Every finding on record at TLC Nursing Center

Based on interviews, record review, review of facility policies titled, Controlled Substances, Identifying Exploitation, Theft and Misappropriation of Resident Property, and Administering Medications, review of a Facility Reported Incident (FRI) received by the State Agency (SA) and review of the facility's investigative file, the facility failed to ensure Licensed Practical Nurse (LPN) #4 did not misappropriate resident property when she failed to follow facility procedures related to handling, storage, disposal, and documentation of controlled substances designed to prevent drug diversion and protect resident safety. Specifically, LPN #4 fabricated other nurses' signatures on Controlled Drug Records of Resident Identifier (RI) #99, #104 and #105, indicating they had observed her dispose of dropped controlled medications, when in fact they did not witness or co-sign controlled medication destruction. On 09/10/2025, LPN #4 forged Registered Nurse (RN) #3's signature on RI #99's Tramadol Controlled Drug Record. On 09/06/2025 LPN #4 forged LPN #7's signature on RI #104's Hydrocodone Controlled Drug Record. On 09/11/2025 LPN #4 forged LPN #6's signature on RI #105's Hydrocodone Controlled Drug Record. Further, LPN #4 signed out doses of the Oxycodone on RI #85's Controlled Substance Record in August for 08/01/2025, 08/04/2025, 08/11/2025, 08/15/2025, 08/18/2025 and 08/22/2025 and for September on 09/05/2025, 09/08/2025, and 09/10/2025 and failed to initial and record evidence of administration of the controlled medication, Oxycodone, on RI #85's August 2025 and September 2025 Medication Administration Record (MAR) for the doses she signed out.These deficient practices affected RI #85, #99, #104 and #105, four of nine residents sampled for misappropriation of resident property and one of five medication carts at the facility. This deficiency was cited as a result of the investigation of a facility reported incident/complaint/report number 2633979.Cross-reference F609.Findings Include: Review of a facility policy titled Identifying Exploitation, Theft and Misappropriation of Resident Property, effective 06/2024, revealed the following: Policy StatementAs part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to recognize exploitation of residents and misappropriation of resident property. Policy Interpretation and Implementation1. Exploitation, theft and misappropriation of resident property are strictly prohibited.4. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings .5. Examples of misappropriation of resident property include: . f. drug diversion (taking the resident's medication); . A facility policy titled Controlled Substances with a revised date of 11/2022, documented the following: Policy StatementThe facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . Policy Interpretation and Implementation . Dispensing and Reconciling Controlled Substances . 2. The system of . disposition of controlled substances includes the following:a. Records of personnel access and usage;b. Medication administration records; .c. Declining inventory records; andd. Destruction, waste .7. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witnes (witness) also signs the disposition sheet.9. Disposal methods are used to prevent diversion . On 10/01/2025 the SA received a FRI alleging misappropriation of resident property occurred on 09/11/2025 when the facility's Administrator (ADM) was made aware of an allegation of falsification of medication administration records after Registered Nurse (RN)#3 identified her signature on a controlled substance record for Tramadol, dated 09/10/2025, next to LPN #4's entry which noted the medication had been dropped. The FRI continued, two additional instances of dropped medications were identified, each accompanied by signatures from other nurses who, when questioned, confirmed they had not signed the entries. The Assistant Director of Nursing (ADON) also identified a resident (RI #85) who had received a PRN (as needed) medication nine times over the previous 40 days. The report indicated that RI #85 did not recall requesting the medication. The report indicated that LPN #4 was called into the facility for an interview regarding these findings and acknowledged she had entered other nurses' signatures and LPN #4 stated she administered RI #85's PRN medications based on her professional judgement that the resident needed it even though the resident had not requested it. LPN #4 was terminated and reported to the Alabama Board of Nursing. The report indicated that following the interview and a review of the available documentation, the leadership team and Human Resources concluded that LPN #4 had indeed falsified documentation by forging other nurses' signatures. The report indicated that LPN #4's conduct was determined to be a serious violation of facility policy, professional standards and the Nurse Practice Act. LPN #4 was terminated and reported to the Board of Nursing. The report indicated that the incident was categorized as Misappropriation of Resident Property. Contained within the facility's investigative file was an Employee Counseling/Disciplinary Action form for LPN #4 which documented the following: . Record of: Termination Employee Name: (name of LPN #4) Position: LPN Hall Nurse . Date 9/11/2025 Time: 04:00 p.m. Reason for counseling/disciplinary action: Group A Offense(s)1. Group A 15. Falsification of any facility record.Group B Offense(s): 1. Group B 22. Violating any policy or procedure established in this facility .Why is this unacceptable? Employee didn't follow policy when discarding medications. Employee forged another nurses signature on medication documentation.What is acceptable? Follow all facility policy and procedures. Never falsify documentation .Employee response: I signed a narcotic pill that was stated dropped but in turn to make the narcotic sheet correct I had (name of LPN #6) sign with me and (name of RN #3) sign as well . RI #99 was admitted to the facility 09/09/2025 and had diagnoses to include Vascular Dementia and Pain. RI #99's September 2025 Order Recap Report (Physicians Order) documented an order for Tramadol HCL (Hydrochloric Acid) Oral Tablet 100 mg (milligrams) two tablets by mouth two times a day for Pain. A review of RI #99's Controlled Drug Record for the Tramadol HCL 100 mg revealed on 09/10/2025 RN #3's signature indicating RN #3 had witnessed LPN #4 dispose of a dropped Tramadol tablet. On 03/11/2026 at 1:48 PM RN #3 was asked what she could tell the surveyor about her signature appearing on a controlled substance record. RN #3 said this occurred back in September of 2025 and she noticed when she was signing a controlled substance sheet the nurse on the previous shift had wasted a narcotic on that sheet and signed her name as a witness. RN #3 said, she started looking at other narcotic sheets and saw at least two other resident narcotic sheets with concerns. RN #3 said the proper procedure when making an entry on a controlled substance record that a medication had been dropped was to get another nurse to witness the medication being wasted and have the witness sign the controlled mediation record. RN #3 said she never signed as a witness with LPN #4 for disposal of a dropped controlled medication. RI #104 was originally admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Diabetes Mellitus with Diabetic Neuropathy, Muscle Spasms, and Pain. RI #104's September 2025 Order Recap Report documented an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg one tablet by mouth three times a day for Pain. A review of RI #104's Controlled Drug Record for the Hydrocodone-APAP (Acetaminophen) 5-325 mg revealed on 09/06/2025 LPN #7's signature indicating that LPN #7 had witnessed LPN #4 dispose of a dropped Hydrocodone tablet. On 03/12/2025 at 5:53 PM an unsuccessful attempt was made to contact LPN #7. RI #105 was admitted to the facility 09/08/2025 and had diagnoses to include Fracture of Superior Rim of Left Pubis, Subsequent Encounter for Fracture with Routine Healing, Chronic Pain and Specified Fracture of Left Pubis, Subsequent Encounter for Fracture with Routine Healing. RI #105's September 2025 Order Recap Report documented an order for Hydrocodone-Acetaminophen Tablet 5-325 mg two tablets every four hours for Severe Pain. A review of RI #105's Controlled Drug Record for the Hydrocodone-Acetaminophen Tablet 10-325 mg revealed on 09/11/2025 LPN #6's signature indicating LPN #6 had witnessed LPN #4 dispose of a dropped Hydrocodone tablet. On 03/12/2026 at 6:44 PM an interview was conducted with LPN #6. When asked if he recalled signing his name on RI #105's Hydrocodone APAP 10-325 mg-Controlled Substance Record as a witness observing LPN #4 dispose of the medication, LPN #6 said no. LPN #6 said when the ADON asked him whether it was his signature on the controlled medication sheet or not he told her it was not his signature. On 03/10/2026 at 4:13 PM, on 03/11/2026 at 12:36 PM, and on 03/12/2026 at 7:45 AM, unsuccessful attempts were made to contact LPN #4. On 03/12/2026 at 8:58 AM an interview was conducted with the ADON, who was also serving as the Interim DON. The Interim DON said RN #3 made her aware of LPN #4 signing other nurses' names in her entries for dropped medications. The Interim DON said she went to the hall and had the nurse show her the signatures. The Interim DON said RI #99 was affected and she had the RN supervisor perform audit to see if there were any other instances of dropped medications. The Interim DON said two other residents, RI #104 and RI #105, were found to have two signatures on their Controlled Substance Records indicating the medication had been dropped. The Interim DON said disposal of controlled medications required two nurses witnessing the disposal. The Interim DON said that it was not done and it was determined that a second nurse's signature had been forged. The Interim DON said it was diversion or misappropriation when there was a discrepancy in a resident's controlled medications. On 03/12/2026 at 10:52 AM the Administrator (ADM) said on 09/11/2025, he was made aware of an incident where LPN #4 signed another nurse's name along with her entry, indicating controlled medications for some residents had been dropped. The ADM said according to the facility's Controlled Substance policy, wasting or disposing of a controlled substance is done in the presence of the nurse and the witness who also must sign the disposition sheet. The ADM said the facility's investigation revealed there were one or more instances where this was not done. The ADM said the facility's investigation concluded LPN #4 falsified medical records by forging the signature of other nurses. The ADM said the incident was reported to Alabama Department of Public Health on 10/01/2025, as misappropriation of resident property. On 03/12/2026 at 3:41 PM a telephone interview was conducted with the facility's Consultant Pharmacist (CP). When asked how many signatures there should be on a resident's-controlled substance sheet when a resident's control substance is being wasted or disposed of, the CP said two. The CP said when there were two signatures on the controlled substance sheet it would mean there was a witness to the disposal and in case there was a question about it there would be a witness. The CP said a nurse should never sign another nurse's signature on the controlled substance sheet. The CP said, it would be considered diversion if a nurse signed another nurse's signature on a controlled medication record. Review of a facility policy titled Administering Medications effective 04/2024 revealed the following: Policy headingMedications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .20. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . RI #85 was admitted to the facility 04/01/2025 and had diagnoses to include Fracture of one Rib, Stable Burst Fracture of Fifth Lumbar Vertebra, and Fracture of Left Femur. A review of RI #85's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 07/02/2025 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. RI #85's August and September 2025 Medication Review Report (Physicians Orders) revealed an as needed order dated 04/03/2025 for Oxycodone HCl Oral Tablet 5 mg tablets by mouth every four hours as needed for Moderate Pain. RI #85's Controlled Drug Record (CDR) for Oxycodone had handwritten entries and signatures for August 2025 indicating one pill was signed out on each of the following dates: 08/01/2025, 08/04/2025, 08/11/2025, 08/15/2025, 08/18/2025 and 08/22/2025. The CDR continued with handwritten entries and signatures for September 2025 indicating one pill was signed out on each of the following dates: 09/05/2025 with a handwritten 8 marked through with a 9. The next date listed was 8/8 instead of 9/8. The next date listed was 8/10 instead of 9/10. These entries were signed by LPN #4. A review of RI #85's August and September 2025 MAR revealed there were no entries initialed, as evidence on the MAR, to indicate the Oxycodone had been administered to RI #85 on the CDR dates. On 03/11/2026 at 1:48 PM RN #3 who initially discovered discrepancies on Controlled Drug Records involving LPN #4, said it would be considered misappropriation of the resident's medication when there was any type of discrepancy with the resident's controlled medication. When asked where there would be evidence that any medication had been administered, RN #3 said on the resident's MAR. On 03/12/2026 at 8:58 AM the ADON/Interim DON was asked about findings during the investigation of controlled medications involving LPN #4. The Interim DON said it was discovered Oxycodone had been signed out nine times in 40 days and all of the signatures after June belonged to LPN #4. The Interim DON said when RI #85 was interviewed the resident did not remember asking for or receiving any of the medication in August. The Interim DON said any type of discrepancy of a resident's controlled medication would be drug diversion and misappropriation. On 03/12/2026 at 3:41 PM a telephone interview was conducted with the Consultant Pharmacist (CP). When asked what it would be considered when there was any type of discrepancy of a resident's controlled medication, the CP said diversion. The CP said when a controlled medication was signed as administered on the Controlled Substance Record and there was no evidence it had been administered, it would be misappropriation of the resident's property. The CP also said it should be documented on the residents MAR that a resident had received their medication.*******************************************************The facility took the following corrective actions: ****************************************************** 09/10/2025: Controlled Drug Record (CDR) entry for Tramadol 100 mg for resident (RI #99) documented as dropped with dual signatures; one later determined not authentic. 09/11/2025: RN (RN #3) reported her signature appeared on CDR without her involvement. ADON initiated immediate review and identified two additional dropped-dose entries with forged cosignatories. 09/11- 09/12/2025: ADON audited over 100 CDRs administered by nurse (LPN #4). No further discrepancies identified. One resident, (RI #85), noted to have received PRN medication 9 times in 40 days; resident did not recall requesting medication on most occasions. Mid [DATE]: (LPN #4) interviewed. admitted to entering other nurses' signatures after the fact. Voluntary drug screen completed and returned negative. 09/15/2025: Nursing leadership, including DON and ADON, conducted MAR and pharmacy audit; no evidence of diversion or missed medications found. 09/16/2025: Corporate nurse confirmed findings. Ad hoc QAPI meeting held; root cause analysis completed and monitoring/education recommended. 09/16-09/17/2025: Alert residents interviewed by Social Services. No reports of missed medications or concerns related to (LPN #4). 09/17/2025: Nursing staff education completed regarding narcotic documentation and PRN administration. 09/19/2025: Second ad hoc QAPI meeting confirmed termination for documentation falsification; no substantiation of diversion or resident harm. Late [DATE]: Independent pharmacy consultant audit completed; no diversion patterns identified. Controls are deemed effective. 10/01/2025: QAPI review of ADPH guidance. Leadership determined incident met threshold for credible allegation due to controlled substance documentation falsification. Allegation reported out of an abundance of caution. Ongoing: LPN #4 terminated and reported to Alabama Board of Nursing. Notifications completed. Continued audits, education, and QAPI monitoring implemented. ************************************************** Upon review and verification of the information provided in the facility's corrective action plan, in-service/education records, the facility's investigation, staff interviews as well as performing narcotic medication match backs, the survey team determined the facility implemented corrective actions from 09/11/2025 - 10/01/2025, with on-going monitoring implemented; thus, past noncompliance was cited.

