementia, unspecified severity, without behavior/psychosis/mood/anxiety.

Based on staff interview, record review, and policy review the facility failed to ensure residents were free from unnecessary drug use as evidenced by no targeted behavior or side effect monitoring for the use of psychotropic medications (Resident #38) and administered an as needed (PRN) antipsychotic medication with no documented targeted behaviors (Resident #104) for two (2) of five (5) residents reviewed for unnecessary medication use. Findings include: Review of the policy titled, Behavior Management and Psych-Pharmacological Medication Monitoring Protocol, revealed Policy: Residents who receive antipsychotic, anti-depressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest lowest dosage necessary to manage the residents' condition. Residents will be reviewed routinely for effectiveness and monitored for side effects.Purpose: Interventions developed will only include the use of medications when the assessment by the physician and interdisciplinary team have validated that non-chemical interventions alone are not successful. Resident #38 Record review of the Physician Orders List for Res. #38 revealed an order dated 2/18/24 for Celexa 20 MG (milligrams) give one table by mouth once daily, an order dated 9/18/23 for Buspirone HCL 10 MG tablet give one tablet by mouth twice daily and an order dated 3/4/24 for Zyprexa 5 MG tablet give 0.5 tab by mouth every day (hold for sedation). Record review of the March 2024 Medication Administration Record (MAR) revealed Resident #38 received Zyprexa 5 mg (milligram) give 0.5 tablet every day at bedtime (HS) from March 1st through March 3rd (Hold for Sedation), Buspirone 10 mg tablet give one by mouth twice daily March 1st through March 13th and Celexa 20 mg tablet give one tablet by mouth once daily from March 1st through 13th with no documentation of monitoring for side effects or behaviors. An interview with Licensed Practical Nurse (LPN) #1 on 3/13/24 12:38 PM, revealed residents on psychotropic drugs are monitored for behaviors and side effects every shift and documented on the MAR to determine if a medication is still appropriate for a resident. She confirmed if there was no monitoring potential adverse reactions or behaviors may be missed. An interview with the Medical Records LPN on 3/13/24 at 3:00 PM, revealed she was unable to find any monitoring for side effects of psychotropic medications and no monitoring for targeted behaviors in Resident #38's medical record. She then revealed the purpose of the monitoring of the psychotropic medications is to ensure the resident does not have adverse side effects. An interview with the Director of Nursing (DON) on 3/13/24 at 3:07 PM, confirmed monitoring for side effects and behavior monitoring should be documented on the MAR on all residents receiving psychotropic medications, to ensure they are not having any adverse reactions or increased behaviors, and the provider should be notified of any concerns identified such as over sedation, loss of appetite, or Tardive Dyskinesia. She confirmed there was no documentation for side effects or behavior monitoring for Resident #38. Record review of the Face Sheet revealed that the facility admitted Resident # 38 to the facility on [DATE] with a diagnosis of Unspecified Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, Depression, and Anxiety disorder. Resident #104 Record review of the Physician Orders List for Resident #104, revealed an order dated 3/12/24 Olanzapine 2.5 mg (milligrams) one tablet by mouth every twelve hours as needed times 14 days. Record review of the March 2024 MAR revealed Resident #104 received Olanzapine 2.5 mg one tablet at 8:00 AM March 9th-12th, 8:00 PM the 9th-11th, and at 5:16 AM on the 13th with no documentation of any behaviors on the MAR. An interview with Registered Nurse (RN) #1 on 3/13/24 at 1:24 PM, she revealed she cares for Resident #104 and has not seen the resident have any behaviors nor has she received any reports from other staff about any behaviors. An interview with the Medical Records LPN on 3/13/24 at 3:05 PM, revealed that she was unable to find any documentation of behaviors for the need to administer the Olanzapine in the medical record. She then revealed possible negative outcomes from receiving the Olanzapine is that the resident could have become over sedated, have loss of appetite, or develop Tardive Dyskinesia. An interview with Certified Nurse Assistant (CNA) #1 and CNA #2 on 3/13/24 at 3:10 PM, they both revealed they have not seen the Resident #104 have any behaviors and confirmed no one from the other shifts have reported to them any behaviors to them either. An interview with the Director of Nursing (DON) on 3/13/24 at 3:40 PM, confirmed Resident #104 should not have been given the PRN Olanzapine without documentation of behaviors requiring the use of the medication. She also revealed monitoring for side effects and behavior monitoring should be documented on all residents receiving psychotropic medications, to ensure they are not having any adverse reactions and the behaviors are not worsening, and to show the continued need for the use of the medications and the provider should be notified of any concerns identified. Record review of the Face Sheet revealed that the facility admitted Resident #104 to the facility on [DATE] with Depression and Unspecified Dementia, unspecified severity, without behavior/psychosis/mood/anxiety.

Based on staff and resident interviews, record review and facility policy review, the facility failed to protect the resident's right to be free from neglect when a resident was transferred utilizing a total lift without two (2) staff members resulting in the lift overturning and the resident falling to the floor. The resident sustained skin tears and a hematoma to her scalp and required transfer to the emergency department. This was for one (1) of seven (7) residents sampled. Resident #1. Findings include: Policy and procedure review of the facility's Abuse Program last revised May 23, 2017, revealed It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect .Neglect is the failure of the facility, its employees or services providers to provide good and services necessary to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. Neglect occurs when facility staff fail to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by residents. Neglect occurs when a facility fails to provide necessary care for residents . Record review of the facility investigation Reportable Incident Form dated 12/7/23 revealed that CNA (Certified Nurse Aide) #1 attempted to transfer Resident #1 with the total lift without assistance on 12/6/23 at approximately 5:30 PM. CNA #1 admitted that she was trying to transfer Resident #1 to the bed from her wheelchair and did not get assistance from another staff member. The lift fell over when CNA #1 turned toward the bed, and Resident #1 landed on the floor. When the nurses arrived, the lift was removed from the lower legs of Resident #1. It was noted Resident #1 had multiple skin tears which were cleaned and treated. The Medical Director was in the facility and gave the order to send Resident #1 to the hospital for further evaluation and treatment. She returned that night at 10:43 PM with no new orders. CNA #1 was suspended immediately after the incident and her employment terminated. Record review of the emergency room (ER) visit on 12/6/23 of Resident #1 revealed the Assessment/Plan 1. Hematoma of scalp, 2. Skin Tear, 3. Back Pain on page five (5) of 27. Record review of Resident #1 Minor Med Care Progress Note dated 12/7/2023, by the Nurse Practitioner revealed 91 y/o (years old) WF (white female) s/p (status post) fall from Hoyer lift in the facility last night with left temple contusion, left elbow skin tear and right medial ankle skin tear. She denies a headache at this time but she does have tenderness to her right ankle and left elbow from the skin tears. Record review of Resident #1's Lift/Transfer Evaluation dated 10/17/23 revealed she was assessed to require Sling Size: XXL (extra, extra large) Sling. Required Total Lift. Select assistance required: Total lift with 2 assist. Total Lift: sling size: Total lift with X-Large Sling Record review of undated Resident #1's Resident Summary, which is on the kiosk for CNAs use, revealed Bed Mobility Extensive Assistance 2 person, Lift Total Lift, Sling Size XXL sling. Record review of the binder connected to each lift in the facility revealed a LONG TERM CARE GUIDE with Resident #1 required the Total Lift for transfers with 2 staff members and an extra extra large sling. On 1/8/24 at 5:00 PM, during an interview with the Administrator on information needed for a facility reported incident regarding Resident #1 falling from a lift and what happened the Administrator stated the Assistant Director of Nursing (ADON) was actually in the facility at the time of the incident working the medication cart. She was Resident #1's assigned nurse that 3-11 shift. CNA #1 was the CNA for Resident #1. CNA #1 attempted to transfer Resident #1 from the wheelchair to bed without getting assistance from another staff member. The CNA turned towards the bed and the lift fell over with Resident #1 in it and she fell on to the floor. CNA #1 admitted she didn't ask for assistance for the Total Lift transfer. She had been recently trained on lift use. She admitted knowing she needed another staff member to assist with the lift but didn't ask anyone. She was suspended that night and terminated after the investigation. He stated, Thank God (Proper Name) Resident #1 wasn't hurt worse. Interview with Resident #1 at 5:15 PM on 1/8/24, revealed that one (1) CNA had attempted to put her in bed using a lift. She stated she doesn't know what happened, but she and the lift fell over. She landed between the bedside table and the head of her bed. She revealed that she had a bump and bruise on her left temple area and some skin tears. Interview with the Assistant Director of Nursing (ADON) on 1/8/24 at 5:45 PM, revealed that she was working on the unit as a medication nurse the 3-11 shift on 12/6/23. She stated that when she came into the room, Resident #1 was on the floor with the lift leaning over. Her head was between the bedside table and bed lying on the floor. She stated she did notice the base of the Total Lift was not spread out to prevent the lift from falling over. CNA #1 admitted to not getting another staff member to assist with the transfer of Resident #1 on the Total Lift. The resident had a skin tear to her left inner arm and on her bilateral lower extremities. She was assessed by nursing staff and 911 called for an ambulance to transfer her to the emergency room for further assessment and treatment. Interview with CNA #1 on 1/9/24 at 1:05 PM, revealed that Resident #1 had been on the light and wanted in bed. She stated, She is a total lift. When asked by the State Agency (SA) if she had asked for help, she stated No. I didn't ask for help. I poked my head out of the door and didn't see anyone, so I tried to lift her alone. She stated, I walked away from the lift toward the bed and the lift fell over. She stated she was attempting to use the total lift to transfer Resident #1 from her wheelchair to the bed without assistance. She denied being trained in abuse, neglect, resident rights, the vulnerable adults act and on lift use. She stated that the information for lift use and other ADL's are located on the kiosk on the walls of the resident halls. She said she thinks there is a folder on the lifts too that have each resident's lift information. Review of CNA #1's personnel file revealed she was hired 9/6/2023. She signed a Lift free facility form and it was dated for 6/9/2023. When the SA interviewed CNA #1 on 1/9/24 at 1:05 PM, she stated that her first day at work was 9/6/23 and she must have accidentally switched the numbers of the date. She signed the abuse/neglect policy for the facility on 9/6/23. She completed the facility's CNAs Skills Check-off on 11/9/23. This included Transfer Using Mechanical Lift. She was terminated from employment on 12/7/23. Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] with her diagnosis' including Chronic Respiratory Failure with Hypercapnia, Morbid (severe) Obesity with Alveolar Hypoventilation, Muscle Weakness, and other Abnormalities of Gait and Mobility. Record review of the Minimum Data Set (MDS) of Resident #1 with an Assessment Reference Date (ARD) of 10/17/2023, Section C-Cognitive Patterns Brief Interview for Mental Status (BIMS) score of 15 indicated she is able to make daily decisions. Based on the facility's implementation of corrective actions on 12/7/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 12/7/23, prior to the SA's first entrance on 1/8/24. Validation of Past non-compliance: On 12/6/23 the resident was assessed by the Director of Nursing and transferred immediately to the emergency room by ambulance. The Survey agency (SA) validated by record review of the nurses notes and emergency room documentation. The Certified Nursing Assistant involved in the incident was immediately suspended and terminated 12/7/23. This was validated by the SA by reviewing the facility discipline form that revealed the termination of CNA #1. The Resident Representative was notified on 12/6/23 and the Survey Agency and Attorney General's office were notified on 12/7/23. This was validated by the SA from record review and interviews. All CNA's and Nurses were in serviced/retrained starting on 12/7/23 on following the individual care plan related to lift use, the facility policies on Total Lift Use, Abuse and Neglect, Care Plans. This was validated by the SA from sampled staff being interviewed to confirm their attendance, knowledge of the training, observation of lift use and record review of the signed documents of the attendance by the staff. As part of the facility monitoring, inservices will continue on the Total Lift use monthly for CNAs and quarterly for nurses throughout 2024. All nursing new hires will be in-serviced upon hire. All residents care plans, lift instructions, resident summary's (information with access for the CNAs in the Kiosk with guidance for individual lift use), and the binders on all the lifts that contained the individual resident information for specific lift use were audited to ensure correct and consistent information. Sampled residents care plans, lift instructions, resident summary's and binders on the lifts were audited by the Survey Agency to confirm they had consistent and correct information. The SA validated through record review and interview that the facility held a Quality Assurance and Performance Improvement meeting on 12/7/23 to discuss the incident with the fall from the Total Lift. On 12/7/23, the Administrator, DON and ADON began monitoring resident halls daily reminding CNAs and nurses of the requirement of always having two staff members when using the Total Lift. The SA was able to validate the actions the facility took after the incident involving Resident #1 and CNA #1 through record review, interviews and observations.