Based on interviews, record review, review of Resident Identifier (RI) #81's hospital records, and review of a facility policy titled Medication Therapy, the facility failed to provide RI #81 care and treatment based on RI #81's hospital discharge orders, plan of care, and medications necessary to treat existing conditions and address significant risk. During record review surveyors discovered that on 02/20/2026 RI #81 was discharged from the hospital to the facility with discharge medications to include aspirin, 81 milligrams (mg) to be administered twice a day, recommended upon discharge for six weeks per orthopedic surgical consult following right femoral neck fracture and hemiarthroplasty (partial hip replacement). There was not any evidence that RI #81 received the aspirin as recommended. When RI #81 was readmitted to the facility, Licensed Practical Nurse (LPN) #9 notified the Medical Director (MD) who was RI #81's attending physician of RI #81's allergy to aspirin. The MD informed the nurse to discontinue the aspirin order, but he did not provide an order for alternate therapy. The MD and the facility failed to follow up with the surgeon for alternate medication therapy. There was not any evidence in RI #81's medical record of LPN #9's conversation with the MD and no evidence of determination of who was responsible for following up with the surgeon for an alternate to aspirin therapy.The facility failed to provide RI #81 alternate anticoagulant therapy for 20 days, until Eliquis was ordered on 03/12/2026 during the survey. This deficient practice affected RI #81, one of three residents reviewed for anticoagulant therapy. RI #81 not receiving anticoagulant therapy for 20 days, placed RI #81 at risk of developing a Deep Vein Thrombosis (DVT), a serious medical condition where a blood clot forms in a deep vein, usually in the legs and thighs, which could break loose and travel to the lungs causing Pulmonary Embolism (PE). Findings Include:Cross reference F710.The facility policy titled, Medication Therapy, with an effective date of 04/2024 included the following: Policy heading1.Each resident's medication regimen shall include . those medications necessary to treat existing conditions and address significant risk. 2. Medication use shall be consistent with an individual's conditions, prognosis .3. All medication orders will be supported by appropriate care processes and practices.Policy Interpretation and Implementation .5. The physician will identify situations where medications should be tapered, discontinued, changed to another medication, .RI #81 was originally admitted to the facility on [DATE] and was readmitted on [DATE] following hospital stay and a partial hip replacement after a Displaced Fracture of Base of Neck of Right Femur. A review of RI #81's hospital discharge summary with a discharge date of 02/17/2026 revealed the following: . Hospital Course with Significant Findings . Right Femoral Neck Fracture s/p (status post) Hemiarthroplasty . Orthopedic Surgery consulted: . recommend discharge on 6 (six) weeks of 81 mg aspirin twice daily . RI #81 was not discharged from the hospital until 02/20/2026.A review of RI #81's February 2026 Order Summary report (Physician orders) revealed RI #81's aspirin 81 mg, was to be given by mouth two times a day for DVT prevention for six weeks had been discontinued due to RI #81 being allergic to aspirin. RI #81's care plan with a focus area of anticoagulant therapy related to right femur fracture with an initiated date of 02/17/2026 documented an intervention to administer anticoagulant medication as ordered by the physician and monitor for side effects and effectiveness every shift. RI #81's physician order dated 03/12/2026 documented Eliquis oral tablet 2.5 mg (Apixaban), give one tablet by mouth two times a day had been confirmed by LPN #9.RI #81's February and March 2026 Medication Administration Records were reviewed and revealed no evidence RI #81 had received administration of anticoagulant medications or aspirin, from readmission on [DATE] until 03/12/2026. On 03/12/2026 at 12:01 PM the surveyor conducted an interview with LPN #9, regarding the care and treatment of RI #81. During the interview LPN #9 confirmed RI #81 had been prescribed aspirin 81 mg twice daily following discharge from the hospital for the purpose of DVT prevention. LPN #9 said the aspirin 81 mg was not administered because RI #81 had an allergy to aspirin. LPN #9 said she notified the physician who did not give her any new orders. LPN #9 said the importance of anticoagulant therapy was to prevent blood clots. LPN #9 said the potential harm of the resident not receiving anticoagulant therapy after surgery was stroke, heart attack, or pulmonary embolism that could lead to death. On 03/12/2026 at 2:46 PM the surveyor conducted a telephone interview with the attending physician /MD regarding the care and treatment of RI #81. The MD confirmed he had been notified by LPN #9 that RI #81 was readmitted to the facility on [DATE] with an order from the surgeon for aspirin. The MD said he did not give a new order for an anticoagulant because he needed to speak to the surgeon to see what the surgeon recommended. When asked if he spoke with the surgeon to see what was recommended, the attending physician said no, he thought the nurse was doing that. The MD said, when LPN #9 called him on 03/12/2026 was when he realized RI #81 was not on an anticoagulant and should have been. The MD said, not receiving anticoagulant therapy following surgery placed RI #81 at risk for complications, including the development of DVT below the surgical site, which could lead to pulmonary embolism. On 03/12/2026 at 3:34 PM the surveyor conducted an interview with the Interim Director of Nursing (IDON) regarding the care and treatment of RI #81. The IDON said the importance of obtaining a replacement anticoagulant medication for RI #81 was because of the hip fracture, and the risk was a blood clot. The IDON said aspirin being ordered after surgery would be to prevent a clot. The IDON said the concern with not receiving anticoagulant therapy after surgery was risk for DVT. On 03/31/2026 at 10:12 AM an interview was conducted with the Certified Nurse Practitioner (CRNP). When asked what the risk would be associated with a resident not receiving anticoagulant therapy for 20 days after surgery when it was recommended by the surgeon for six weeks, the CRNP said the risk to that would be DVT. The CRNP said with RI #81 in particular, if it was recommended by the Orthopedic Doctor it should have been carried out. On 03/31/2026 at 3:52 PM a follow-up interview was conducted with the IDON. When asked who identified that RI #81 was never on any type of anticoagulant therapy after his/her hip surgery was done, the IDON said she believed it was a state surveyor. The IDON said when it was identified that RI #81 was never on any type of anticoagulant therapy after his/her surgery, the nurse got in touch with RI #81's attending physician on 03/12/2026 and RI #81 was placed on anticoagulant therapy. When asked who else could or should have identified RI #81 was not receiving any type of anticoagulant therapy prior to the surveyor, the IDON said, the hall nurse. The IDON said everyone dropped the ball. The IDON said if it had been put in the nurses' note it would have been seen the next morning and could have received prompt follow up. The IDON said the facility failed to ensure continuity of care and medication changes were followed up with or documented so that RI #81 got the best care. On 03/31/2026 at 4:43 PM the surveyor conducted a telephone interview with the Clinical Pharmacist (CP). When asked what the risk could be for a resident not receiving anticoagulant therapy for 20 days after surgery, when it was recommended for six weeks, the CP replied, RI #81 could develop a DVT or PE. The CP said the resident would need to receive that therapy, especially if it was recommended. The CP said the resident could definitely develop a clot. On 04/01/2026 at 8:54 AM the surveyor conducted a telephone interview with RI #81's Orthopedic Surgeon. When asked what he would expect the facility staff to do if he ordered aspirin and the resident was allergic to aspirin, he replied, he expected the facility to call him or talk to the attending physician to get an alternate therapy. RI #81's Orthopedic Surgeon said he was never informed that RI #81 was allergic to aspirin. He further stated if he had been informed, he would have recommended RI #81 take Eliquis since RI #81 had an allergy to aspirin. When asked about the risk associated with not receiving anticoagulation therapy for 20 days after surgery when it was recommended for six weeks, he stated, increased risk for DVT.

Based on interviews, record review and review of facility policies titled Medical Director and Medication Therapy, the facility failed to ensure Resident Identifier (RI) #81's attending physician/MD (Medical Director) provided orders to meet RI #81's medical needs upon discharge from the hospital post arthroplasty with partial hip replacement. On 02/20/2026, the facility's attending physician was notified that RI #81 was allergic to aspirin which had been ordered by the Orthopedic surgeon. The attending physician failed to provide an order for RI #81 to receive alternate anticoagulant therapy or follow-up to ensure the prescribing surgeon was notified of RI #81's allergy to aspirin and the need for alternate therapy. Because of this failure RI #81 did not receive aspirin or anticoagulant therapy for 20 days after readmission, from 02/20/2026 until 03/12/2026 during the survey. This deficient practice affected RI #81, one of three residents reviewed for anticoagulant therapy. Failure of the attending physician to ensure alternate anticoagulant therapy was provided at the time of RI #81's readmission placed RI #81 at risk for developing a Deep Vein Thrombosis (DVT), a serious medical condition where a blood clot forms in a deep vein, usually in the legs and thighs, which could break loose and travel to the lungs causing Pulmonary Embolism (PE). Findings Include: Cross reference F684. Review of a facility policy titled, Medical Director, with an effective date of 02/2024, revealed the following: Policy Statement Physician services shall be under the supervision of the medical director. Policy Interpretation and Implementation1. Physician services are under the general supervision of the medical director.2. The medical director . is responsible for:a. ensuring adequate and appropriate physician services; .e. participating in efforts to improve quality of care and services; .3.Medical director functions also include, but are not limited to: .c. helping assure that residents receive adequate services appropriate to meet their needs; . Another facility policy titled, Medication Therapy, with an effective date of 04/2024, revealed the following: . Policy Interpretation and Implementation .5. The physician will identify situations where medications should be tapered, discontinued, or changed to another medication . A review of RI #81's Discharge summary, dated [DATE], revealed it was recommended by RI #81's Orthopedic surgeon that RI #81 be discharged back to the facility on aspirin 81 mg (milligrams) twice a day for six weeks. RI #81 was discharged back from the hospital on [DATE] with a diagnosis of Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. On 03/12/2026 at 12:01 PM an interview was conducted with Licensed Practical Nurse (LPN) #9. The LPN said on 02/20/2026 RI #81's aspirin order was discontinued because RI #81 was allergic to aspirin. LPN #9 said she was the one who called RI #81's attending physician and notified him of RI #81's allergy to aspirin. LPN #9 said RI #81's attending physician did not give her any other medication order. When asked what the potential harm of a resident not receiving an anticoagulant medication after surgery, LPN #9 said stroke, heart attack, pulmonary embolism which could lead to death. On 03/12/2026 at 2:46 PM a telephone interview was conducted with RI #81's attending physician. RI #81's attending physician said on 02/20/2026 LPN #9 did notify him that RI #81's Orthopedic surgeon had ordered aspirin and RI #81was allergic to aspirin. RI #81's attending physician said he did not order a new anticoagulant that day because he needed to speak to the surgeon to see what the surgeon recommend to replace the aspirin. RI #81's attending physician said he never spoke to the surgeon because he thought the nurse would notify the surgeon. RI #81's attending physician said it was an oversite, but RI #81 should have been on an anticoagulant. On 04/01/2026 at 8:54 AM a telephone interview was conducted with RI #81's Orthopedic surgeon. RI #81's Orthopedic surgeon said he was never notified RI #81 was allergic to aspirin. RI #81's Orthopedic surgeon said either the nurse or RI #81's physician could have notified him of the allergy. RI #81's Orthopedic surgeon said he probably would have ordered Eliquis. When asked what the risk would be for the resident not receiving anticoagulant therapy for 20 days after surgery when the recommendation was for anticoagulant therapy for six weeks, RI #81's Orthopedic surgeon said increased risk of DVT.

Based on interviews, record review and review of facility policies titled, Discontinued Medication and Charting and Documentation, the facility failed to maintain Resident Identifier (RI) #81's medical records in a manner to ensure the record was complete and accurately reflected RI #81's condition and consultation of RI #81's attending physician. Licensed Practical Nurse (LPN) #9 failed to document in RI #81's medical record when she notified the attending physician of RI #81's allergy to aspirin after RI #81 was readmitted on [DATE] from the hospital with an order for aspirin to be administered for six weeks. The facility failed to identify in RI #81's medical record what would be provided in place of the aspirin. This deficient practice affected RI #81, one of 18 residents for whom records were reviewed. LPN #9's failure to document in RI #81's medical records that RI #9's aspirin had been discontinued by RI #81's attending physician placed RI #81 at risk of not receiving continuity of care.Findings Include: Review of a facility policy titled Discontinued Medications with an effective date of 04/2024 revealed the following: . Policy Interpretation and Implementation1. A provider's order to discontinue a resident's medication is documented in the resident's clinical record .2. The nurse receiving the order to discontinue a medication is responsible for recording the information . A facility policy titled Charting and Documentation with an effective date of 01/2024 documented the following:Policy StatementAll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 1. Documentation in the medical record may be electronic, manual, or a combination.3. Documentation in the medical record will be objective . complete, and accurate.7. Documentation of procedures and treatments will include care-specific details, including: .f. notification of . physician or other staff if indicated . RI #81 was admitted to facility on 02/12/2025 and readmitted to the facility on [DATE] with a diagnosis of Displaced Fracture of Base of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. A review of RI #81's February 2026 Order Summary Report (Physician Orders) revealed RI #81's aspirin, 81 mg to be given two times per day for DVT prevention, had been discontinued due to RI #81 being allergic to aspirin. On 03/12/2026 at 12:01 PM LPN #9 said she notified RI #81's attending physician that RI #81 was allergic to aspirin when RI #81 was readmitted on [DATE]. When asked if she documented in RI #81's medical chart or clinical records when she notified RI #81's physician, LPN #9 said she did not. When asked why she did not document in RI #81's medical chart that she had notified RI #81's attending physician of RI #81's allergy to aspirin, LPN #9 said, she had given report to another nurse. LPN #9 acknowledged the importance of documenting in the medical chart to make sure other nurses were aware of a resident's allergies and orders given by the physician. On 04/02/2026 at 1:16 PM Registered Nurse (RN) #3 was asked where it would be documented when the nurse communicated with the physician. RN #3 replied, in the chart (nurses notes). RN #3 said it would be important to document the nurse's notes because if it was not documented, it was not done. RN #3 said documenting in the nurses' notes was important for other nurses to see changes that were made. On 04/02/2026 at 1:41 PM an interview was conducted with RN #14. When asked where it would be documented when the nurse communicated with the physician, RN #14 replied documentation would be under the progress notes. When asked why it would be important to document the progress notes, RN #14 replied, so other nurses knew what was going on. RN #14 further stated supervisors read the progress notes every morning to see if there had been any change in conditions. On 04/02/2026 at 3:10 PM an interview was conducted with LPN #16. When asked where it would be documented when the nurse communicated with the physician, LPN #16 said, in the nurses' or progress notes. LPN #16 said it would be important to document the nurses' notes to show continuity of care for the resident

Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, and review of a Facility Reported Incident (FRI) received by the State Agency (SA) on 10/01/2025 at 1:19 PM, the facility's Administrator (ADM) failed to ensure an allegation of misappropriation of resident property was reported to the SA in the required timeframe of 24 hours, when he was made aware on 09/11/2025 that Licensed Practical Nurse (LPN) #4 was falsifying residents' Controlled Drug Records (CDR) and failing to follow facility procedures related to handling, storage, disposal, and documentation of controlled substances designed to prevent drug diversion and protect resident safety. LPN #4 forged other nurses' signatures as witnesses of dropped medication disposal on Controlled Drug Records and LPN #4 signed out controlled medications on a Controlled Drug Record and failed to document them as administered on Medication Administration Records, per facility policy for evidence of administration.The facility failed to timely report one of three Facility Reported Incidents reviewed during the survey. This deficient practice had the potential to affect Resident Identifier (RI) #'s 99, 104, 105, and 85, four of 88 residents who resided at the facility.Findings Include:Cross-reference F602. Review of a facility policy titled Abuse, Neglect, Exploitation of or Misappropriation - Reporting and Investigating effective 06/2024 revealed the following: Policy StatementAll reports of resident abuse . or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current /regulations) . Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities .2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility;b. The local/state ombudsman; .e. Law enforcement officials; . 3. Immediately is defined as: .b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . On 10/01/2025 at 1:19 PM the SA received a FRI alleging the occurrence of misappropriation of resident property which the facility staff and Administrator became aware of on 09/11/2025 involving LPN #4.On 03/12/2026 at 8:58 AM an interview was conducted with the ADON/Interim DON. When asked how she was made aware of an incident where RI #4 had signed someone else's name by hers, indicating that narcotics for some residents had been dropped and the disposal was witnessed by other nurses, the Interim DON said she was first made aware when RN #3 notified her that morning. The Interim ADON said the affected residents were RI #99, RI #104 and RI #105. The Interim DON said the incident occurred back in September of 2025 and was reported to Alabama Department of Public Health (ADPH) on 10/01/2025. When asked, according to the facility's policy, what was the time frame for reporting incidents like this one to ADPH, the Interim DON said within 24 hours. The Interim DON said this incident was not reported in a timely manner. On 03/12/2026 at 10:52 AM an interview was conducted with the ADM. The ADM said one of his job responsibilities was to ensure the facility followed regulations. The ADM said he was made aware of an incident where LPN #4 signed someone else's name by hers indicating that narcotics for some residents had been dropped on 09/11/2025. When asked when the incident was reported to ADPH, the ADM said on 10/01/2025. The ADM said according to the facility's policy the time frame for reporting incidents like this one to ADPH was within 24 hours. When asked, according to regulations, if the incident was reported in a timely manner, the ADM said no. The ADM said, when a Quality Assurance and Performance Improvement (QAPI) meeting was conducted on 10/01/2025 the leadership team made the decision to report the incident as an allegation of abuse. ************************************************************The facility took the following corrective actions: ************************************************************* 9/11/2025 Incident regarding a nurse forging signatures - determination - not reportable. No reportables to ADPH in September, 2025 10/1/2025 QAPI mtg re 9/11/25 nurse forgery incident - updated determination - reportable as an allegation of abuse, potential misappropriation/drug diversion. No other reportables to ADPH in October, 2025 11/21/25 OCTOBER QAPI Meeting, Regulatory Compliance Monitoring began for reporting incidents to ADPH. No reportables in November, 2025 12/23/25 NOVEMBER QAPI Meeting, Continued Regulatory Compliance Monitoring for reportables to ADPH. No reportables in December, 2025 01/23/26 DECEMBER QAPI Meeting, Continued Regulatory Compliance Monitoring for reportables to ADPH. No reportables in January, 2026 02/19/26 January QAPI Meeting, Continued Regulatory Compliance Monitoring for reportables to ADPH. One (1) reportable in February, 2026 pertaining to abuse (misappropriation). Review revealed the incident was reported in a timely manner. 02/25/26 Ad hoc QAPI meeting re February reportable held, no concerns identified in reporting to ADPH in a timely manner. No other reportables at this time. ************************************************************* Upon review and verification of the information provided in the facility's corrective action plan, in-service/education records, the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 10/01/2025 to 02/25/2026, with on-going monitoring implemented; thus, past noncompliance was cited.

Based on medical record review and an interview, the facility failed to ensure Resident Identifier (RI) #1 had comprehensive care plans developed. This affected RI #1, one of three residents observed for care plans. Findings Include: RI #1 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 11/14/19 at 10:00 a.m., the surveyor reviewed RI #1's medical records and found baseline care plans, but no comprehensive care plans. On 11/14/19 at 10:07 a.m., the surveyor conducted an interview with EI #4, Licensed Practical Nurse/Minimum Data Set/Care Plan Nurse. The surveyor asked EI #4 when should a resident recevie a comprehensive care plan. EI #4 said if they were at the facility more than 21 days. EI #4 was asked when reviewing RI #1 care plans, what was noted. EI #4 said baseline care plans. EI #4 was asked when RI #1 was admitted on [DATE] and discharged on [DATE], should RI #1 have had a comprehensive care plan. EI #4 said yes, RI #1 was there more than 21 days. EI #4 was asked who was responsible for developing the comprehensive care plans. EI #4 said herself. This deficiency was written as a result of the investigation of complaint/report #AL 446.