Based on record review, policy procedure review and interviews, the facility failed to implement a comprehensive person-centered care plan for one (1) of seven (7) residents sampled, Resident #1, as evidenced by on 12/6/23, Certified Nurse Aide (CNA) #1 failed to follow the Resident Care Summary and ADL's (activities of daily living) Care Plan for Resident #1 when she attempted to transfer Resident #1 using the total lift without the assistance of another staff member. Findings include: Policy and procedure review of the facility's Care Plans policy last updated 2/03/2023 revealed, Policy: Each resident will have a person centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .DEFINITIONS: Resident Care Summary-part of the Comprehensive Care Plan and used as the tool to make staff aware of the resident's daily care needs; serves as ADL care plan . Record review of Resident #1's care plan revealed Requires assistance for all ADL's related to impaired mobility and incontinence with a Start Date 11/24/2020 .Intervention: TOTAL LIFT X (times) 2 person assist with XXL (extra extra large) sling. Record review of the facility investigation Reportable Incident Form dated 12/7/23 revealed that CNA #1 attempted to transfer Resident #1 with the total lift without assistance on 12/6/23 at approximately 5:30 PM. CNA #1 admitted that she was trying to transfer Resident #1 to the bed from her wheelchair and did not get assistance from another staff member. The lift fell over when CNA #1 turned toward the bed, and Resident #1 landed on the floor. When the nurses arrived, the lift was removed from the lower legs of Resident #`1. It was noted resident #1 had multiple skin tears which were cleaned and treated. The Medical Director was in the facility and gave the order to send Resident #1 to the hospital for further evaluation and treatment. She returned that night at 10:43 PM with no new orders. CNA #1 was suspended immediately after the incident and her employment terminated. Record review of undated Resident #1's Resident Summary, which is the care guidance located on the kiosk for CNA use, revealed Bed Mobility Extensive Assistance 2 person, Lift: Total Lift, Sling Size XXL sling. Record review of the binder connected to each lift in the facility revealed a LONG TERM CARE GUIDE with Resident #1 required the Total Lift with 2 person assistance and the 2XL sling. During an interview with Resident #1 on 1/8/24 at 5:15 PM, she stated that one Certified Nurse Aide (CNA) had attempted to put her in bed using a lift. She stated she doesn't know what happened, but she and the lift fell over. She landed between the bedside table and the head of her bed. She revealed that she had a bump and bruise on her left temple area and some skin tears. On 1/8/24 at 5:45 PM, an interview with the Assistant Director of Nursing (ADON) revealed that when she went into Resident#1's room, CNA #1 stated she did not get help to use the Total Lift from another staff member. She stated, No, she did not follow the Resident Summary or the ADL care plan. Both the Resident Summary and the ADL care plan state to have 2 staff members to use the Total Lift. We are a lift free facility which means that staff do not physically lift residents. We use 2 staff always with the Total Lift. During an interview with CNA #1 on 1/9/24 at 1:05 PM, she stated that Resident #1 had been on the light and wanted in bed. She is a total lift. When asked by the State Agency (SA) if she had asked for help, she stated No. I didn't ask for help. I poked my head out of the door and didn't see anyone, so I tried to lift her alone. She stated, I walked away from the lift toward the bed and the lift fell over. She stated she was attempting to use the total lift to transfer Resident #1 from her wheelchair to the bed without assistance. She stated that the information for lift use and other Activities of Daily Living (ADL) are located on the kiosk on the walls of the resident halls. She said she thinks there is a folder on the lifts too that have each resident's lift. During an interview with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) on 1/9/24 at 1:55 PM revealed that information used to determine the lift use for a resident is by the residents care and mobility in the hospital, facility therapy department will assess residents for safety reasons and the nurses on admission will also evaluate the resident for lift use and mobility. The evaluation/assessment is done every 90 days and as needed by the Minimum Data Set (MDS) nurse. If there are changes on the care plans, it is made in the computer and automatically updates in the kiosk. Record review of the Face Sheet of Resident #1 revealed that she admitted to the facility on [DATE] with her diagnosis' including Chronic respiratory failure with hypercapnia, Morbid (severe) obesity with alveolar hypoventilation, Muscle weakness, other abnormalities of gait and mobility. Review of the Minimum Data Set (MDS)-Version 3.0 of Resident #1 with an Assessment Reference Date (ARD) of 10/17/2023, Section C-Cognitive Patterns Brief Interview for Mental Status (BIMS) score of 15. She is able to make daily decisions. Based on the facility's implementation of corrective actions on 12/7/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 12/7/23, prior to the SA's first entrance on 1/8/24. Validation of Past non-compliance: On 12/6/23 the resident was assessed by the Director of Nursing and transferred immediately to the emergency room by ambulance. The Survey agency (SA) validated by record review of the nurses notes and emergency room documentation. The Certified Nursing Assistant involved in the incident was immediately suspended and terminated 12/7/23. This was validated by the SA by reviewing the facility discipline form that revealed the termination of CNA #1. The Resident Representative was notified on 12/6/23 and the Survey Agency and Attorney General's office were notified on 12/7/23. This was validated by the SA from record review and interviews. All CNA's and Nurses were in serviced/retrained starting on 12/7/23 on following the individual care plan related to lift use, the facility policies on Total Lift Use, Abuse and Neglect, Care Plans. This was validated by the SA from sampled staff being interviewed to confirm their attendance, knowledge of the training, observation of lift use and record review of the signed documents of the attendance by the staff. As part of the facility monitoring, inservices will continue on the Total Lift use monthly for CNAs and quarterly for nurses throughout 2024. All nursing new hires will be in-serviced upon hire. All residents care plans, lift instructions, resident summary's (information with access for the CNAs in the Kiosk with guidance for individual lift use), and the binders on all the lifts that contained the individual resident information for specific lift use were audited to ensure correct and consistent information. Sampled residents care plans, lift instructions, resident summary's and binders on the lifts were audited by the Survey Agency to confirm they had consistent and correct information. The SA validated through record review and interview that the facility held a Quality Assurance and Performance Improvement meeting on 12/7/23 to discuss the incident with the fall from the Total Lift. On 12/7/23, the Administrator, DON and ADON began monitoring resident halls daily reminding CNAs and nurses of the requirement of always having two staff members when using the Total Lift. The SA was able to validate the actions the facility took after the incident involving Resident #1 and CNA #1 through record review, interviews and observations.

Based on record review, interview and facility policy/procedure review, the facility failed to ensure an environment that is free from accident hazards and provide the necessary supervision to prevent injury for one (1) of seven (7) sampled residents, Resident #1. Findings include: Policy and procedure review of the facility's Total Lift Vanderlift II, last Updated 2/3/2023 revealed the Responsibility: All Licensed Nursing Personnel and All Other Staff Providing Care to Resident or Lifting. Two people are required to operate the Total Lift. Record review of the facility investigation Reportable Incident Form dated 12/7/23 revealed that CNA (Certified Nurse Aide) #1 attempted to transfer Resident #1 with the total lift without assistance on 12/6/23 at approximately 5:30 PM. CNA #1 admitted that she was trying to transfer Resident #1 to the bed from her wheelchair and did not get assistance from another staff member. The lift fell over when CNA #1 turned toward the bed, and Resident #1 landed on the floor. When the nurses arrived, the lift was removed from the lower legs of Resident #1. It was noted Resident #1 had multiple skin tears which were cleaned and treated. The Medical Director was in the facility and gave the order to send Resident #1 to the hospital for further evaluation and treatment. She returned that night at 10:43 PM with no new orders. CNA #1 was suspended immediately after the incident and her employment terminated. Record review of Resident #1's the emergency room (ER) visit on 12/6/23 revealed the Assessment/Plan 1. Hematoma of scalp, 2. Skin Tear, 3. Back Pain on page five (5) of 27. Record review of Resident #1 Minor Med Care Progress Note dated 12/7/2023, by the Nurse Practitioner revealed 91 y/o (years old) WF (white female) s/p (status post) fall from Hoyer lift in the facility last night with left temple contusion left elbow skin tear and right medial ankle skin tear. She denies a headache at this time but she does have tenderness to her right ankle and left elbow from the skin tears. Record review of Resident #1's Lift/Transfer Evaluation dated 10/17/23 revealed she was assessed to require an XXL (extra extra large) Sling with the Total lift with the assistance of 2 staff members. Record review of undated Resident #1's Resident Summary, which is on the kiosk for CNA use, revealed Bed Mobility Extensive Assistance 2 person, Lift Total Lift, Sling Size XXL sling. Record review of the binder connected to each lift in the facility revealed a LONG TERM CARE GUIDE with Resident #1 required the Total Lift with 2 person assistance and the XXL sling. Interview with the Administrator on 1/8/24 at 5:00 PM, reviewing information needed for a facility reported incident regarding Resident #1 falling from a lift and what happened the Administrator stated the Assistant Director of Nursing (ADON) was actually in the facility at the time of the incident working the medication cart. She was Resident #1's assigned nurse that 3-11 shift. CNA #1 was the CNA for Resident #1. CNA #1 attempted to transfer Resident #1 from the wheelchair to bed without getting assistance from another staff member. The CNA turned towards the bed and the lift fell over with Resident #1 in it and she fell on to the floor. CNA #1 admitted she didn't ask for assistance for the Total Lift transfer. She had been recently trained on lift use. She admitted knowing she needed another staff member to assist with the lift but didn't ask anyone. She was suspended that night and terminated after the investigation. He stated, Thank God (Proper Name) Resident #1 wasn't hurt worse. On 1/8/24 at 5:15 PM, an interview with Resident #1 revealed her saying that one Certified Nurse Aide (CNA) had attempted to put her in bed using a lift. She stated she doesn't know what happened, but she and the lift fell over. She landed between the bedside table and the head of her bed. She revealed that she had a bump and bruise on her left temple area and some skin tears. On 1/8/24 at 5:45 PM an interview with the ADON revealed that she was working on the unit as a medication nurse on the 3-11 shift on 12/6/23. She stated that when she came into the room, Resident #1 was on the floor with the lift leaning over. Her head was between the bedside table and bed lying on the floor. She stated she did notice the base of the Total Lift was not spread out to prevent the lift from falling over. CNA #1 admitted to not getting another staff member to assist with the transfer of Resident #1 on the Total Lift. The resident had a skin tear to her left inner arm and on her bilateral lower extremities. She was assessed by nursing staff and 911 called for an ambulance to transfer her to the emergency room for further assessment and treatment. On 1/9/24 at 1:05 PM an interview with CNA #1 revealed that Resident #1 had been on the light and wanted in bed. She is a total lift. When asked by the State Agency (SA) if she had asked for help, she stated No. I didn't ask for help. I poked my head out of the door and didn't see anyone, so I tried to lift her alone. She stated, I walked away from the lift toward the bed and the lift fell over. She stated she was attempting to use the total lift to transfer Resident #1 from her wheelchair to the bed without assist. She denied being trained in abuse, neglect, resident rights, the vulnerable act and on lift use. Record review of CNA #1's personnel file revealed she was hired 9/6/2023. She signed a Lift free facility form and it was dated for 6/9/2023. When the State Agency (SA) interviewed CNA #1 on 1/9/24 at 1:05 PM, she