Based on medical record reviews and interviews, the facility failed to ensure Resident Identifier (RI) #1's physician's orders regarding transfers to the potty chair were implemented. This affected RI #1, one of three residents sampled for following physician's orders. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE],with [DIAGNOSES REDACTED]. A review of RI #1's orthopedic orders, dated 07/11/19, revealed: .Work on transfers to potty chair . On 11/12/19 at 5:25 p.m., the surveyor conducted an interview with RI #1 and his/her spouse. RI #1 was asked when was the bedside commode bought to his/her room. RI #1 said on the day of discharge. RI #1 was asked when the bedside commode was brought to the room, who performed sliding board training to the bedside commode. RI #1 said no one. RI #1 was asked who brought the bedside commode to the room. RI #1 said Employee Identifier (EI) #3, a Certified Occupational Therapy Assistant. RI #1 and his/her spouse said they talked with EI #3 about the need to learn to use the sliding board for transfer on to the bedside commode because the wheelchair would not fit through their bathroom door. RI #1 was asked when was EI #3 made aware of the wheelchair not fitting through the bathroom door. RI #1 said from the start of therapy. On 11/13/19 at 11:50 a.m., the surveyor conducted an interview with EI #3. EI #3 was asked when RI #1's spouse gave her the physician orders on 07/11/19, what did she do with them. EI #3 said she gave a copy to the nurse and she kept a copy. EI #3 was asked what were the orders. EI #1 said the doctor prescribed a bedside commode. EI #3 was asked when did the sliding board training to the bedside commode begin. EI #3 said she did not start. EI #3 was asked why did the training not start. EI #3 said due to RI #1 being unable to maintain shifting weight from side to side to pull clothing up and down, it was her professional opinion this was an unsafe task. EI #3 was asked where was the evidence the physician was made aware of this task being unsafe at the time this order was written. EI #3 said she did not contact the physician because the spouse was keeping in contact with the physician. EI #3 was asked where was the proof RI #1's spouse was made aware of the physician orders not being followed. EI #3 said she talked to the spouse on the day the orders were received and she did not document their conversation. EI #3 was asked when did RI #1 receive a bedside commode. EI #3 said three days before discharging home. EI #3 was asked when did she perform sliding board transfer training to the bedside commode with RI #1. EI #3 said she did not perform transfer training due to the fact RI #1 was unable to void at the time the bedside commode was brought to the room. EI #3 was asked where was the proof RI #1 was educated on the reason the physician orders could not be followed. EI #3 said she did not document the reason; however, she did educate RI #1 on toilet use versus bedpan use. EI #3 was asked when talking with RI #1 and spouse, did they make her aware the wheelchair would not fit through their bathroom door. EI #3 said no. EI #3 was asked did she ask if the wheel chair would fit through their bathroom door. EI #3 said no. EI #3 was asked when a physician order was unsafe in her professional opinion, what should have happened. EI #3 said she should have called the orthopedic doctor, educated both parties and documented her rationale with safety on toilet use versus potty chair use. EI #3 was asked when she received the therapy orders and she felt they were unsafe, who did she tell. EI #3 said she was the therapy director and felt she was providing the best of care for the resident. On 11/14/19 at 11:15 a.m., the surveyor conducted an interview with EI #1, Nursing Home Administrator. EI #1 was asked when was he made aware of RI #1 receving a bedside commode. EI #1 said he learned about it on (MONTH) 29, 2019, during the morning meeting. EI #1 said they looked for a bedside commode with a drop arm and did not have one in the building so they ordered one. EI #1 was asked when a resident received an order from the orthopedic physician and the task was considered unsafe from a therapy assessment, what should have happened. EI #1 said it would be the same as other orders, the interdisciplinary team should have reviewed the orders, consulted with the ordering doctor and the attending for clarification. EI #1 was asked where would the proof be found clarifying the order. EI #1 said he did not know. This deficiency was written as a result of investigation of complaint/report #AL 446

Based on observation, interview, the (YEAR) Food Code, the facility's policy titled, Cleaning Dishes/Dish Machine, and a review of the Low Temp (temperature) Dish Machine Temp, log, the facility failed to: 1. prevent potential cross-contamination by staff during dishwashing (staff going from the dirty side to the clean side without washing hands) and by not ensuring the dishwashing sanitizer was checked before washing breakfast dishes on 9/11/18; 2. ensure accurate documentation on the dishwasher sanitizer log for breakfast dishwashing during (MONTH) (YEAR); 3. prevent potential cross-contamination by not ensuring air gaps existed between the floor drains and the drain pipes for the pot and pan sinks, the dishmachine, and the food preparation sinks and 4. prevent potential cross-contamination by allowing a build-up of dust on the ceiling and fan unit of the walk-in cooler. This had the potential to affect all 94 of 94 residents receiving meals from the kitchen. Findings Include: 1. The facility's policy titled, Cleaning Dishes/Dishmachine, with a date of 2013, included: . Policy: All flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitation. Procedure: 1. Prior to use, run the machine until verification of proper temperatures and machine function is made. 6. The person loading dirty dishes should not handle the clean dishes unless they change into a clean apron and wash hands thoroughly before moving from dirty to clean dishes. Note: . Those machines installed after the Food Code 2001 was implemented must automatically dispense . sanitizers, and must incorporate visual means or other visual audible alarm to alert the user to any concerns (such as .sanitizer not dispensing properly). The (YEAR) Food Code recommendations of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration included: . 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: . (C) Chemical . mechanical operations, including the application of SANITIZING chemicals by . pressure spraying methods . (2) . a chlorine solution of 50 mg (milligrams)/(per) L (liter) . On 09/11/18 at 8:54 AM, the surveyor observed dishwashing in the dishroom by Dietary Aides, Employee Identifier (EI) #8 and EI #9. EI #8 was scraping food off dirty dishes and went to the clean side of the dishmachine to pull a rack of clean dishes free of the dishmachine handle. EI #8 asked if he did something wrong when the surveyor asked him his name. When the surveyor said he went from the dirty to the clean side. EI #8 said he only touched the rack. When asked what would be the problem with that, EI #8 said cross-contamination. EI #9 was asked to check the chemical concentration of the dishmachine. Using the chlorine test strips, EI #9 found the chlorine concentration to be 10 PPM (parts per million which is equivalent to mg/L). When asked what should the strip indicate for an acceptable chlorine concentration, both EI #8 and EI #9 said at least 100 PPM. EI #9 said Maintenance needed to be called and asked EI #6, the (DM) Dietary Manager, to get Maintenance to come check the dishmachine. When asked what the chlorine concentration was earlier that morning, EI #9 said it was not checked. The surveyor looked at the posted dishmachine log sheet, Low Temp Dish Machine Temp, and saw the following numbers recorded for breakfast on 9/11/18, as initialed by EI #8: Temp 120, Temp 133, PPM 135. 2. On 09/11/18 at 9:03 AM, EI #8 was interviewed about the numbers recorded on the dishmachine log for the morning of 9/11/18, and for his previous breakfast documentation, from 9/6/18 through 9/10/18. EI #8 said the first temperature number was for the wash temperature and the second was for the rinse temperature. When asked how he got the number of 135 for PPM, EI #8 said he recorded the number from the pressure gauge on the machine to get the PPM. On 09/11/18 at 09:04 AM the surveyor asked EI #6 for a copy of the posted dishmachine log sheet. The Low Temp Dish Machine Temp log for (MONTH) (YEAR), included the following documentation for PPM by EI #8 for breakfast: 9/6/18 - 135 9/7/18 - 132 9/8/18 - 135 9/9/18 - 135 9/10/18 - 135 9/11/18 - 135 In addition, there was no PPM recorded for breakfast on 9/2/18. During an interview on 09/12/18 at 11:18 AM, EI #6, DM said the dishmachine repairman told her that the dishmachine's cylinder had burned out and it was not pulling up the chlorine sanitizer. When asked how long this had been an issue, EI #6 said it had to be after the evening of 9/10/18, because EI #6 said she had checked the chlorine concentration that evening and, although she did not record it, it was within normal limits. EI #6 further said EI #10, a dietary aide, had checked the chlorine concentration later that evening and recorded it on the log as indicated by EI #10's initials. The Low Temp Dish Machine Temp log for dinner on 9/10/18, showed documentation for 100 PPM. Upon being asked what was the problem with the dishmachine not dispensing the chlorine sanitizer, EI #6 said germs and the dishmachine was not sanitizing the dishes. When asked how would the residents be affected, EI #6 said they possibly could have gotten sick. 3. The (YEAR) Food Code recommendations of the U.S. Public Health Service and the U.S. Food and Drug Administration included: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 09/11/18 at 8:50 AM, an observation of the three-compartment pot and pan sink revealed it had two drain pipes that extended into the floor drain. There was no air gap between the end of the drain pipes and the top of the floor drain. On 09/12/18 at 11:29 AM, the drain from the dishmachine tank was observed to be protruding into the floor drain. There was no air gap between the end of the drain pipe and the top of the floor drain. On 09/12/18 at 12:37 PM, EI #12, Maintenance Technician, used a measuring tape to obtain the following: a.) the pot and pan sink had two drain pipes. One extended three and one-half inches from the top of floor drain and down into the floor drain and the other extended six to six and one-half inches from the top of the floor drain and down into the floor drain; b.) the dishmachine drain pipe extended five inches from the top of the floor drain and down into the floor drain and c.) the preparation sink drain was extended one and one-half inches from the top of the floor drain and down into the floor drain. On 09/12/18 at 12:50 PM, EI #13, the Maintenance Supervisor, entered the kitchen. EI #13 did not understand the air gap problem affecting the sinks and dishwasher and was going to consult with a plumber. On 09/12/18 at 12:54 PM, EI #7, the Regional District Manager for the food service management company, was interviewed. When asked about the importance of an air gap for drains, EI #7 said an air gap could prevent a backwash/back siphoning of dirty water. EI #7 was shown the washing and food preparation sink drain pipes extending into the floor drains. EI #7 said it was a problem because any sewage water could back up into the drain pipes and thereby contaminate the sinks and the dishmachine. 4. The (YEAR) Food Code recommendations of the U.S. Public Health Service and the U.S. Food and Drug Administration included: . 3-305.11 Food Storage. (A) .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to . dust, or other contamination; . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 09/11/18 at 8:41 AM, an observation was made of the walk-in cooler, which contained lettuce, desserts, deli meat, milk, and juice. Small clumps of grey material were observed on the ceiling of the walk-in cooler. EI #6, the Dietary Manager, was able to remove some of the grey clumps with a paper towel. EI #6 said it was dust and it should not be there. The grey material/dust was also on the sides and front of the fan unit in the walk-in cooler. When questioned, EI #6 did not think the dietary staff normally cleaned the ceiling of the walk-in cooler. EI #6 said Maintenance should be cleaning the fan housing, but did not know when the cleaning had last been done or if Maintenance was actually assigned to do it. EI #6 was asked what was the problem with the dust build-up in the walk-in cooler. EI #6 said possible cross-contamination, as the dust might get into the food.

Based on interview, record review and a review of the facility's policy titled, Resident Rights, the facility failed to ensure the business office staff did not open a letter addressed to RI (Resident Identifier) #35. This affected RI #35, one of one sampled resident whose mail was received opened by the facility. Findings Include: A review of an undated facility policy titled, Resident Rights revealed: 7. Information and communication. .i. The resident has the right to .receive mail, and to receive letters .including the right to: i. Privacy of such communications . RI #35 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #35's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/03/18, revealed RI #35 had a BIMS (Brief Interview For Mental Status) score of 15, which indicated RI #35 was cognitively intact. On 09/11/18 at 3:47 PM, during an interview, RI #35 told the surveyor he/she cashed in his/her daughter's burial policy from the insurance company and was waiting on the check. RI #35 said when the check did not come, he/she called the insurance company and they said they would send another check. RI #35 said he/she went to the business office a few days later and told them he/she was still waiting on the check, and to be on the look out for it. RI #35 said that was when EI (Employee Identifier) #5, Business Office Manager, said it had already come and they had opened it, stamped it and put it into the Medicaid account. On 09/12/18 at 10:53 AM, an interview was conducted with EI #5. EI #5 was asked if she received resident's mail. EI #35 said not normally. EI #5 was asked if she ever received mail addressed to RI #35. EI #5 said last week it (the mail) was opened by mistake. EI #5 said they thought it was an invoice because they paid RI #35's bills. EI #5 was asked when did RI #35 receive the mail that had been opened. EI #5 said probably the next day. EI #5 was asked who should have been the one to open that particular item of mail. EI #5 said the resident should have.