stated that her first day at work was 9/6/23 and she must have accidentally switched the numbers. She signed the abuse/neglect policy for the facility on 9/6/23. She completed the facility's CNAs Skills Check-off on 11/9/23. This included Transfer Using Mechanical Lift. She was terminated from employment on 12/7/23. Record review of the Face Sheet of Resident #1 revealed that she admitted to the facility on [DATE] with her diagnosis' including Chronic respiratory failure with hypercapnia, Morbid (severe) obesity with alveolar hypoventilation, Muscle weakness, other abnormalities of gait and mobility. Review of the Minimum Data Set (MDS)-Version 3.0 of Resident #1 with an Assessment Reference Date (ARD) of 10/17/2023, Section C-Cognitive Patterns Brief Interview for Mental Status (BIMS) of 15. She is able to make daily decisions. Based on the facility's implementation of corrective actions on 12/7/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 12/7/23, prior to the SA's first entrance on 1/8/24. Validation of Past non-compliance: On 12/6/23 the resident was assessed by the Director of Nursing and transferred immediately to the emergency room by ambulance. The Survey agency (SA) validated by record review of the nurses notes and emergency room documentation. The Certified Nursing Assistant involved in the incident was immediately suspended and terminated 12/7/23. This was validated by the SA by reviewing the facility discipline form that revealed the termination of CNA #1. The Resident Representative was notified on 12/6/23 and the Survey Agency and Attorney General's office were notified on 12/7/23. This was validated by the SA from record review and interviews. All CNA's and Nurses were in serviced/retrained starting on 12/7/23 on following the individual care plan related to lift use, the facility policies on Total Lift Use, Abuse and Neglect, Care Plans. This was validated by the SA from sampled staff being interviewed to confirm their attendance, knowledge of the training, observation of lift use and record review of the signed documents of the attendance by the staff. As part of the facility monitoring, inservices will continue on the Total Lift use monthly for CNAs and quarterly for nurses throughout 2024. All nursing new hires will be in-serviced upon hire. All residents care plans, lift instructions, resident summary's (information with access for the CNAs in the Kiosk with guidance for individual lift use), and the binders on all the lifts that contained the individual resident information for specific lift use were audited to ensure correct and consistent information. Sampled residents care plans, lift instructions, resident summary's and binders on the lifts were audited by the Survey Agency to confirm they had consistent and correct information. The SA validated through record review and interview that the facility held a Quality Assurance and Performance Improvement meeting on 12/7/23 to discuss the incident with the fall from the Total Lift. On 12/7/23, the Administrator, Director of Nursing and ADON began monitoring resident halls daily reminding CNAs and nurses of the requirement of always having two staff members when using the Total Lift. The SA was able to validate the actions the facility took after the incident involving Resident #1 and CNA #1 through record review, interviews and observations.

Based on interviews, record/video surveillance review, personnel record review, and facility policy review, the facility failed to prevent diversion of controlled substances by a nurse for one (1) of four (4) residents reviewed, Resident #1. Findings include: Policy/procedure review of the facility's Abuse, Neglect and Exploitation policy dated 10/24/2022 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The definition of Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Interview with the Administrator on 12/18/23 at 11:00 AM revealed that administrative staff was notified on 12/6/23 on the 3-11 shift by Resident #4 about Licensed Practical Nurse (LPN) #1 acting tired. LPN #1 was sent home. The Administrator stated that he, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) watched the surveillance video on 12/7/23 prior to the next 3-11 shift. When LPN #1 came in to work 3-11 PM shift on 12/7/23, LPN #1 was taken immediately into a room, told of the suspicions, and agreed to take a drug test. LPN #1 denied taking medications. He was suspended after submitting the drug test. His drug test was positive for Marijuana, Opiates/Morphine, Amphetamines, and Benzodiazapine. The Administrator stated their investigation started on 12/7/23 and was reported in the appropriate time frames. The allegations were reported to the Board of Nursing, Licensing State Agency, local police, the Attorney General office, and the Board of Pharmacy. He stated that LPN #1 was arrested by the local police department. LPN #1 was hired recently and that on 12/6/23 3-11 PM shift was the first shift that LPN #1 had worked by himself. His pre-hire drug test was negative for any drugs. He stated that all of Resident #1's liquid Morphine and Ativan were discarded, and new bottles of both medications were reordered. Record/video surveillance review by the State Agency (SA) on 12/18/23 of facility video surveillance dated 12/6/23 of LPN #1 during medication pass on the 3-11 shift. Video surveillance review revealed that the recording starts at 5:25:42 PM dated 12/6/23. It was noted that at 5:25:42 PM, LPN #1 backs his medication cart to the exit door of that hall and facing the nursing desk/station. There is a video camera above his head over his right shoulder. At 5:27:30, LPN #1 opened the narcotic box. The video shows the top of the narcotic box of the medication cart is open. There is not a view of the inside of the narcotic box. At 5:27:35, it is noted LPN #1 pours a clear liquid from the water pitcher into one (1) of the 30 milliliter (ml) medication cups the facility uses for medication pass. Beginning at 5:27:37, LPN #1 takes an empty medication cup towards the open narcotic box. LPN #1 then took the full cup of clear liquid towards the open narcotic box. LPN #1 knelt down behind the medication cart and then at 5:28:54 PM LPN #1 put a medication cup with a blue colored liquid onto the top of the medication cart. Beginning at 5:29:12 PM, the blue liquid in the medication cup is spilled onto the top of the medication cart. LPN #1 then takes a straw out of a soda can that was located on top of the medication cart and drank the blue liquid with the straw. Beginning at 5:29:20 PM, LPN #1, looked toward the nursing station and then wiped up the blue liquid left on the top of the medication cart that he didn't drink. At 5:30:00 PM, LPN #1 is noted taking the medication cup with a small amount of blue liquid remaining and went back to the open narcotic box. The medication cart has not moved so the SA was unable to see inside the narcotic box. At 5:30:23 PM, LPN #1 poured clear liquid from the water pitcher into another empty medication cup and went back towards the open narcotic box. At 5:30:29 PM, it is noted there is blue liquid in an eight (8) ounce (oz) cup noted on top of the medication cart. He then poured clear liquid from the water pitcher into the 8 oz cup with the blue liquid. At 5:30:43 PM LPN #1 puts an empty medication cup onto the top of the medication cart moving from the direction of the open narcotic box. At 5:30:59 PM, LPN #1 put a medication cup with blue liquid in it on top of the medication cart. The medication cup appears to be full of the blue liquid. Between 5:31:30 PM and 5:31:53, LPN #1 is noted taking a pill from a medication card from the medication cart and a pill from the open narcotic box and putting these into a medication cup. At 5:32:00 PM, LPN #1 poured the blue liquid from a medication cup into the 8 oz cup of now light blue liquid and then pours the light blue liquid from the 8 oz cup into the soda can on top of the medication cart. At 5:32:14 PM, LPN #1 is noted putting the pills from the medication cup into his mouth and drank the liquid from the soda can. At 5:32:35 PM, LPN #1 is observed drinking blue liquid from an 8 oz cup as he looks towards the nurses station. At 5:32:46 PM, LPN #1 is noted pouring the remaining blue liquid from the 8 oz cup into the soda can. The narcotic box lid is no longer seen at 5:31:51 PM. At 5:34:03 PM, LPN #1 pours liquid from the soda can into a small brown bottle and at 5:34:07 PM he drank the liquid from the brown bottle. LPN #1 continues to drink from the soda can beginning at 5:34:22 PM. He is noted to move the medication cart up the hall towards the nurses station and parks it between resident rooms. He took the soda can towards the nurses station and out of view at 5:36:32 PM. He returned to the medication cart with the soda can at 5:38:25 PM. He is noted drinking from the soda can at 5:40:47 PM. Interview with the ADON on 12/18/23 at 11:48 AM, revealed that Resident #4 called the receptionist desk and said she was concerned about the male nurse and that he seemed tired. Interview with Resident #4 on 12/18/23 at 1:20 PM, revealed that she saw a male nurse recently standing at the medication cart near the door of her room on the 100 hall making strange hand movements and not paying attention to what he was doing. She confirmed that she called the front office and told the person answering the phone that the male nurse seemed tired. Resident #4 stated she talked to the male nurse and tried to get him to sit down for a moment. I thought he was sick. She stated that the male nurse was just standing at the med cart moving his computer mouse back and forth for what seemed like an hour. She stated someone came up to the male nurse and asked if was feeling ok. She said that soon another nurse came and started passing medications from that medication cart and she has not seen that male nurse in the facility again. Record review of Resident #4 on 12/18/23 revealed she has a Brief Interview for Mental Status (BIMS) of 15 with the Assessment Reference Date (ARD) being 11/24/23. Interview with the DON on 12/18/23 at 11:30 AM, revealed that the only resident that takes a blue liquid medication is Resident #1. Resident #1 is on palliative care and has Morphine Sulfate 20 mg (milligrams)/5 ml (millimeters) solution prescribed as needed (PRN). Resident #1 is the only resident on the 100 hall that has that prescribed. She stated that at that time, the Morphine solution was colored blue. Interview with the ADON on 12/18/23 at 10:50 AM revealed that she was the nurse that counted the narcotic medications with LPN #1 when he was told to go home and get some rest. She stated the narcotic count had no issues. She stated that the Morphine sulfate prescribed to Resident #1 and the liquid Ativan for Resident #1 was correct. The narcotic count was correct. She stated that administration thought LPN #1 was tired and that is why he was sent home on 12/6/23 early in the shift. She said that when she asked LPN #1 which residents had been given their medications and he stated he had given all the residents on the left side of the hall their medications. He asked if he could administer medications to another resident on that hall and she told him no. She stated that during count, she noted the narcotic medications for that other resident was off and LPN #1 said he had given those medications and just forgot to sign the narcotic book. She said she noticed a liquid spill on top of the medication cart and LPN #1 said he had spilled his energy drink. She stated a hand towel on top of the medication cart had some blue liquid on it. She noted the morphine sulfate for Resident #1 was blue, but the count was correct. Record review of the Face Sheet revealed the facility admitted Resident #1 on 2/24/21 with diagnoses including Unspecified Dementia, Anxiety disorder, Unspecified protein-calorie malnutrition, and Dysphagia. Record review of the Minimum Data Set with an Assessment Reference Date of 11/28/23 revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated that she was severely cognitively impaired. Record review of Resident #1's Physician Orders for December 2023 revealed an order dated 11/16/23 for Morphine Sulfate 20 mg/5 ml solution dissolve 1/2 ml under the tongue every two (2) hours as needed for pain and respirations greater than 27, an order dated 11/13/23 for Norco 5-325 mg give 1 tablet per G-tube twice a day, an order dated 11/09/23 for Norco 5-325 mg tablet give 1 tab per PEG (percutaneous endoscopic gastrostomy tube) every six (6) hours as needed for pain, and an order dated 11/13/23 for Lorazepam 2 mg/ml oral concentrate dissolve 1/2 ml under the tongue every 2 hours as needed for restlessness. Record review of Resident #1's Medication Administration Record (MAR) on 12/18/23 revealed that as of 12/17/23, Resident #1 has not received a dose of Morphine Sulfate or Lorazepam for the month of December 2023. Record review of the Drug Test Record Form dated 12/7/23 revealed LPN #1 tested positive for Marijuana, Opiates/Morphine, Amphetamines, and Benzodiazapine. Record review of the Personnel Termination Notice revealed LPN #1 was terminated on 12/7/23 for consuming narcotics out of our resident med cart .

47157 Based on observation, staff and resident interview, record review and facility policy review the facility failed to date oxygen, nebulizer tubing, and humidifier bottles and place oxygen signage on the doors for three (3) of 14 residents reviewed for oxygen administration. Resident #2, Resident #100, and Resident #149 and no physician order for oxygen for two (2) of three (3) residents. Resident #2 and Resident #149 Findings include: Resident #2 A record review of the facility's policy titled Oxygen-Administration, Concentrator, Storage & Assemblage, dated August 17, 2015, revealed the Purpose: To provide adequate tissue oxygenation by providing supplemental oxygen. Oxygen Safety: 14. Post the NO SMOKING -OXYGEN IN USE sign on the door in the resident's room. Instructions for Humidifier bottle: 1. When bottle is empty or essentially empty, detach the flow gauge and date and reattach a new prefilled bottle. A record review of the facility's policy titled Physician Orders-Transcribing and Implementing, dated August 17,2015, revealed the Purpose: It is the policy of the facility that all physician's orders will be implemented timely and carried out in a professional manner by the nursing staff. The nurse receiving the physician's orders, whether verbal or in writing, must assure that orders are transcribed properly and implemented. An observation on 11/28/22 at 8:52 PM, revealed Resident #2 receiving Oxygen (O2) at 2 liters Per Minute (LPM) via nasal canula with no label or date on the tubing and humidifier bottle and no O2 in use sign on the resident's door. An observation, on 11/29/22 at 8:35 AM, revealed Resident #2's O2 tubing and humidifier bottle not labeled or dated and no O2 in use sign on the resident's door. An observation and interview, with Resident # 2 on 11/29/22 at 1:33 PM, revealed O2 tubing unlabeled and undated and no sign on door and resident #2 confirmed she had been wearing oxygen for years. Record review of Resident #2's Physician's orders revealed no order for oxygen therapy and review the medication record revealed oxygen with a discontinue date of 11/04/22. An observation and interview on 11/29/22 at 3:00 PM, with the Director of Nursing (DON) verified she was unable to find an order for oxygen use in Resident #2's record and stated somehow a stop date was entered removing the order from the medication record. She confirmed the order should not have been stopped. The DON confirmed all residents on oxygen should have a physician's order. The DON also confirmed the oxygen tubing was not labeled or dated and should be changed weekly, labeled and dated. The DON verified the was not a smoking sign and one should be in view on the the resident's door. The DON confirmed a possible complication from not dating the tubing and not having smoking signs in view is a fire or infection. Record review of Resident #2's Face Sheet revealed he was admitted on [DATE] with diagnoses of Chronic Respiratory Failure with hypercapnia and Morbid obesity with Alveolar Hypoventilation. Record review of the Admission Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/22 revealed Resident# 2 had a Brief Interview for Mental Status (BIMS) of 14, indicating she was cognitively intact. Resident #149 An observation on 11/29/22 at 9:31 AM, revealed Resident #149 receiving Oxygen (O2) at 2 liters/LPM by nasal canula with the tubing and the humidifier bottle not labeled or dated and no O2 in use sign on the resident's door. An observation, on 11/29/22 at 1:34 PM, revealed the O2 tubing, and humidifier bottle not labeled or dated and no O2 in use sign on resident's door. An interview, with Resident #149 on 11/29/22 at 1:33 PM, revealed she has been wearing oxygen for years. An observation and interview, with the DON on 11/29/22 at 3:00 PM, confirmed she was unable to find an order for oxygen use for Resident #149 and confirmed all residents on Oxygen should have a physician's order. The DON also confirmed the oxygen tubing was not labeled and confirmed it should be changed, labeled and dated every week and a no smoking sign should be in view on the the resident's door. The DON confirmed a possible complication from not dating the tubing and not having smoking signs in view is a fire or infection. An interview, with the Administrator on 11/30/22 at 8:15 AM confirmed that the facility is a no smoking facility, but no smoking signs should be in view from all rooms with oxygen in use and confirmed a potential hazard is a fire or combustion. Record review of the physician orders revealed there was no physicians order for oxygen therapy. Record review for Resident #149 revealed an admitted [DATE], with diagnoses of Type 2 Diabetes, Paroxysmal Atrial Fibrillation, and Edema. Record review of the Admission MDS) Section C with an ARD of 11/29/22 revealed Resident# 149 had a BIMS of 13, she was cognitively intact. Resident #100 An observation, on 11/28/22 at 08:19 PM revealed oxygen tubing and humidifier bottle was not dated and no bag noted for storage. The nebulizer was laying on the bedside table, not in a bag. Resident #100 stated that he uses oxygen and nebulizer treatments. An observation, on 11/29/22 at 1:45 PM revealed Resident #100 wearing his oxygen. The oxygen tubing was not dated. The nebulizer tubing was not dated. An interview, on 11/29/22 at 1:48 PM with Resident #100 revealed that he did not think they had a routine for changing the tubing. He confirmed his nebulizer was not in a bag yesterday. An interview, on 11/30/22 at 9:00 AM with the administrator (ADM) revealed if a resident has oxygen, their tubing should be dated, a bag for storage should be in the room and there should be a sign on the door. Record review revealed a physician order dated 11/16/22 for Oxygen (O2) at 3 liters via nasal canula. A physician's order dated 11/15/22 revealed Iprat-Albut 0.5-3(2.5) milligrams (mg) /3 millimeters (ml). Inhale 3 mls per hand held nebulizer three times daily and Acetylcysteine 20% vial inhale 3 ml per hand held nebulizer three times daily for thirty days. Record review of the five day Admission Minimum Data Set (MDS), Section C, revealed Resident #100 had a Brief Interview for Mental Status score of 15 which revealed the resident was cognitively intact. Resident #100's face sheet revealed an admitted [DATE]. Admission diagnoses included: Lobar Pneumonia, Chronic Respiratory Failure, and Malignant Neoplasm of part of bronchus or lung.

Based on observation, staff interview, record review and facility policy review, the facility failed to follow proper sanitation and food storage to prevent the likelihood of food borne illness for one (1) of two (2) dietary tours. Findings include: Review of the facility's Storage of Refrigerated Food policy, originated 9/04, revealed: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 3. Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered. 4. All non-hazardous, opened foods are labeled with name of food and date stored. 5. All hazardous foods are labeled with the name of food and date to be discarded or the date stored. Cooked foods should not be held longer than 48 hours. Review of the facility's Storage of Canned and Dry Food policy, originated 9/04, revealed: Procedure: 6. Opened products are stored in tightly covered containers. Zip lock bags may be used. 7. Opened packages are labeled with name of product and date opened. Review of the facility's Employee Sanitation Practices policy, dated 9/04, revealed: Policy: Food service employees shall follow sanitary practices to prevent the spread of foodborne illness and reduce those practices which result in food contamination and compromised food safety. Procedure:. 2. b. Gloves are worn to protect food by creating a barrier between the hand and food but should be used only when doing one task. c. Gloves should be changed: i. As soon as they become soiled or torn, ii. Before beginning a different task. On 12/02/19 10:10 AM, an observation during the dietary tour with Dietary Staff #2/Cook, revealed the microwave oven's entire inside was splattered with a cream color dried matter. In the refrigerator there was an open package of 160 slices of Yellow Pasteurized Processed American Cheese slices with approximately one half (1/2) of the 160 slices present and open to air. A fourth of a head of iceberg lettuce was wrapped in plastic wrap with no label or date. Green Onions, approximately 8 in. x 12 in. x 2 in. were wrapped in original packaging and clear plastic wrap with an 11/6/19 date. The green onions were turning brown and mushy/slimy. There was one half of a meat and cheese sandwich on wheat bread wrapped in plastic wrap that was not labeled or dated. A gallon zip lock bag 1/4 full of what appeared to be red peppers or pimento type food was not labeled or dated. In the freezer, a 6x 6 plastic container with a lid contained what appeared to be green beans not labeled or dated. A full gallon zip lock bag of frozen macaroni type material was not labeled or dated. In the pantry, a 50 pound (lb) paper bag of sugar was open with a date of 11/30/19 and loosely rolled down from the top. It contained approximately six (6) inches depth of sugar in the bottom of the bag. A 50 lb. paper bag of Buttermilk Biscuit Mix with a date of 4/24/19, was open and loosely rolled down from the top. It contained approximately 8 inch depth of mix in the bottom of the bag. One half package of Dry Fruit Punch mix was wrapped in plastic wrap and stored in the original box. No open date was on the plastic wrap. Punch mix crystals were falling out of the plastic wrap into the box. An interview with Dietary Staff #2 at this time revealed that all food should be labeled and dated after opening and wrapped tightly. She stated that she would throw it away. She stated that workers on the other shift probably did not label the food. During an observation of the tray line temperatures and interview, on 12/2/19, at 11:15 AM, revealed Dietary Staff #2 wiped the thermometer probe with gloved fingers between each food tempted. She stated, I thought it was ok, it's all going to the same place. She took several pieces of Country Fried Steak from the large steam pan and placed it in a smaller steam pan. She tore the steak up with her fingers to make the chopped steak. She then wiped her gloves with a dish cloth that was lying on the counter of the steam table and spooned Black Eyed Peas, Carrots, and Corn Bread into smaller steam pans to make pureed foods. She stated, It's the dish cloth I clean with. She took the foods and the dish cloth over to the preparation table by the blender and proceeded to make the pureed food. She then wiped the counter with the same dish cloth. In an interview and observation, on 12/02/19, at 10:45 AM, with the Administrator, he confirmed the cheese was not wrapped, the lettuce, sandwich, red peppers/pimento type food in the refrigerator and the frozen macaroni type food, and green beans were not labeled and dated. He confirmed the sugar and biscuit mix were not sealed properly and the Fruit Punch dry mix was not labeled, dated, and sealed properly. He stated the cheese could become spoiled and molded, the green onions should be thrown away due to the brown, mushy appearance, and that all foods not labeled and stored properly should be discarded due to the risk of food borne illness. He stated, If its not labeled, we don't know what it is and it should not be used. He confirmed that the microwave needs attention. An interview, on 12/4/19 at 10:00 AM, with the Dietary Staff #1/Dietary Manager, he stated that dry foods should be stored in a sealed container because something might get in it if the bag was folded over. He stated that all foods that have been opened or refrigerated should be labeled and dated. He stated Residents could get sick if you serve something out of date. In regards to the tray line temps and dish cloth, he stated that It could contaminate things and make residents sick. You are supposed to throw gloves away and wash hands. You must change gloves between different tasks. Meats should be put in the chopper, not torn by hand. Review of an In-Service Form, Subject: Infection Control. How to decrease bacteria growth in food to reduce the likelihood of food borne illness in the residents eating food prepared by dietary, presented by the Registered Dietitian, on 10/29/19, revealed that Dietary Staff #2 attended. Contents of the in-service include, According to the FDA (Food and Drug Administration), cloths used for wiping counters and other surfaces shall be: 1) Held between uses in a chemical sanitizer solution All items stored in refrigerators must be covered, labeled, and dated with an open/expiration date.