Based on observation, interview, medical record review, and the facility's menu, the facility failed to ensure the pork chops served to residents for lunch on 9/11/18, were not hard and dry. This affected Resident Identifier (RI) #65, RI #241, and RI #35, three of 94 residents receiving lunch meal trays from the Dietary department on 9/11/18. Findings Include: The facility's lunch menu for Tuesday on Week #2 indicated a 3-ounce Pork Cutlet was to be served on the Regular diet trays. 1) RI #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On the quarterly Minimum Data Set (MDS), dated [DATE], RI #65's Brief Interview for Mental Status (BIMS) score was 15, which indicated RI #65 was cognitively intact. RI #65's Physician order [REDACTED]. 5/02/18 . DIET: REGULAR, CCD (Consistent Carbohydrate Diet) . On 9/11/18 at 12:40 PM, RI #65 stated he/she did not eat lunch because the pork chop was hard and dry. RI #65 further said he/she could not cut the pork chop with the knife and asked the CNA (Certified Nursing Assistant) to cut it, but the CNA also was unable to cut the pork chop. 2) RI #241 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #241's Physician order [REDACTED]. 9/06/18 . DIET: REGULAR . The Admission Nursing Evaluation, dated 9/6/18, assessed RI #241 as being alert and oriented to self, time, and place. On 9/11/18 at 2:48 PM, RI #241 told the surveyor the pork chop was dry and tough at lunch that day. 3) RI #35 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. On the quarterly MDS, dated [DATE], RI #35's BIMS score was 15, which indicated RI #35 was cognitively intact. RI #35's Physician order [REDACTED]. 10/23/17 . DIET: REGULAR . On 9/11/18 at 12:55 PM, RI #35 requested the State surveyors to come see his/her tray. RI #35 said the pork chop was hard and dry. The pork chop did appear dried out to the surveyor. With RI #35's permission, the surveyor attempted to cut the pork chop with a table/butter knife and the knife bowed when pressure was applied to the pork chop. The pork chop was extremely hard to cut. At 1:02 PM, RI #35 used the call light. A CNA responded immediately and RI #35 requested to see someone from the Dietary department. At 1:04 PM, Employee Identifier (EI) #6, the Dietary Manager, and EI #7, the Regional District Manager for the food service management company, responded. They listened to RI #35's complaint about the pork chop. On 09/11/18 at 3:55 PM, EI #6 was interviewed. When asked if anyone complained about the pork chops served at lunch that day, EI #6 said RI #35 was the only one she was aware of who had a complaint about the pork chop, and she had been called to RI #35's room. EI #6 stated RI #35 said the pork chop was hard and overcooked. When asked how RI #35's pork chop looked to her, EI #6 said the pork chop did appear to be overcooked. On 9/11/18 at 4:06 PM, EI #7 was interviewed. When asked if anyone complained about the pork chops served at lunch that day, EI #7 said, not that she had heard of, except for RI #35. When asked how RI #35's pork chop looked to her, EI #7 said it did look a little dry.

Based on observations and interviews the facility failed to ensure the grease container was free of grease like substance on the left top side of the container, at the opening of the container, the front side of the container and on the ground. This was observed on 8/8/2017. This affected one of one grease container observed and had the potential to affect all residents residing in the facility Finding Include: On 8/8/2017 at 7:50 a.m., the surveyor observed grease on the left side of the container, at the opening of the container, at the front side of the grease container, and on the ground. On 8/9/2017 at 4:35 p.m., an interview was conducted with EI #9, Dietary Manager. EI #9 was asked what was on the side and front side of the grease container. EI #9 replied, it looked like grease and dirt. EI #9 was asked why was it there. EI #9 replied, employee neglect. EI #9 was asked who was responsible for making sure the grease container was cleaned. EI #9 replied, maintenance. EI #9 was asked when was the grease container cleaned last. EI #9 replied, she did not know. EI #9 was asked what was the facility policy regarding the cleanliness of the grease container. EI #9 replied, she never seen a preventive maintenance schedule. EI #9 said dietary never cleaned. EI #9 was asked what was the potential harm when grease was on the front and side of the grease container. EI #9 replied, rodents, flies and accidents. On 8/10/2017 at 9:15 a.m. an interview was conducted with EI #13, Maintenance Director. EI #13 was asked who was responsible for making sure the grease container was cleaned. EI #13 replied, dietary was supposed to write up a ticket and maintenance would clean. EI #13 was asked what was the facility policy regarding the cleanliness of the grease container. EI #13 replied when it is wrote up, we will clean it. EI #13 was asked when was the grease container cleaned last. EI #13 replied six months ago.

Based on observations, interviews and a review of the facilities policies DIETARY FOOD STORAGE, DIETARY HANDWASHING, DIETARY SANITATION, DIETARY SILVERWARE, and DIETARY DRY STORAGE AREA, the facility failed to ensure: 1. dietary staff washed their hands when entering the kitchen, 2. a food item in the freezer was labeled, 3. cups were free of a white like substance, 4. a knife, spoon and fork was not wet in a utensil bag, 5. food items in dry storage were sealed properly and 6. a food item in dry storage had a used by date. This affected 88 of 91 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, DIETARY FOOD STORAGE with a revised date of 07/14 revealed: .Procedure .Hands must be washed .prior to handling food items . A review of a facility policy titled, DIETARY HANDWASHING with a revised date of 07/14 revealed: Policy Dietary staff will wash hands .when returning to work . On 8/8/2017 at 7:50 a.m., the surveyors entered the kitchen with the dietary manager, (Employee Identifier) EI #9. The surveyors washed their hands at the employee handwashing sink. EI #9 did not wash her hands. On 8/9/2017 at 3:43 p.m., the surveyor conducted an interview with EI #9. EI #9 was asked when should she wash her hands in the kitchen. EI #9 replied, anytime you smoke, go to the bathroom, when they wipe their hands across their nose, when they sneeze and anytime they go from one job to another. EI #9 was asked why should she wash her hands in the kitchen. EI #9 replied, infection control and good hygiene. EI #9 was asked did she wash her hands on 8/8/2017 after entering the kitchen with the surveyors. EI #9 replied, she did not remember. EI #9 was asked did she enter the freezer and touch a bag of food. EI #9 replied, she grabbed the food item and gave it to an employee. EI #9 was asked what was the facility policy on washing hands when entering the kitchen. EI #9 replied, wash her hands when entering dietary and before she did anything else. EI #9 was asked what was the potential harm when entering the kitchen and start handling food and she did not wash her hands. EI #9 replied, germs, bacteria and contamination. 2) A review of a facility policy titled, DIETARY FOOD STORAGE with a revised date of 07/14 revealed: . Procedure .7. Leftover food .is clearly labeled and dated . On 8/8/2017 at 7:50 a.m., the surveyors observed a large plastic bag in the freezer on the bottom shelf. The bag had no information on it. The surveyors could not tell what the meat product was. On 8/9/2017 at 3:52 p.m., the surveyor conducted an interview with EI #9. EI #9 was asked what food item in the freezer was not labeled. EI #9 replied, chicken. EI #9 was asked who was responsible for labeling food items in the freezer. EI #9 replied, all staff, assistant dietary manager was responsible when groceries come in. EI #9 was asked why should food items be labeled. EI #9 replied, to know what they were and how long they had to use them. EI #9 was asked what label information was on the bag of chicken. EI #9 replied, nothing. EI #9 was asked what was the potential harm when there was no label on a food item. EI #9 replied, it could be mistaken for a different item. EI #9 said when there was no label they did not know when they needed to expose of it. 3) A review of a facility policy titled, DIETARY SANITATION with a revised date of 07/14 revealed: .Procedure .Plastic ware .that cannot be sanitized or are hazardous . or loss of glaze shall be discarded . On 8/8/2017 at 11:02 a.m., the surveyor observed six cups with a white like substance in them. The cups were used to serve coffee. On 8/9/2017 at 4:05 p.m., the surveyor conducted an interview with EI #9. EI #9 was asked what did she see in the cups that were used to serve coffee in. EI #9 replied, lime build up. EI #9 was asked why was it there. EI #9 replied, it should not be there. EI #9 replied, it needed to be scrubbed. EI #9 was asked who was responsible for making sure cups were free of a white like substance. EI #9 replied, dietary manager, dietary assistant or whatever employee was assigned on that shift. EI #9 was asked what did the facility policy say regarding cleaning white substance in cups. EI #9 replied, white substance should not be in there. EI #9 said they should be cleaned on a regular basis. EI #9 was asked when were the cups cleaned last. EI #9 replied, on August 3, 2017. EI #9 was asked what was the potential harm when the residents were given cups with a white like substance in them. EI #9 replied, it could make the residents sick. On 8/10/2017 at 10:40 a.m., the surveyor conducted an interview with EI #11, the cook. EI #11 was asked what did she see in the cups that were used to serve coffee. EI #11 replied, a white powder substance. EI #11 was asked why was it there. EI #11 replied, we kept sending them through the dish washer and did not hand wash them. EI #11 was asked who was responsible for making sure cups were free of a white like substance. EI #11 replied, everyone in dietary. EI #11 was asked when washing the cup did the white substance come out. EI #11 replied, yes ma'am. 4) A review of a facility policy titled, DIETARY SILVERWARE with a revised date of 09/13 revealed: .Procedure .6. Remove from dishmachine and air dry . On 8/8/2017 at 11:02 a.m., the surveyor observed an adaptable fork, knife and spoon in a utensil bag with water on each utensil. On 8/9/2017 at 4:12 p.m., the surveyor conducted an interview with EI #9, dietary manager. EI #9 was asked what was on a knife, a spoon and fork inside of a utensil bag. EI #9 replied, water. EI #9 was asked who was responsible for putting the utensils in the utensil bags. EI #9 replied, the aide two and four. EI #9 was asked how should utensils be allowed to dry. EI #9 replied, air dry. EI #9 was asked when should utensils be placed in a utensil bag. EI #9 replied, when they were totally dry. EI #9 was asked what was the facility policy regarding giving wet utensils to the resident. EI #9 replied, we were not to give wet utensils to the residents. EI #9 was asked what was the potential harm when residents were given wet silverware in a utensil bag. EI #9 replied, bacteria can grow. 5) A review of a facility policy titled, DIETARY DRY STORAGE AREA with a revised date of 07/14 revealed: .Procedure .13. Containers with tight-fitting covers should be used .dried vegetables . A review of a facility policy titled DIETARY FOOD STORAGE with a revised date of 07/14 revealed: .Procedure .7. Leftover food is stored in covered containers or wrapped carefully and securely . On 8/8/2017 at 7:50 a.m., the surveyor observed a 25 pound bag of rice and beans opened at the top. The product was not properly sealed. At the bottom of the shelf on the floor was two dead c[DIAGNOSES REDACTED]. The surveyor observed chocolate chip cookies in a zip lock bag and the bag was opened. On 8/9/2017 at 4:22 p.m., the surveyor conducted an interview with EI #9. EI #9 was asked what items in dry storage was not sealed properly. EI #9 replied, chocolate chip cookies and rice and beans. EI #9 was asked why were they opened. EI #9 replied, employee neglect. EI #9 was asked who was responsible for making sure items were sealed after opening. EI #9 replied, all staff. EI #9 was asked what did the facility policy say on how to seal food items once opened. EI #9 replied, placed bulk items in container/rice and beans. EI #9 replied, cookies in a zip lock bag and close. On 8/10/2017 at 10:32 a.m., the surveyor conducted an interview with EI #10 assistant dietary manager. EI #10 was asked what items in dry storage was not sealed properly. EI #10 replied, great northern beans. EI #10 was asked who was responsible for making sure items were sealed properly. EI #10 replied, me assistant manager/cook. EI #10 was asked what did the facility policy say on how to seal food items once opened. EI #10 replied, put in a zip lock air tight bag and date. EI #10 was asked what was the potential harm when food items were not sealed properly. EI #10 replied, bacteria and rodent. 6) A review of a facility policy titled, DIETARY FOOD STORAGE with a revised date of 07/14 revealed: . Procedure .8 .f. All food should be covered, labeled and dated . On 8/8/2017 at 7:50 a.m., the surveyor observed a box of cake mix opened with no use by date. On 8/9/2017 at 4:30 p.m., the surveyor conducted an interview with EI #9. EI #9 was asked what item in dry storage did not have a use by date. EI #9 replied, cake mix. EI #9 was asked who was responsible for labeling. EI #9 replied, anybody that opened and used that product. EI #9 was asked why should food items be labeled with a use by date. EI #9 replied, to prevent spoilage.