Based on facility policy review, staff interview, and record review, the facility failed to develop a comprehensive care plan related to medications for two (2) of 18 care plans reviewed, Resident #24 and Resident #11. Findings include: Review of the facility's Care Plans policy, not dated, revealed each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. Responsibility: All members of the interdisciplinary team. Monitored by the MDS (Minimum Data Set) and Director of Nurses. Procedures included: The care plan will be reviewed and revised at quarterly intervals in conjunction with the completion of MDS assessments (quarterly, significant change, annual) and with changes in resident's condition as needed. Upon a change in condition, the care plan will be updated or an initial care plan will be initiated. Resident #11 Review of Resident #11's [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. An order, dated 9/26/17, for [MEDICATION NAME] ER (Extended Release) 30 mg take 2 tablets daily for Hypertension. An order, dated 2/19/19, for [MEDICATION NAME] 20 mg daily for Heart Failure. An order, dated 9/26/17, for [MEDICATION NAME] 10 mg twice daily due to Hypertension, and an order, dated 9/26/17, for Sildenafil 20 mg 3 times daily due to Hypertension. Review of the comprehensive care plan for Resident #11 revealed no care plan was developed for the cardiovascular [DIAGNOSES REDACTED]. On 12/03/19 at 12:31 PM, an interview with Registered Nurse (RN) #1/Minimum Data Set (MDS) Coordinator confirmed there was no care plan developed for Resident #11 related to cardiovascular [DIAGNOSES REDACTED].#1 revealed she does not know why there was not a care plan, she thought there had been one developed. RN #1 revealed there should be a care plan developed for any medications and diagnosis. Resident #24 Review of the comprehensive care plan for Resident #24 revealed no care plan developed for the medication Eliquis and its potential side effects. Review of Resident #24's physician's orders [REDACTED]. On 12/04/19 at 12:31 PM, an interview with Registered Nurse (RN) #1/ Minimum Data Set (MDS) Coordinator confirmed there was no care plan developed for Resident #24 related to Eliquis or interventions related to the anticoagulant medication. RN #1 revealed she does not know why there was not a care plan, she thought there had been one developed. RN #1 revealed there should be a care plan developed for any anticoagulants.

Based on facility policy review, record review and staff interview, the facility failed to revise a care plan for nutrition for one (1) of 18 residents reviewed, Resident #9. Findings include: Review of the facility's Care Plans policy, not dated, revealed each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. Responsibility: All members of the interdisciplinary team. Monitored by the MDS (Minimum Data Set) and Director of Nurses. Procedures included: The care plan will be reviewed and revised at quarterly intervals in conjunction with the completion of MDS assessments (quarterly, significant change, annual) and with changes in resident's condition as needed. Upon a change in condition, the care plan will be updated or an initial care plan will be initiated. Resident #9 Review of the (MONTH) 2019 physician's orders [REDACTED]. Review of the care plan, with a start date of 6/12/19, revealed, Problem, Inadequate nutritional intake: Protein Calorie Malnutrition, PEG (Percutaneous Endoscopic Gastrostomy) tube for nutrition, at risk for alteration in nutrition status, at risk for alteration in hydration status, resident is nothing by mouth (NPO) and receives nutrition by Percutaneous Gastrostomy Tube (PEG) tube only, at risk for aspiration, Category: Nutrition. The Mechanical Soft Diet was not care planned for Resident #9. Interview on 12/03/19, at 11:36 AM, with Registered Nurse #1 (RN)/Minimum Data Set (MDS) Coordinator, revealed RN#1 confirmed the Mechanical Soft Diet was not care planned and stated it should have been care planned. She stated the purpose of a care plan would be to describe how the resident should be cared for. RN #1 stated that care plans should be updated quarterly, yearly and with changes. She revealed that when the new order is taken, the care plan should be updated soon after. She confirmed it is the policy of the facility to update the care plan with changes and the policy was not followed. Review of the Face Sheet revealed Resident #9 was admitted by the facility, on 5/30/19, with [DIAGNOSES REDACTED].

Based on observation, staff interview, resident interview, record review, facility policy review, manufacturer's recommendation, and review of the Mississippi Nursing Practice Law, the facility failed to administer a metered dose inhaler per manufacturers recommendations for one (1) of five (5) residents observed for medication administration, Resident #2. Findings include: Review of the Mississippi Nursing Practice Law, with an effective date of (MONTH) 1, 2010, revealed on pages three (3) and four (4) of 26: 73-15-5 Definitions. (2) The practice of nursing by a registered nurse means the performance for compensation of services which requires substantial knowledge of biological, physical, behavioral, psychological, and sociological sciences, and of nursing theory as the basis for assessment, diagnosis, planning intervention, and evaluation in the promotion, maintenance of health; management of individual's responses, to illness, injury or infirmity; the restoration of optimum function; or the achievement of a dignified death. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation, and supervision of nursing, and execution of the medical regimen, including the administration of medications, and treatments prescribed by any licensed or legally authorized physician, or dentist. (5) The practice of nursing by a licensed practical nurse means the performance for compensation of services requiring basic knowledge of the biological, physical, behavioral, psychological, and sociological sciences, and of nursing procedures which do not require the substantial skill, judgement, and knowledge required of a registered nurse. These services are performed under the direction of a registered nurse, or a licensed physician, or licensed dentist, and utilize standardized procedures in the observation, and care of the ill, injured, and infirm; in the maintenance of health; in action to safeguard life and health; and in the administration of medications, and treatments prescribed by any licensed physician, or licensed dentist authorized by state law to prescribe. Review of the facility's Oral Inhalation Administration policy, not dated, revealed the policy is to allow for correct administration of oral inhalers to residents and for instruction in proper technique for those residents able to administer the medication to themselves. The procedure instructions guide staff to instruct the resident to breath out through their mouth, inhale slowly over three (3) to five (5) seconds as they depress the canister to release the medication, to hold their breath for 10 seconds and then to exhale slowly. Instructions include if there are repeat doses the resident is to breathe normally for one (1) minute, wait one (1) to two (2) minutes and repeat the steps. Review of the [MEDICATION NAME] HFA inhaler manufacture's insert revealed steps for use included breathe out through your mouth and push as much air from your lungs as you can. Put the mouthpiece in your mouth and close your lips around it. Push the top of the metal canister all the way down while you breathe in deeply and slowly through your mouth. Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. Wait about 30 seconds and shake the inhaler well for five (5) seconds and repeat steps. On 12/03/19 at 8:50 AM, an observation during the medication pass revealed Licensed Practical Nurse (LPN) #1 handed the [MEDICATION NAME] metered dose inhaler to Resident #2. Resident #2 placed the inhaler in her mouth and pressed the top of the canister two (2) times, one right after the other, without exhaling, taking a deep breath, shaking the canister or waiting for 30 seconds. LPN #1 did not instruct Resident #2 on the proper use. Review of Resident #2's (MONTH) 2019 physician's orders [REDACTED]. On 12/03/19 at 8:50 AM, an interview with Licensed Practical Nurse, (LPN) #1 confirmed she did not instruct Resident #2 before or during the administration of the [MEDICATION NAME] inhaler. LPN #1 confirmed Resident #2 did not wait 30 seconds between puffs and did not shake the inhaler between puffs. LPN #1 confirmed the [MEDICATION NAME] insert revealed in the steps for how to use the inhaler to breathe out, place inhaler in your mouth, dispense medication and inhale, hold your breath 10 seconds, wait 30 seconds, shake canister for five (5) seconds and repeat steps. LPN #1 revealed that by not waiting 30 seconds and following the instructions the resident would not get the most effect of the medication in her lungs and it may not help her breathing as much as it should. On 12/03/19 at 9:00 AM, an interview with Resident #2 confirmed she did not know she should wait 30 seconds between the 2 puffs of her [MEDICATION NAME] and had not been waiting. Resident #2 revealed no one had told her to wait between puffs, but she is glad she now knows because she wants her medicine to work the best it can. Record review of Resident #2's Face Sheet revealed the [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter/incontinent care in a manner to prevent the potential for trauma and infection for three (3) of six (6) care observations; Resident #1, #2 and #4. Findings include: Review of the facility's Catheter Care (Indwelling Catheter), policy, dated 01/03, revealed its purpose is to prevent infection and reduce irritation. The procedure includes to Secure catheter with catheter strap. A review of the facility's Incontinent Care policy, not dated, revealed when washing the Perineal area, wash the entire area moving from front to back. Resident #2: An observation on 09/28/17 at 10:35 AM, revealed Certified Nurse Assistant (CNA) #2 performed catheter care on Resident #2 with assistance from CNA #3. There was no catheter strap in place to secure the tubing. A catheter strap was noted on the floor near foot of bed. During catheter care, CNA #3 placed the catheter bag on top of Resident #2's bed covers while fastening the brief. Once the brief was applied, the catheter bag was hung on the side of bed. Resident #2 was covered up without a catheter strap being applied for security of the tubing upon completion of care. During an interview on 09/28/17 at 11:50 AM, CNA #2 stated, What is a catheter strap? CNA #2 state Resident #2 was not wearing a catheter strap and that she did not apply one after finishing catheter care. An interview on 09/28/17 at 12:15 PM, with CNA #3 confirmed Resident #2 was not wearing a catheter strap. CNA #3 stated I saw it on the floor. Interview on 09/28/17 at 12:40 PM, with Licensed Practical Nurse (LPN) #3 revealed using a leg strap to secure the catheter strap is part of our policy. Review of the Face Sheet revealed the facility admitted Resident #2 on 04/03/17, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/07/17, revealed Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. Resident #1 On 9/28/17 at 9:10 AM, an observation of incontinent care on Resident #1, by Certified Nursing Assistant (CNA) #4, assisted by CNA #2, revealed CNA #4 used a washcloth made into a mitt with liquid soap applied, cleaned the anterior pubic area, wiping front to back down the right, left sides and then center area without rotating the cloth mitt or changing cloths. CNA #4 then, after the center wipe with a small amount of brown stool noted on the mitted cloth, continued with the same mitted area and wiped from back to front with the same area of the mitted cloth. On 9/28/17 at 12:15 PM, an interview with CNA #2 revealed when asked to describe the incontinent care she assisted CNA #4 with by holding and positioning the resident, confirmed the findings of contamination of Resident #1's anterior perineal area by CNA #2's failure to rotate the washcloth or change it and by wiping from back to front. On 9/28/17 at 12:20 PM, CNA #4 revealed during an interview, she had contaminated Resident #1's anterior Perineal area by not rotating or changing the washcloth during incontinent care and by wiping incorrectly from back to front. She stated she knew better than to use this practice through her CNA training. She replied she knew she did it wrong and thinks she must have been nervous. Review of the facility's face sheet revealed, the facility admitted the resident on 4/14/09, with a readmission on 3/23/17. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 6/26/17, revealed the Resident #1 had a Brief Interview of Mental Status score of 8, indicating the resident had moderately impaired cognition. Resident #4: Observation of Resident #4's incontinent care, performed by CNA #1, on 09/29/17 at 11:20 AM, revealed the CNA filled the water basin with water, and added soap to the basin via the hand soap dispenser. She used this water to wash and rinse the resident's penis, groin area, buttocks and anal area with back and forth and circular wiping motions in the groin and buttock area during his incontinent care. Staff interview, on 09/28/17 at 11:50 AM, with CNA #1, confirmed she performed incontinent care on Resident #6, by using back to front and circular wiping motions on the resident. Said she used the soapy water in the basin to clean and rinse the resident's groin, buttocks and anal area, throughout the resident's incontinent care. Staff interview, on 09/28/17 at 12:45 PM, with Licensed Practical Nurse/Staff Development/Infection Control Nurse #2, confirmed CNA #1 failed to provide incontinent care correctly when she used back to front strokes, and failed to change the soapy water when washing and rinsing Resident #4's groin, buttocks and anal area. Review of the facility's face sheet revealed, the facility admitted the resident on 11/22/11. Resident #4's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 08/26/17, revealed staff assessed Resident #4 with severely impaired cognition.

Based on record review, staff interview and facility policy review, the facility failed to develop a comprehensive care plan for Resident #2 and Resident #4, related to wound care, for two (2) of 14 resident records reviewed. Findings include: Review of the facility's Care Plans policy, not dated, revealed each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The Care Plan shall be fully developed within seven (7) days after completion of Admission Minimum Data Set (MDS) assessment. Resident #2: A review of the current comprehensive care plan, for Resident #2, revealed there was not a care plan to address skin or Pressure Ulcer risk. Review of the admission MDS assessment with an Assessment Reference Date (ARD) of 04/10/17, under Care Area Assessment (Section V) revealed Pressure Ulcer triggered and would be care planned. Resident #2 triggered for Pressure Ulcer due to being incontinent, [DIAGNOSES REDACTED]. Interview on 09/28/17 at 12:40 PM, with Licensed Practical Nurse (LPN) #3 revealed after reviewing the admission MDS assessment and comprehensive care plan, that there was not a care plan to address Pressure Ulcers. Interview on 09/28/17 at 1:20 PM, with the Corporate Registered Nurse revealed she completed the admission MDS assessment and comprehensive care plan for Resident #2. Upon review of Section V of the admission MDS assessment and the comprehensive care plan for Resident #2, the Corporate Registered Nurse confirmed there was not a care planned developed to address Pressure Ulcer. The Corporate Registered Nurse stated, There should be one. I don't see it. A review of the Face Sheet revealed the facility admitted Resident #2 on 04/03/17, with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS, with an ARD of 07/07/17, revealed Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. The MDS was coded under M0150 as a risk to develop pressure ulcers. Resident #4: Review of Resident #4's current care plans did not reveal a care plan related to wound care of the Stage III wound to his right heel. Review of the physician's orders [REDACTED]. Staff interview, on 09/28/17 at 2:50 PM, with Minimum Data Set (MDS) Nurse, LPN #3, confirmed Resident #4 did not have a care plan to address wound care to his right heel wound. LPN #3 stated that the Wound Care Nurse was responsible for initiating and revising the care plans for residents receiving wound care. Staff interview, on 09/28/17 at 12:45 PM, with the Registered Nurse (RN) #1, confirmed Resident #4 did not have a comprehensive care plan related to wound care of his Stage III right heel. He confirmed he was the staff responsible for initiating and updating the wound care plans. Review of the facility's face sheet revealed the facility admitted the resident on 11/22/11. Resident #4's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/17, revealed staff assessed Resident #4 with severe cognitive impairment.

Based on record review, staff interview and facility policy review, the facility failed to follow the comprehensive care plan for Resident #1, #2, and #4, for three (3) of 14 resident records reviewed. Findings include: Review of the facility's Care Plan policy, not dated, stated that each resident will have a person-centered plan of care to identify problems, needs and strengths to identify how the interdisciplinary team will provide care. The responsibility of the care plan is all members of the interdisciplinary team and monitored by the Administrator. The Care Plan contains resident problems/needs/strengths, resident goals and interdisciplinary approaches. The Certified Nursing Assistant (CNA) Care Guide is part of the Comprehensive Care Plan and used as the tool to make staff aware of the residents' daily care needs; serves as Activities of Daily Living (ADL) care plan. Assigned disciplines will carry out the care plan interventions. Resident #1: Review of Resident #1's care plan, initiated 3/23/17, revealed to provide incontinent care every two (2) hours per facility policy. On 9/28/17 at 9:10 AM, an observation of incontinent care on Resident #1, by Certified Nursing Assistant (CNA) #4, assisted by CNA #2, revealed CNA #4 used a washcloth and cleaned the anterior pubic area, wiping front to back down the right, left sides and then center area without rotating the or changing cloth. CNA #4 then, after the center wipe with a small amount of brown stool noted on the mitted cloth, wiped from back to front with the same area of the cloth. In an interview, on 9/28/17 at 12:20 PM, CNA #4 confirmed she had provided incontinent care incorrectly by not rotating or changing the washcloth during incontinent care and by wiping incorrectly from back to front. Review of the facility's face sheet revealed, the facility admitted the resident on 4/14/09, with a readmission on 3/23/17. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 6/26/17, revealed the Resident #1 had a Brief Interview of Mental Status score of 8, indicating the resident had moderately impaired cognition. Resident #2: Review of the comprehensive care plan, for Resident #2, revealed a problem to address a suprapubic catheter and risk for infection, initiated 4/3/17. Interventions included: Secure Foley tubing with leg strap. Observation on 09/28/17 at 10:35 AM, revealed Certified Nurse Assistant (CNA) #2 performed catheter care on Resident #2 with assistance from CNA #3. Prior to starting care, there was no catheter strap in place to secure the tubing. A catheter strap was observed on the floor near the foot of the bed. Upon completion of the catheter care, the resident was covered up without a catheter strap being applied. In an interview, on 09/28/17 at 12:40 PM, Licensed Practical Nurse (LPN) #3 confirmed, upon reviewing the care plan and being informed of observation of catheter care on Resident #2, that the care plan was not followed related to using a leg strap to secure the catheter tubing. A review of the Face Sheet revealed the facility admitted Resident #2 on 04/03/17, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment with an ARD of 07/07/17, revealed Resident #2 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated no cognitive impairment. Resident #4: Review of Resident #4's care plan related to bowel and bladder incontinence, with an onset date of 08/12/15, revealed an intervention to perform in continent care every two (2) hours and as needed. Observation of incontinent care for Resident #4, provided by Certified Nursing Assistant (CNA) #1, on 9/28/17 at 11:20 AM, revealed the CNA used circular motions when wiping the resident's groin, buttocks and anal area, and washed and rinsed from the top of the buttocks to the groin area (back to front). CNA #1 used soapy water to wash and rinse the resident's whole Perineal area. Staff interview, on 09/28/17 at 11:50 AM, with CNA #1, confirmed she performed incontinent care on Resident #6, by using back to front and circular wiping motions on the resident. CNA #1 said she used the soapy water in the basin to clean and rinse the resident's groin, buttocks and anal area, throughout the resident's incontinent care. CNA #1 acknowledged this was not the appropriate way to do incontinent care, thus plan of care was not carried out correctly. Staff interview, on 09/28/17 at 12:45 PM, with Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Nurse #3, confirmed the staff did not follow the resident's bowel/bladder incontinent care plan as evidenced by not proving the care correctly. LPN #3 stated the CNA did not wipe the resident from front to back during incontinent care and used soapy water for the whole procedure. Review of the facility's face sheet revealed, the facility admitted the resident on 11/22/11. Resident #4's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 08/26/2017, revealed staff assessed Resident #4 with severe cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to honor the resident's food preferences for one (1) of eight (8) resident meal observations, Resident #6. Findings include: Review of the facility's Dietary Admission Interview policy, with a revision date of 01/30/14, revealed the resident's food preferences should be updated yearly or more frequently as needed. The Dietary Manager (DM) uses this information to create and update the resident's food dislikes for the tray card system. The Dietary Admission Interview form is completed and kept in the dietary department for future reference. Observation on 09/27/17 at 12:35 PM, revealed Resident #6 was being fed by Certified Nurse Aide (CNA) #1. She was served baked chicken and corn bread, which were listed on her diet slip, which was located on her lunch tray, as food dislikes. Staff interview with CNA #1, on 09/27/17 at 12:35 PM, revealed Resident #6 was served baked chicken and corn bread, and confirmed the resident did not eat these foods, and said they were listed on diet slip as food dislikes. Interview with Resident #6, on 09/27/17 at 12:35 PM, revealed she was served baked chicken and corn bread on her lunch tray and confirmed she did not eat these foods. The resident confirmed corn bread and chicken were listed on her diet slip, which was located on the serving tray in her room, as food dislikes. Resident #6 declined an offer for other food items. Staff interview with the Dietary Manager, on 09/27/17 at 5:10 PM, revealed Resident #6 was served baked chicken and corn bread for lunch, and confirmed the resident did not eat these foods and should not have gotten them on her food tray. The Dietary Manager said these foods were listed on resident's diet slip as food dislikes. Review of the facility's face sheet revealed, the facility readmitted the resident on 06/24/16. Resident 6's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/17, revealed Resident #6 had a Brief Interview Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.