Based on record reviews and interviews, the facility failed to ensure the Pharmacist identified Resident Identifier (RI) #10 with an allergy of Lyrica, a medication listed on the face sheet and physician orders [REDACTED]. Findings Including: A review of a facility policy titled, PHARMACY PHYSICIAN DRUG ORDERS with a revised date of 07/14 revealed: .Procedure .7. Drug and biological orders must be recorded on the physician's orders [REDACTED]. Such orders are reviewed by the pharmacist on a monthly basis. RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10 most recent yearly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/22/2017 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicates the resident is capable of making decisions. A review of the RI #10's history and physical document from the hospital on [DATE] indicated RI #10 was allergic to Lyrica. A review of the RI #10's Physician order, an order was written on 5/16/17 for the drug Lyrica 100 mg two times a day. A review of the physician order [REDACTED].>A review of RI #10's August 2017 eMar (electronic medication administration record) Lyrica was given BID (two times a day). On 8/9/2017 the surveyor conducted an interview with RI #10. RI #10 was asked did he/she have any unsteadiness, muscle pain, weakness, swelling of hand and feet, back pain, dizziness and weight gain. RI #10 replied, yes. On 8/10/2017 at 11:15 a.m., interview was conducted with EI #14 LPN (Licensed Practical Nurse). EI #14 was asked did she give RI #10 Lyrica this morning. EI #14 replied, yes. EI #14 was asked what drug was RI #10 allergic to. EI #14 replied, Amoxicillin, Lyrica, Penicillin and Prednisone. EI #14 was asked how long had RI #10 used Lyrica. EI #14 replied, since 5/16/2017. EI #14 was asked was it standard practice to give a resident a drug he/she was allergic to. EI #14 replied, no ma'am. EI #14 was asked what was the potential harm in given a resident a medication he/she was allergic to. EI #14 replied, they could have anaphylactic reaction and all kind of stuff. On 8/10/2017 at 11:30 a.m., the surveyor conducted an interview with EI #1, DON (Director of Nursing). EI #1 was asked was it standard practice to give a resident a drug he/she was allergic to. EI #1 replied, no. EI #1 was asked what drug was RI #10 taking that he/she was allergic to. EI #1 replied, Lyrica. EI #1 was asked what was the potential harm in giving a drug to a resident that he or she was allergic to. EI #1 replied, possible adverse reaction. On 8/10/2017 at 12:00 p.m., the surveyor conducted an interview with EI #15, Nurse Practitioner. EI #15 was asked who was responsible for making sure a resident did not receive a drug he/she was allergic to. EI #15 replied, we all were. EI #15 stated the nurse, nurse practioner and pharmacist. EI #15 was asked what was the potential harm when a resident was given a drug he/she was allergic to. EI #15 replied, short of breath, heart issues and allergic reaction. EI #15 was asked did she review allergy list before writing a prescription. EI #15 replied yes. On 8/10/2017 at 2:20 p.m., the surveyor conducted an interview with EI #16, pharmacist. EI #16 was asked when he came to the facility what did he review. EI #16 replied, charts reviews, audits, narcotic destruction, med pass reviews observation and anything else that need to be done. EI #16 was asked did he review patient medication and what they were allergic to. EI #16 replied, the dispensing pharmacy run allergic reports. EI #16 was asked did he read hospital history and physical. EI #16 replied, he did look at diagnoses. EI #16 was asked what was the potential harm when a resident received a drug he/she was allergic to. EI #16 replied, nausea, vomiting, rash, diarrhea, and constipation. EI #16 was asked who was responsible for making sure a resident did not receive a drug he/she was allergic to. EI #16 replied, the physician who wrote the prescription, the pharmacy dispensing the drug, the facility when transcribing the order and the pharmacist when he come in to review.

Based on observation, interview, record review and review of a facility policy NURSING INJECTION/INSULIN, the facility failed to ensure licensed staff provided privacy by closing the door to the hallway when giving Resident Identifier (RI) #12's insulin injection on 8-8-2017. This affected one of five nurses observed for medication pass. Findings Include: A review of facility policy NURSING INJECTION/INSULIN with a revised date of 07/14 revealed: Policy . Procedure to administer an insulin injection. 1. Bring equipment to bedside and screen resident for privacy. RI #12 was readmitted to the facility 3/31/17 with a [DIAGNOSES REDACTED]. A review of RI #12's August 2017 Physician order [REDACTED]. On 8/8/17 at 3:50 p.m., Employee Identifier (EI) #8, Registered Nurse (RN), was observed preparing PM medications for RI #12. EI #8 prepared medications to include [MEDICATION NAME] 70-30 Insulin Injection of six units. EI #8 went in RI #12's room and gave the by mouth medications. EI #8 washed her hands and donned gloves then gave the insulin to RI #12. EI #8 did not provide privacy by closing the room door to the hallway nor closing the blinds or privacy curtains. On 8/8/17 at 4:00 p.m., an interview was conducted with EI #8. EI #8 was asked what the policy was for giving insulin medication. EI #8 replied she should provide privacy, however those residents preferred the curtain not be pulled between them. EI #8 was asked if she closed the door to the hallway. EI #8 replied no. EI #8 was asked if she should provide privacy; she replied yes. EI #8 was asked what the harm was in not providing privacy. EI #8 replied, not treating RI #12 with dignity. On 8/9/17 at 2:40 p.m., an interview was conducted with EI #2, Assistant Director of Nursing. EI #2 was asked if privacy should be provided while giving a resident an insulin injection. EI #2 replied yes. EI #2 was asked how should privacy be provided. EI #2 replied, by pulling the privacy curtains, closing the blinds and closing the room door. EI #8 was asked if privacy should be provided to a resident if both residents agree to not pulling the privacy curtain between them. EI #8 replied the door to the hallway should be closed. EI #8 was asked what the harm was in not providing privacy to a resident during giving an insulin injection. EI #8 replied, it would be a dignity issue and could be violation of privacy.

Based on observations, interview, record review and review of a facility policy titled CERTIFIED NURSING ASSISTANT (CNA) MEAL SERVICE, the facility failed to ensure a CNA, Employee Identifier (EI) #4 did not stand while feeding Resident Identifier (RI) #2 the lunch meal on 08/08/17. This deficient practice affected RI #1, one of four residents observed for assistance with meals. Findings Include: A facility policy titled CERTIFIED NURSING ASSISTANT MEAL SERVICE, with a revised date of 07/14, documented: . If the resident requires feeding assistance with meals: . 7. Bring a chair to the bedside and sit at eye level with the resident . RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment with an Assessment Reference Date of 07/21/17, assessed RI #2 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. RI #2 was also assessed as being totally dependent on staff for eating with one person physical assist. On 08/08/17 at 1:22 p.m., the surveyor observed EI #4 standing while feeding RI #2 the lunch meal. On 08/08/17 at 1:36 p.m., the surveyor observed that EI #4 stood the entire time she was feeding RI #2 the lunch meal. On 08/09/17 at 2:09 p.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4, on yesterday (08/08/17) when she fed RI #2 the lunch meal, what position was she in. EI #4 said she was standing. The surveyor asked EI #4 what position should she have been in. EI #4 replied, Sitting. The surveyor asked EI #4 what type concern was it when you stood while feeding a resident. EI #4 said it was a dignity issue.

Based on record review, interview and review of facility policy NURSING MDS 3.0 COMPLETION the facility failed to ensure Resident Identifier (RI) #10's 6-22-2017 Annual Minimum Data Set (MDS) was coded to reflect a fall on 6-21-2017. This affected one of 16 MDSs reviewed. Findings Include: A review of facility policy NURSING MDS 3.0 COMPLETION with a revised date of 07/14 revealed: . III. Assessment Reference Date .b) The last day of MDS Observation Period: date refers to a specific endpoint in the MDS assessment process . c). Observation should continue through the assessment reference date at midnight. RI # 10 was admitted to the facility 6/16/16 with a [DIAGNOSES REDACTED]. A review of a facility Resident Incident Report revealed: RI #10 fell [DATE] at 3:00 PM . A review of RI #10's Annual MDS with and Assessment Reference Date of 06/22/2017 Section J indicated RI #10 had Falls since admit/reentry/prior assessment: any falls No . On 8/10/2017 at 11:50 a.m., an interview was conducted with Employee Identifier (EI) #3, MDS/Care Plan Coordinator. EI #3 was asked when did RI #10 have a fall. EI #3 replied 6/21/17 at 3:00 p.m. EI #3 was asked when was the next MDS done. EI #3 replied 6/22/17. EI #3 was asked if the fall on 6/21/17 was captured on the 6/22/17 MDS. EI #3 replied no, it was coded with a 0. EI #3 was asked if the fall on 6/21/17 should have been coded on the 6/22/17 MDS. EI #3 replied yes. EI #3 was asked if the MDS dated [DATE] was considered accurate. EI #3 replied no.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #2's Fall care plan was updated after RI #2 had a fall on 05/31/17. This deficient practice affected RI #2, one of 16 sampled residents whose plan of care was reviewed. Findings Include: RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #2's Departmental Notes (Nurses Notes) dated 05/31/2017 at 6:50 a.m., documented: . Resident noted at 5:10 am (a.m.) to be lying pron (prone) in the hallway in front of (his/her) w/c (wheelchair) . RI #2's Incident Investigation report, dated 05/31/17, documented: . Intervention to Prevent Reoccurrence: . resident will be up to nurses desk in w/c for observation whenever staff has him/her out of bed . This interventions was initiated by Employee Identifier (EI) #6, the Licensed Practical Nurse (LPN) assigned to care for RI #2 when the resident fell on [DATE]. RI #2's Post-Incident Actions report dated 05/31/17, documented: . Immediate Post-Incident Action: WHEN RESIDENT IS IN W/C (HE/SHE) WILL BE PLACED AT NURSES DESK FOR OBSERVATION . A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 07/21/17, assessed RI #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. Under Section J - Health Conditions, RI #2 was also assessed as having had one fall with no injury since admit/reentry/prior assessment during this assessment period. A review of RI #2's Fall care plan titled I am at risk for falls r/t (related to)[MEDICAL CONDITION](Cardiovascular Accident), (R) (right) side Hemiplega ([MEDICAL CONDITION])/ weakness/impaired mobility with a Problem Onset Date of 07/21/17 revealed RI #2's Fall care plan had not been updated to reflect the approach to have RI #2 up to nurses desk in w/c for observation whenever staff has him/her out of bed after RI #2 fell on [DATE]. On 08/10/17 at 11:17 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6, according to RI #2's incident report, what intervention was put in place after RI #2 fell on [DATE]. EI #6 said it was said anytime RI #2 was up they (facility staff) would keep RI #2 around the nursing desk for observation when RI #2 was in the wheelchair. The surveyor asked EI #6 was the intervention placed on RI #2's care plan, EI #6 replied, No. On 08/10/17 at 1:34 p.m., the surveyor conducted an interview with EI #3, the MDS/Care plan Coordinator. The surveyor asked EI #4 what was the intervention after RI #2 fell on [DATE]. EI #4 said there were no new interventions on the care plan at that time. The surveyor asked EI #4, according to the nurses immediate post incident action, what was the intervention. EI #4 replied, When in W/C (he/she) will be placed at nurses desk for observation. The surveyor asked EI #4 should that intervention have been carried over to the care plan. EI #4 said, Yes Ma'am.

Based on interviews and record review, the facility failed to ensure the intervention to have Resident Identifier (RI) #2 at the nurses station when up in the wheelchair (w/c) was implemented after RI #2 had a fall on 05/31/17. On 07/31/17, while up in a wheelchair in the resident's room, RI #2 experienced a fall from the wheelchair. This deficient practice affected RI #2, one of seven residents sampled for falls. Findings Include: RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 07/21/17, assessed RI #2 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. Under Section J - Health Conditions, RI #2 was also assessed as having a fall with no injury since admit/reentry/prior assessment during this assessment period. RI #2's Incident Investigation report, dated 05/31/17, documented: . Intervention to Prevent Reoccurrence: . resident will be up to nurses desk in w/c for observation whenever staff has him/her out of bed . This interventions was initiated by Employee Identifier (EI) #6, the Licensed Practical Nurse (LPN) assigned to care for RI #2 when the resident fell on [DATE]. RI #2's Resident Incident Report, dated 07/31/17, documented: . Incident Type: Found on Floor . Location: Resident room . Narrative of incident and description of injuries: Resident found on floor with right side of face against the floor with wheelchair turned over ontop of (him/her) . On 08/10/17 at 11:46 a.m., the surveyor conducted an interview with Employee Identifier (EI) #12, the CNA assigned to care for RI #2 on 07/31/17. The surveyor asked EI #12, on RI #2's 05/31/17 fall, what interventions were put in place to prevent the reoccurrence of a fall. EI #12 said RI #2 was not suppose to be in his/her room when he/she was in his/her wheelchair. On 08/10/17 at 11:17 a.m., the surveyor conducted an interview with EI #6, LPN. The surveyor asked EI #6, according to RI #2's incident report, what intervention was put in place after RI #2 fell on [DATE]. EI #6 said, it was said anytime RI #2 was up they (facility staff) would keep RI #2 around the nursing desk for observation when RI #2 was in the wheelchair. The surveyor showed EI #6 RI #2's 07/31/17 fall investigation and asked, looking at RI #2's 07/31/17 fall, where was RI #2 when he/she fell . EI #6 replied, In his/her room. The surveyor asked EI #6 was RI #2 in a wheelchair. EI #6 said yes. The surveyor aked EI #6, what was the reason for keeping RI #2 at the nurses station when RI #2 was in a wheelchair. EI #6 said at the nurses station was a more general location. EI #6 said usually someone was around and RI #2 would be in a more visible site. On 08/10/17 at 1:34 p.m., the surveyor conducted an interview with EI #3, the MDS/Care plan Coordinator. The surveyor asked EI #3, since RI #2's admission to the facility, how many falls had RI #2 had. EI #3 said three. The surveyor asked EI #3 when was RI #2's first fall. EI #3 said 03/02/17. The surveyor asked EI #3 when was RI #2's next fall. EI #3 said 05/31/17. The surveyor asked EI #3, according to the nurses immediate post incident action after the 05/31/17 fall, what was the intervention. EI #3 said when RI #3 was in a wheelchair, he/she was to be placed at the nurses desk for observation. The surveyor asked EI #3 when was RI #2's next fall. EI #3 said 07/31/17. The surveyor asked EI #3 where was RI #2 when he/she fell . EI #3 replied, Resident's room.

Based on record reviews and interviews, the facility failed to ensure Resident Identifier (RI) #10 did not receive [MEDICATION NAME] a medication listed on the face sheet and physician orders [REDACTED]. Findings Including: A review of a facility policy titled, PHARMACY PHYSICIAN DRUG ORDERS with a revised date of 07/14 revealed: .Procedure .7. Drug and biological orders must be recorded on the physician's orders [REDACTED]. Such orders are reviewed by the pharmacist on a monthly basis. A review of [MEDICATION NAME] Side Effects: . Major Side Effects . Difficult of labored breathing, shortness of breath, tightness in chest .dizziness, fast heartbeat, joint or muscle pain, puffiness or swelling . RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10 most recent yearly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/22/2017 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicates the resident is capable of making decisions. A review of the RI #10's history and physical document from the hospital on [DATE] indicated RI #10 was allergic to [MEDICATION NAME]. A review of the RI #10's Physician order, an order was written on 5/16/17 for the drug [MEDICATION NAME] 100 mg two times a day. A review of the physician order [REDACTED].>A review of RI #10's August 2017 eMar (electronic medication administration record) [MEDICATION NAME] was given BID (two times a day). On 8/9/2017 the surveyor conducted an interview with RI #10. RI #10 was asked did he/she have any unsteadiness, muscle pain, weakness, swelling of hand and feet, back pain, dizziness and weight gain. RI #10 replied, yes. On 8/10/2017 at 11:15 a.m., interview was conducted with EI #14 LPN (Licensed Practical Nurse). EI #14 was asked did she give RI #10 [MEDICATION NAME] this morning. EI #14 replied, yes. EI #14 was asked what drug was RI #10 allergic to. EI #14 replied, [MEDICATION NAME] and [MEDICATION NAME]. EI #14 was asked how long had RI #10 used [MEDICATION NAME]. EI #14 replied, since 5/16/2017. EI #14 was asked was it standard practice to give a resident a drug he/she was allergic to. EI #14 replied, no ma'am. EI #14 was asked what was the potential harm in given a resident a medication he/she was allergic to. EI #14 replied, they could have anaphylactic reaction and all kind of stuff. On 8/10/2017 at 11:30 a.m., the surveyor conducted an interview with EI #1, DON (Director of Nursing). EI #1 was asked was it standard practice to give a resident a drug he/she was allergic to. EI #1 replied, no. EI #1 was asked what drug was RI #10 taking that he/she was allergic to. EI #1 replied, [MEDICATION NAME]. EI #1 was asked what was the potential harm in giving a drug to a resident that he or she was allergic to. EI #1 replied, possible adverse reaction. On 8/10/2017 at 12:00 p.m., the surveyor conducted an interview with EI #15, Nurse Practitioner. EI #15 was asked who was responsible for making sure a resident did not receive a drug he/she was allergic to. EI #15 replied, we all were. EI #15 stated the nurse, nurse practioner and pharmacist. EI #15 was asked what was the potential harm when a resident was given a drug he/she was allergic to. EI #15 replied, short of breath, heart issues and allergic reaction. EI #15 was asked did she review allergy list before writing a prescription. EI #15 replied yes. On 8/10/2017 at 2:20 p.m., the surveyor conducted an interview with EI #16, pharmacist. EI #16 was asked when he came to the facility what did he review. EI #16 replied, charts reviews, audits, narcotic destruction, med pass reviews observation and anything else that need to be done. EI #16 was asked did he review patient medication and what they were allergic to. EI #16 replied, the dispensing pharmacy run allergic reports. EI #16 was asked did he read hospital history and physical. EI #16 replied, he did look at diagnoses. EI #16 was asked what was the potential harm when a resident received a drug he/she was allergic to. EI #16 replied, nausea, vomiting, rash, diarrhea, and constipation. EI #16 was asked who was responsible for making sure a resident did not receive a drug he/she was allergic to. EI #16 replied, the physician who wrote the prescription, the pharmacy dispensing the drug, the facility when transcribing the order and the pharmacist when he come in to review.

Based on observations, interviews, record review and review of facility policies titled NURSING ASSISTANT PERINEAL CARE and NURSING MEDICATION/ADMINISTRATION, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA), Employee Identifier (EI) #5, changed her contaminated gloves after wiping Resident Identifier (RI) #2's right buttocks, and before touching RI #2's clean incontinent brief and pad and applying a moisture barrier ointment to RI #2's right buttocks during incontinent care on 08/09/17; and 2) a Registered Nurse (RN)/medication nurse, EI #8, did not place a prepared insulin syringe in her uniform pocket, wash her hands, put on gloves then remove the syringe from her pocket and administer RI #12 the insulin injection on 08/08/17. These deficient practices affected RI #2, one of three residents observed for incontinent care, and EI #8, one of five nurses observed during the medication administration pass. Findings Include: A facility policy titled NURSING ASSISTANT PERINEAL CARE, with a revised date of 07/14, documented: Policy Perineal care serves to cleanse the perineum, provide comfort and dignity and assist in preventing infection, skin breakdown, and odors . 7. Always remove gloves before repositioning . bed linens . 1) RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/21/17, assessed RI #1 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. RI #2 was also assessed as being totally dependent on staff for personal hygiene and always incontinent of bowel and bladder. On 08/07/17 at 3:15 - 3:35 p.m., the surveyor observed incontinent care being provided to RI #2. EI #5 used a personal wipe and wiped RI #2's buttocks in an upward motion then placed the wipe in a plastic bag. EI #5 then pulled RI #2's clean incontinent pad and adult brief, with her contaminated gloves still on, under RI #2. EI #5 picked up the container of moisture barrier ointment, squeezed some onto the contaminated glove and rubbed RI #2's right buttock with the ointment. On 08/09/17 at 3:33 p.m., the surveyor conducted an interview with EI #5. The surveyor read back the above observation to EI #5. The surveyor asked EI #5 what should she have done after she wiped RI #2's right buttocks, and before touching RI #2's clean incontinent pad and applying moisture barrier. EI #5 said she should have changed her gloves. The surveyor asked EI #5 what was there a potential for when not changing gloves during or while providing incontinent care. EI #5 replied, Contamination. On 08/10/17 at 12:50 p.m., the surveyor conducted an interview with EI #2, the Infection Control Nurse. The surveyor read back the above incontinent care observation to EI #2. The surveyor asked EI #2 what should the CNA (EI #5) have done after she wiped RI #2's buttocks, and before touching RI #2's clean incontinent pad and moisture barrier ointment. EI #2 said EI #5 should have had the other staff member to hold RI #2 and go to the bathroom, remove her gloves, wash her hands and apply clean gloves. The surveyor asked EI #2 what was there a potential for when those procedures are not done. EI #2 replied, Spread of bacteria. 2) A review of facility policy NURSING MEDICATION/ADMINISTRATION with a revised date of 07/17 revealed: . Procedure .1. Maintain a clean technique throughout the procedure. RI # 12 was readmitted to the facility 3/31/17 with a [DIAGNOSES REDACTED]. A review of RI #12's August 2017 Physician order [REDACTED]. On 8/8/17 at 3:50 p.m., Employee Identifier (EI) #8, Registered Nurse (RN), was observed preparing PM medications for RI #12. EI #8 prepared medications to include [MEDICATION NAME] 70-30 Insulin Injection of six units. EI #8 went in RI #12's room and gave the by mouth medications. EI #8 then put the prepared insulin injection in the pocket of her jacket. EI #8 washed her hands and donned gloves then took the insulin syringe from the pocket of her jacket and gave the insulin to RI #12. On 8/8/17 at 4:00 p.m., an interview was conducted with EI #8 EI #8 was asked where she put the prepared insulin injection when she went in the bathroom to wash her hands. EI #8 replied in her pocket. EI #8 was asked if the pocket was considered clean or dirty. EI #8 replied dirty. EI #8 was asked what the harm was in putting a prepared insulin injection in her pocket. EI #8 replied contamination. On 8/9/17 at 2:40 p.m., an interview was conducted with EI # 2, Infection Control Nurse. EI #2 was asked what the policy was for giving insulin. EI #2 replied use clean to sterile technique, once drawn up place the syringe on a barrier while the other medication was given. EI #2 was asked what should the nurse do with the prepared insulin injection while giving the other medications. EI #2 replied the nurse should lay the syringe on a barrier, if she needed to leave the bedside she should roll the bedside table with her or be sure the medication remained in her line of sight. EI #2 was asked if the nurse should put a prepared insulin injection in her pocket while she washed her hands and put on gloves, then take the insulin injection from her pocket and give it to the resident. EI #2 replied no. EI #2 was asked if the pocket of the nurse's jacket was considered clean or dirty. EI #2 replied dirty. EI #2 was asked what the harm was in the nurse placing the prepared insulin syringe in her pocket then removing it and giving it to the resident. EI #2 replied it was not a clean technique, also infection control issue with herself and the resident.