CI # Based on observation, record review, staff interview, and policy review, the facility failed to implement care plans regarding bed or chair alarms as care planned to prevent falls for one (1) of four (4) residents reviewed for falls (Resident #2), and one (1) unsampled resident (Unsampled Resident A). Findings include: Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #2's cognitive status was severely impaired. Review of the functional status of section of this MDS revealed that the Resident #2 required limited assistance for transfers and the support of one (1) person for walking in the room. Review of Fall Risk Assessments completed 2/14/13 and 3/4/13 revealed that Resident #2 was at high risk for falls. Review of Resident #2's care plan revealed, "8/29/12 - Problem: "(Name of Resident #2) is at risk for falls related to hx (history)of falls, dx (diagnosis) of [DIAGNOSES REDACTED], [MEDICAL CONDITION], and Multiple Dx resulting in weakness." The care plan was revised on 2/25/13 to reflect a fall and the use of a chair alarm was identified as an approach to help prevent falls. On 2/28/13 the care plan addressed another fall and a bed alarm was identified as an approach for the prevention of falls. Review of the Resident #2's Resident Incident Report, dated 2/25/13 at 4:41 p.m., noted, Called to resident room. Resident noted sitting on floor beside bed on bottom with legs out in front of her..." This report indicated that the "Activity at time: From chair w/o (without) asst (assistance)." Review of the Resident #2's Resident Incident Report, dated 2/28/13 at 10:15 p.m., noted, "The Activity at time: To/frm (from) bathrm (bathroom)-alone ... 10:15 PM Called to residents room per CNA staff. Resident noted up in wheelchair. Blood noted to resident's face, hands, and shirt. Laceration noted (on) residents (resident's) eyebrow/forehead. Resident stated, "I fell in the bathroom." "Complained of pain ..." Review of the Incident investigation, noted, "... Neurocheck (neurological checks) wnl (within normal limits) for resident. MD (Physician) notified. Will transfer resident to ER (emergency room ) for evaluation. R/P (responsible party) notified. B/P (Blood pressure) 150/80, P (pulse) 83, R (respirations) 18, T (temperature) 96.5..." This incident report did not address the chair alarm care planned 2/25/13, if there was a chair alarm in use, or if the chair alarm had sounded. Review of the Resident #2's Resident Incident Report, dated 5/1/13, noted, "The "Activity at time: From chair w/o (without) asst (assistance) ...CNA (Certified Nurse Aide) stated found resident on floor at the foot of her roommates (roommate's) bed when making rounds. Resident was on knee holding onto bottom of (the) roommates (roommate's) bed." This incident report did not address the chair alarm that was care planned 2/25/13 or the bed alarm that was care planned 2/28/13 as being in use and operational. Observation on 5/2/13 at 4:15 p.m. revealed that a chair alarm had been placed on the wheelchair of Resident #2. Interview on 5/2/13 at 4:20 p.m. with Certified Nurse Aide (CNA) #1 revealed she had been assigned to Resident #2 the night before. Interview with CNA #1 regarding the care required for Resident #1 revealed she failed to mention the need for a bed or chair alarm. CNA #1 was specifically asked about the need of a chair alarm and she agreed that there was to be a chair alarm used. CNA #1 was asked about the need for a bed alarm and CNA #1 was not sure of whether or not Resident #1 was to have a bed alarm. CNA #1 was asked to demonstrate how the chair alarm functioned. CNA #1 asked Resident #2 to stand. The alarm did not sound as it should have when the resident stood. CNA #1 and Licensed Practical Nurse (LPN) #1 worked with the chair alarm which began to sound with the resident sitting in her chair. The alarm was turned off and then turned back on. The resident was again asked to stand and again the alarm did not sound. LPN #1 stated that the resident usually kept the alarm in her purse and began questioning the resident as to the location of her purse. On 5/2/13 at 4:30 p.m. LPN #1 changed out the control box of the chair alarm for Resident #2 and the chair alarm was noted to be functioning correctly. At this time Registered Nurse (RN) #1/Nursing Supervisor was asked to assist in the observation of the bed alarm for Resident #2. There was no bed alarm in place. Observation on 5/2/13 at 4:45 p.m. revealed RN#1 was observed to place a bed alarm on the bed of Resident #2. Upon testing this alarm to determine if it was working it was found not to alarm. The batteries were replaced and the alarm was functioning as it should. Unsampled Resident A Record review revealed that Unsampled Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 6, which indicated that Unsampled Resident A's cognitive status was severely impaired. Interview on 5/3/13 at 8:20 a.m. with the Director of Nursing (DON) revealed the DON provided a list of residents requiring bed/chair alarms. The list documented that Unsampled Resident A was to have a bed alarm and a chair alarm in use. Review of the care plan, dated 3/6/13, noted, "Problem of "(Name of Unsampled Resident A) is at risk for falls related to hx (history) of falls and weakness." A chair alarm was care planned after a fall on 3/17/13 and a bed alarm was care planned after a fall on 3/19/13. Interview on 5/2/13 at 4:20 p.m. with Certified Nurse Aide (CNA) #1 revealed she had been assigned to Resident #2 the night before. Interview with CNA #1 regarding the care required for Resident #1 revealed she failed to mention the need for a bed or chair alarm. CNA #1 was specifically asked about the need of a chair alarm and she agreed that there was to be a chair alarm used. CNA #1 was asked about the need for a bed alarm and CNA #1 was not sure of whether or not Resident #1 was to have a bed alarm. CNA #1 was asked to demonstrate how the chair alarm functioned. CNA #1 asked Resident #2 to stand. The alarm did not sound as it should have when the resident stood. CNA #1 and Licensed Practical Nurse (LPN) #1 worked with the chair alarm which began to sound with the resident sitting in her chair. The alarm was turned off and then turned back on. The resident was again asked to stand and again the alarm did not sound. LPN #1 stated that the resident usually kept the alarm in her purse and began questioning the resident as to the location of her purse. On 5/2/13 at 4:30 p.m. LPN #1 changed out the control box of the chair alarm for Resident #2 and the chair alarm was noted to be functioning correctly. At this time Registered Nurse (RN) #1/Nursing Supervisor was asked to assist in the observation of the bed alarm for Resident #2. There was no bed alarm in place. Observation on 5/2/13 at 4:45 p.m. revealed RN#1 was observed to place a bed alarm on the bed of Resident #2. Upon testing this alarm to determine if it was working it was found not to alarm. The batteries were replaced and the alarm was functioning as it should. Observation on 5/3/13 at 9:30 a.m., with the assistance of Licensed Practical Nurse (LPN) #2, revealed that Unsampled Resident A was in the bathroom. There was a chair alarm in place on the resident's wheelchair, a chair alarm in the resident's recliner, and a bed alarm on the resident's bed. None of the alarms were sounding to alert staff that the resident was up and in need of assistance. Interview on 5/3/13 at 9:35 a.m. with Registered Nurse (RN) #1/Nursing Supervisor, revealed that this resident could turn off the alarms. RN #1 continued, saying that the alarm on the resident's wheelchair had been changed to the type that was under the seat of the wheelchair, making it more difficult for the resident to turn off the alarm. RN #1 speculated that a CNA (Certified Nurse Aide) had assisted the resident to the bathroom and had turned off the alarm. Interview on 5/3/13 at 10:15 a.m. with RN #1 revealed that she was unable to identify any CNA that had assisted Unsampled Resident A to the bathroom and turned off the alarms. RN #1 agreed that if this had been the case, the CNA should have remained with the resident to assist her to/from the bathroom. Review of the facility's "Bed and Chair Alarms" policy, not dated, noted, "Policy: Bed/chair alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for falls. Purpose: For each resident to reach his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience. Procedure: 1. Fall Risk Assessment of each resident must be done on admission, quarterly, and with change in status to evaluate if he/she is at risk for falls. 2. A plan of care must be formulated with the Interdisciplinary Team (Nursing, Physical Therapy, Occupational Therapy, Dietary, Activities, Social Worker, and Resident/Family, to determine the need for tab or bed alarms and documented in the care plan. 3. The chair alarm will be utilized on the resident when they are out of bed in a wheelchair or chair. 4. The bed alarm will be utilized on the resident while they are in bed. 5. After applying the tab alarm or bed/chair alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident." Review of the facility's "Care Plans" policy, not dated, noted, "Policy: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care...Procedure: ... 5. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention..."

CI # Based on observation, record review, staff interview, and policy review, the facility failed to provide adequate supervision, and failed to implement planned interventions to prevent falls and injury of residents for three (3) of four (4) sampled residents (Residents #1, #2 and #3 and one (1) unsampled resident (Unsampled Resident A). Findings include: Resident #1 Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 5/2/13 at 11:10 a.m. revealed Resident #1 was observed sitting in her wheelchair in the hallway. Resident #1 was clean and well groomed. Review of the Minimum Data Set Assessment (MDS), dated [DATE], a Brief Interview for Mental Status score of 0, which indicated that Resident #1's cognitive status was severely impaired. This MDS coded that Resident #1 was totally dependent in bed mobility and transfers, requiring two (2) + (plus) persons physical assist. Review of Resident #1's Fall Risk Assessment, dated 8/22/12, noted that the resident was at high risk for falls. Review of Resident #1's Resident Lift/Transfer Assessment, dated 2/12/13, noted that the resident required a Sit to Stand Lift. Review of the care plan, noted "Problem of "(Name of Resident #1) is at risk for falls related to dx (diagnosis) of Alzheimer's, anxiety, depression, and limited mobility. She also has hx (history) of falls." One intervention for this problem was "Use mechanical lift for transfers." On 4/13/13 the care plan was updated, noted, "Fall/lowered to floor from lift r/t (related to) combative behavior." Review of the Resident Incident Report, dated 4/13/13 at 2:45 p.m., noted, "... Activity at time: From chair w (with)/assit (assistance) ...Staff reported that resident had fallen in her room. RN (Registered Nurse) went to room to assess situation and found resident sitting up in wheelchair. CNA (Certified Nurse Aide) present states resident was fighting against the equipment but did not fall." Review of the Incident Investigation, dated 4/13/13 at 2:45 p.m., noted, "Narrative of investigation: Staff reported that resident had fallen in her room. State resident's roommate came into the hall yelling. RN went to room assess situation and found resident sitting up in a wheelchair. CNA and other nurses present at that time. No apparent injury to resident. Denies current pain and able to move extremities with no problems noted. Staff reports resident did not fall but was fighting against the lift being used to transfer her. MD (physician) notified via communication book and granddaughter (Name of granddaughter) also notified. V/S (Vital Signs) and neuro (neurological) checks implemented." Review of the Incident Witness Statement for CNA #2 , dated 4/13/13, noted, "Narrative of incident: While using the stand up lift (Name of Resident #1) was extremely combative, she refused to cooperate, therefore, while on the lift she began kicking with feet, grabbing staff member on duty who was providing patient care to her; she (Name of Resident #1) began hitting/fighting with all of her almighty while up on lift; therefore after changing her diaper, I immediately lowered her to the floor, called for help and took lift off her. Involved Person's statement: No! pt. (patient) didn't fall from lift; yes! Pt. was lowered completely to the floor because she became combative while on the lift machine." Review of the Incident Witness Statement for CNA #3, dated 4/13/13, noted, "Narrative of incident: Resident's roommate stopped me in the hall stating (Resident #1's first name) was acting out and now she is on the floor. I entered the room and saw CNA (CNA #2's first name) and resident on the floor. I also noted resident somehow still was connected to lift. CNA stated she was resisting care and she lowered her to the floor. (First name of CNA #2) got up off the floor and resident was transferred to wheelchair." Interview with CNA #3 on 5/2/13 at 2:55 p.m. regarding the 4/13/13 incident revealed that CNA #2 had not used the ankle/leg sling for the transfer with the sit-to-stand lift and there was no second staff assisting CNA #2. CNA #3 demonstrated the use of the sit-to-stand lift including the use of the ankle/leg sling. Interview on 5/2/13 at 2:25 p.m. with the Director of Nursing (DON) revealed that it is facility policy to have two staff assisting when a mechanical lift is used and CNA #2 had used the lift for Resident #1 without help. The DON stated that CNA #2 was terminated. Review of the facility's "Disciplinary Report", dated 4/18/13, revealed that Certified Nurse Aide #2 was Action taken: discharged . Offense: Non-Compliance of Policy and Procedure ...Number of Warnings: On 4/12 - Received In-Service Training on use of Lifts and Transfers. On 4/13/13, an Incident occurred while caring for resident by herself using sit/stand lift when two staff members are required." Review of the facility's "Sit to Stand Lifts" policy, not dated, noted, "Policy: The Sit to Stand lift is to assist weight-bearing residents when standing and toileting, and for use as a short distance resident transfer aid ... Procedure: ... 5. Transfer Sling: ... f. Connect leg straps onto leg connection knobs. The leg pieces should be pulled tight, but comfortable ..." Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated that Resident #2's cognitive status was severely impaired. Review of the functional status of section of this MDS revealed that the Resident #2 required limited assistance for transfers and the support of one (1) person for walking in the room. Review of Fall Risk Assessments completed 2/14/13 and 3/4/13 revealed that Resident #2 was at high risk for falls. Review of Resident #2's care plan revealed, "8/29/12 - Problem: "(Name of Resident #2) is at risk for falls related to hx (history)of falls, dx (diagnosis) of [DIAGNOSES REDACTED], Osteoarthritis, and Multiple Dx resulting in weakness." The care plan was revised on 2/25/13 to reflect a fall and the use of a chair alarm was identified as an approach to help prevent falls. On 2/28/13 the care plan addressed another fall and a bed alarm was identified as an approach for the prevention of falls. Review of the Resident #2's Resident Incident Report, dated 2/25/13 at 4:41 p.m., noted, "Called to resident room. Resident noted sitting on floor beside bed on bottom with legs out in front of her..." This report indicated that the "... Activity at time: From chair w/o (without) asst (assistance)." Review of the Resident #2's Resident Incident Report, dated 2/28/13 at 10:15 p.m., noted, "... Activity at time: To/frm (from) bathrm (bathroom)alone ... 10:15 PM Called to residents room per CNA staff. Resident noted up in wheelchair. Blood noted to resident's face, hands, and shirt. Laceration noted (on) residents (resident's) eyebrow/forehead. Resident stated, "I fell in the bathroom." "Complained of pain ..." Review of the Incident investigation, noted, "... Neurocheck (neurological checks) wnl (within normal limits) for resident. MD (Physician) notified. Will transfer resident to ER (emergency room ) for evaluation. R/P (responsible party) notified. B/P (Blood pressure) 150/80, P (pulse) 83, R (respirations) 18, T (temperature) 96.5..." This incident report did not address the chair alarm care planned 2/25/13, if there was a chair alarm in use, or if the chair alarm had sounded. Review of the Resident #2's Resident Incident Report, dated 5/1/13, noted, "... Activity at time: From chair w/o (without) asst (assistance) ...CNA (Certified Nurse Aide) stated found resident on floor at the foot of her roommates (roommate's) bed when making rounds. Resident was on knee holding onto bottom of (the) roommates (roommate's) bed." This incident report did not address the chair alarm that was care planned 2/25/13 or the bed alarm that was care planned 2/28/13 as being in use and operational. Observation on 5/2/13 at 3:55 p.m. of Resident #2 with the Director of Nursing (DON) revealed that the resident was standing in the doorway of her room. No bed alarm or chair alarm was sounding. Observation, at this time, revealed that there was no chair alarm on the resident's chair and no bed alarm on the resident's bed. Interview with the DON at the time of this observation revealed that bed/chair alarms were nursing interventions and required no physician orders. The DON confirmed that the facility did not document of the use of a bed/chair alarm other than the resident's care plan and there was no documented evidence of monitoring for the use of alarms and the testing of the alarms to determine if they were operational. Review of the emergency room report, dated 2/28/13, noted, Resident #1 sustained a laceration located over the right eyebrow which was two (2) centimeters in length. The laceration required four (4) sutures. Observation on 5/2/13 at 4:15 p.m. revealed there was a chair alarm in place on the wheelchair of Resident #2. Interview on 5/2/13 at 4:20 p.m. with Certified Nurse Aide (CNA) #1 revealed that she had been assigned to Resident #2 the night before. When CNA #1 was questioned about the care required for Resident #2, she failed to mention the need for a bed/chair alarm. When CNA #1 was specifically asked about the need for a chair alarm she agreed that there was to be a chair alarm used. When CNA #1 was asked about the need for a bed alarm, CNA #1 was unsure of whether or not the resident was to have a bed alarm. CNA #1 was asked to demonstrate how the chair alarm functioned. CNA #1 asked Resident #2 to stand. The alarm did not sound as it should have when the resident stood. CNA #1 and Licensed Practical Nurse (LPN) #1 worked with the chair alarm which began to sound with the resident sitting in her chair. The alarm was turned off and then turned back on. The resident was again asked to stand and again the alarm did not sound. LPN #1 stated that the resident usually kept the alarm in her purse and began questioning the resident as to the location of her purse. On 5/2/13 at 4:30 p.m. LPN #1 changed out the control box of the chair alarm for Resident #2 and the chair alarm was noted to be working. At this time RN #1, Nursing Supervisor was asked to assist in the observation of the bed alarm for Resident #2. There was no bed alarm in place. On 5/2/13 at 4:45 p.m., RN#1 was observed placing a bed alarm on the bed of Resident #2. Upon testing this alarm to determine if it was working it was found not to alarm. The batteries were replaced and the alarm was functioning as it should. Interview on 5/2/13 at 4:45 p.m. revealed Registered Nurse (RN) #1 was asked to identify residents requiring chair orbed alarms. RN #1 (from memory) gave the names of one (1) resident requiring both a chair alarm and a bed alarm, one (1) resident requiring only a chair alarm, and two (2) residents requiring only bed alarms. On 5/2/13 at 4:50 p.m. the Director of Nursing was asked to provide an accurate list of residents requiring chair or bed alarms. On 5/3/13 at 8:20 a.m. the DON provided the list of resident's requiring a chair or bed alarm. Three (3) residents were identified as needing both a chair and bed alarm. Four (4) residents were listed as needing only a chair alarm. One (1) resident was identified as needing only a bed alarm. Unsampled Resident A Interview on 5/3/13 at 8:20 a.m. with the Director of Nursing (DON) revealed the DON provided a list of residents requiring bed or chair alarms. The list documented that Unsampled Resident A was to have a bed alarm and chair alarm in use. Record review revealed that Unsampled Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 6, which indicated that Unsampled Resident A's cognitive status was severely impaired. Review of the care plan, dated 3/6/13, noted "Problem of "(Name of Unsampled Resident A) is at risk for falls related to hx (history) of falls and weakness." A chair alarm was care planned after a fall on 3/17/13 and a bed alarm was care planned after a fall on 3/19/13. Observation on 5/3/13 at 9:30 a.m., with the assistance of Licensed Practical Nurse (LPN) #2, revealed that Unsampled Resident A was in the bathroom. There was a chair alarm in place on the resident's wheelchair, a chair alarm in the resident's recliner, and a bed alarm on the resident's bed. None of the alarms were sounding to alert staff that the resident was up and in need of assistance. Interview on 5/3/13 at 9:35 a.m. with Registered Nurse (RN) #1/Nursing Supervisor, revealed that this resident could turn off the alarms. RN #1 continued, saying that the alarm on the resident's wheelchair had been changed to the type that was under the seat of the wheelchair, making it more difficult for the resident to turn off the alarm. RN #1 speculated that a CNA (Certified Nurse Aide) had assisted the resident to the bathroom and had turned off the alarm. Interview on 5/3/13 at 10:15 a.m. with RN #1 revealed that she was unable to identify any CNA that had assisted Unsampled Resident A to the bathroom and turned off the alarms. RN #1 agreed that if this had been the case, the CNA should have remained with the resident to assist her to/from the bathroom. Review of the facility's "Bed and Chair Alarms" policy, not dated, noted, "Policy: Bed/chair alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for falls. Purpose: For each resident to reach his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience. Procedure: 1. Fall Risk Assessment of each resident must be done on admission, quarterly, and with change in status to evaluate if he/she is at risk for falls. 2. A plan of care must be formulated with the Interdisciplinary Team (Nursing, Physical Therapy, Occupational Therapy, Dietary, Activities, Social Worker, and Resident/Family, to determine the need for tab or bed alarms and documented in the care plan. 3. The chair alarm will be utilized on the resident when they are out of bed in a wheelchair or chair. 4. The bed alarm will be utilized on the resident while they are in bed. 5. After applying the tab alarm or bed/chair alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident." Resident #3 Record review revealed Resident #3 was admitted to the facility 4/5/07, with [DIAGNOSES REDACTED]. Observation on 5/2/13 at 9:50 a.m. revealed Resident #3 was up in a wheelchair at her bedside. There was a pink scar on her forehead. Her left arm was in a sheepskin trough. Resident #3 was holding a lap throw in her right hand to her mouth and was chewing on it. Review of a Minimum Data Set (MDS), dated [DATE], a Brief Interview for Mental Status score of 0, which indicated that Resident #3's cognitive status was severely impaired. Review of the functional status section of this MDS coded that bed mobility as "Total dependence-full staff performance every time during entire 7 day period with two+ person physical assist." Review of Resident #3's Fall Risk Assessment, dated 4/9/13, revealed that Resident #3 was at high risk for falls. Review of Resident #3's care plan, dated 10/12/12, noted, "Problem of "(Name of resident) requires total assistance of one/two staff member with ADLS (Activities of Daily Living)." One intervention noted, "Provide total assistance of staff x (times) 1-2 (CNAs) with toileting, bed mobility, and bathing." Review of Resident #3's Resident Incident Report, dated 4/16/13 at 5:50 a.m., noted, "Called to resident's room, by CNA (Certified Nurse Aide) upon entering room noted resident lying on floor in between CNA's legs, CNA holding resident head. CNA stated, "she fell and hit her head." Resident assited (assisted) back into bed, checked for injuries, skin tear noted to forehead and nose, bleeding noted. Bleeding controlled, skin tear cleaned with WC (Wound Cleanser), applied transparent dressing Resident alert and verbal at this time. Resident cont (continued) to yell "A, B" Vitals (vital signs) taken, neuro (neurological) checks started, PERRL (Pupils equal, round, react to light), visual monitoring in progress. Skin tear to forehead, skin tear to nose noted at this time..." Review of the Departmental Notes, dated 4/16/13 at 8:38 a.m., noted, "Resident lying in bed. Abnormal neuro checks noted at this time. Residents let (left) eye dilated non reactive to light, right eye slow to react to light. (Name of nurse practitioner) NP notified, new order received transfer to hospital for evaluation. R.P. notified voices understanding. (Name of ambulance service) notified." Review of the hospital's admission History and Physical, dated 4/16/13, noted, "... Impression: 1. Forehead laceration post fall: The patient will be monitored closely for any acute changes in her level of consciousness. We will follow up with a.m. labs..." Interview on 5/3/13 at 11:00 a.m. with Certified Nurse Aide #4, the staff identified as working with Resident #3 the morning of 4/16/13, revealed that she was providing the resident with incontinent care when she realized that the pad under the resident needed changing. She turned her back to the resident to retrieve a clean pad that was on an over bed table that was located between the two (2) resident's bed toward the end of the bed. CNA #4 stated that she heard a noise and turned around and saw the resident on the floor. CNA #4 stated that the resident was on her right side in about the center of the bed when the CNA turned to retrieve the clean pad. CNA #4 stated that the resident did not hit the side rail as she fell .