Based on interviews, medical record review, review of the facility's policy titled ADMINISTRATIVE ELOPEMENT ALARMS, the INCIDENT REPORT, the facility's investigative file, and review of a complaint from the Alabama State Agency, the facility failed to ensure Resident Identifier (RI) #1, a resident identified by the facility as having a history of wandering, receiving medications that could cause confusion, and a [DIAGNOSES REDACTED]. Staff interviews revealed RI #1 was last seen in the dining room on 02/12/17 around 7:20 a.m., eating breakfast. Facility staff stated they heard their alarm system sound about 7:35 a.m. The responding staff member, Employee Identifier (EI) #4, a Restorative Certified Nursing Assistant (CNA), stated he deactivated the alarm system and stepped outside the front door, but failed to check the parking lot and surrounding areas. The facility's ADMINISTRATIVE ELOPEMENT ALARMS directs the staff to investigate the cause of the alarm and inspect the surrounding area, inside and outside the facility on every occurrence, even if the cause appears to be immediately determined. The facility staff failed to implement policy as written. RI #1 was found in a car in the facility's parking lot by an off duty employee, EI #5, the weekend receptionist around 7:40 - 7:45 a.m. When EI #5 arrived to the facility for work on 02/12/17, she stated there was no staff observed at the front door looking out or checking the outside of the facility. RI #1 was returned to the facility without injuries. This deficient placed RI #1, one of six residents sampled for wandering, in immediate jeopardy of serious injury, harm or death. On 03/04/17 at 6:04 p.m., Employee Identifier (EI) #1, the facility's Administrator; EI #2, the Director of Nursing and EI #15, a corporate representative were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 323. Findings Include: The facility's policy titled ADMINISTRATIVE ELOPEMENT ALARMS, with a revised date of 07/14, documented Policy Door alarms for elopement prevention shall be thoroughly monitored to lessen the occurrence of unsupervised exit from the facility by residents. Procedure . 3. When a door alarm sounds: a. Personnel will go to the door with the activated alarm to investigate the cause of the alarm activation. b. The investigation will include both the general area inside and outside the door on every occurrence, even if the cause appears to be immediately determined . RI #1 was admitted to the facility on [DATE], with an admit [DIAGNOSES REDACTED].#1's medical history included [DIAGNOSES REDACTED]. RI #1's Admission Wandering Assessment dated 07/14/16, revealed RI #1 had a history of [REDACTED]. RI #1's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 01/27/17, assessed RI #1 as being severely impaired in cognitive skills for daily decision making. RI #1 was also assessed as having exhibited the behavior of wandering daily during this assessment period. On 02/24/17, the Alabama State Agency received a complaint which alleged the employees did not investigate the alarm when sounded. The resident (RI #1) was found outside in the facility's parking lot in a parked car on 02/11/17 (02/12/17). The facility's INCIDENT REPORT indicated on 02/12/17 at 7:35 a.m., RI #1 left the building, unobserved by staff. The facility's ELOPEMENT INVESTIGATION REPORT revealed on 02/12/17 at 7:35 a.m., RI #1 wandered from the front door. The resident's security bracelet was on and the alarm functioned properly. The report further documented . Resident on ABT (antibiotics) for UTI, appears more agitated. Door alarm sounded resident not in site (sight) when staff got to front door . What action was taken? Recommended? Inservice staff on making sure they look outside the facility when turning alarms off at any door. RI #1's Departmental Note dated 02/12/2017 at 12:19 p.m., written by EI #3, a Licensed Practical Nurse (LPN), documented Around 7:35am this morning front door alarm sounded. When staff went to see if resident was around door resident was not in staffs site. Staff member turned alarm off and resumed regular activities. Resident was found sitting in a car in front of facility as staff member was coming in for her shift. Resident assisted back into facility by staff member. Within next couple of minutes alarm sounding again as Staff member was escorting resident into facility. Staff member stated resident was just out front sitting in a car. Sponsor and MD (Medical Doctor) notified. On 02/28/17 at 2:43 p.m., the surveyor conducted an interview with EI #3, the LPN assigned to care for RI #1 on 02/12/17. The surveyor asked EI #3 if RI #1 exited the facility without staff knowledge on 02/12/17. EI #3 said, Yes. When asked when she became aware, EI #3 said after breakfast the alarm at the front door sounded. When EI #3 went to the front door, there were two staff members (EI #4 and a housekeeping staff member) standing there and they turned the alarm off. EI #3 said she did not see any residents around, so she went back to the floor to continue medication pass. EI #3 said when she got back to her medication cart, she heard the alarm sound again, so she walked back to the front and saw a staff member (EI #5) who was just coming to work walk RI #1 back into the facility. According to EI #3, the last time she saw RI #1, it was around 7:00 AM and the resident was in the dining room eating breakfast. When asked what the facility's elopement policy directed staff to do when an alarm sounds, EI #3 replied, We are supposed to check and look inside and outside of the building to make sure we don't see anyone. The surveyor asked EI #3 was that done by the staff on 02/12/17. EI #3 said she assumed it was. EI #3 said the staff at the door said they had it. EI #3 was asked, did she ask anyone if they checked outside. EI #3 replied, No Ma'am, I just assumed they had. Contained within the facility's investigative file was a statement from EI #4, a Restorative Certified Nursing Assistant (CNA), dated 02/12/17, which read I went to the lobby to help housekeeping cut the alarm off. They did not say anything about anyone walking out. So I just went back to work. Few minutes later (EI #5) brought (RI #1) back in the door. I had no idea anyone left. On 02/28/17 at 5:11 p.m., a telephone interview was conducted with EI #4, the Restorative CNA. EI #4 said he just happened to walk by and see the guy who mops the floor trying to put the code in. EI #4 said he went to the front door and cut the alarm off. Then later, EI #4 said the alarm sounded again and he saw EI #5 bring RI #1 in the facility. When asked where EI #5 found RI #1, EI #4 said the resident was in someone's car. Contained within the facility's investigative file was a statement from EI #5, the weekend receptionist, dated 02/12/17, which read I was driving into parking lot. Parked my car and say a (man/lady) open the door to a car. It was (RI #1). (RI #1) opened the door again and told me to get in. I told (RI #1) to come with me that (he/she) did not need to be outside. Me and (RI #1) came into the building. On 02/28/17 at 9:16 a.m., a telephone interview was conducted with EI #5, the weekend receptionist. EI #5 confirmed that she did observe RI #1 in a parked car in the facility's parking lot on 02/12/17. EI #5 said it was around 7:40 or 7:45 a.m. When asked to describe how she found RI #1, EI #5 said as she was walking toward the car she saw someone opening and shutting a car door. EI #5 said she went up to the car and observed the person to be RI #1. EI #5 said RI #1 wanted her to come and get in the car. EI #5 said RI #1 opened the door as she walked up to the car. EI #5 said she then called RI #1's name and told RI #1 she did not need to be in the car. EI #5 said RI #1 said okay, got out of the car, and walked to the front door with her. In a follow-up telephone interview with EI #5 on 03/02/17 at 8:31 a.m., she was asked did she observe any staff in the parking lot on 02/12/17. EI #5 said,No Ma'am. When asked if she observed any staff at the front door looking out or checking the outside of the facility. EI #5 said, no. On 02/28/17 at 12:51 p.m., the surveyor conducted an interview with EI #6, one of the CNAs assigned to work on the morning of 02/12/17, on the hall RI #1 resided. EI #6 described RI #1 as being an alert, confused resident who wanders. EI #6 said on 02/12/17, she was assigned to the dining room to assist with meals. According to EI #6, the breakfast meal is served at 6:30 a.m. EI #6 said RI #1 was in the dining room for breakfast. When asked if she observed RI #1 leave the dining room, EI #6 said no, and explained that when she left the dining room around 7:20 a.m., RI #1 was still there. EI #6 explained that as she was passing trays on the hall, she heard an alarm sound. EI #6 was asked, when the alarm sounded what she did. EI #6 said she continued to pass out the breakfast trays to other residents and after about a minute, the door alarm stopped sounding. EI #6 said she did not know that RI #1 exited the facility, which door the resident exited from or who turned the alarm off. When asked when she observed RI #1 again after she saw the resident in the dining room around 7:20 a.m. EI #6 replied, about 7:45 a.m. EI #6 said she was told RI #1 had been found in the parking lot. On 03/01/17 at 7:48 a.m., the surveyor conducted an interview with EI #8, the other CNA assigned to work on the morning of 02/12/17, on the hall RI #1 resided. EI #8 said she also heard the door alarm sounding on the morning of 02/12/17, and continued to pass out breakfast trays. EI #8 said she did know who responded to the sounding door alarm. The surveyor asked EI #8 what staff should do when a door alarm sounds. EI #8 said staff should go to find which door was alarming and look to see if anyone had gone out the door. The surveyor asked EI #8 did anyone do that on 02/12/17. EI #8 replied, I'm not sure. EI #8 said she was told when RI #1 was brought back to the hall, RI #1 had gotten out of the front door and was in the parking lot. On 03/01/17 at 9:14 a.m., the surveyor conducted an interview with EI #7, a CNA working on another hall in the facility on 02/12/17. When asked if she heard the door alarm sound on 02/12/17, EI #7 replied, Yes Ma'am I did. EI #7 said there was a resident who was a wanderer on her hall, and she went to check on that resident. EI #7 said when she saw that the resident was in his/her room, she went back to passing out the breakfast trays on her hall. EI #7 said she became aware RI #1 had exited the facility when she looked through a blind on the hall she worked, and saw RI #1 outside the facility in the front parking lot walking back toward the facility with EI #5. On 03/01/17 at 2:41 p.m., the surveyor conducted an interview with EI #2, the DON. The surveyor asked EI #2 what the facility's policy has directed staff to do when a door alarm sounds. EI #2 replied, Look around the area and go outside to check the area for anyone that went outside. EI #2 said the area to be checked would include the parking and that was not done when the alarm sounded on 02/12/17. EI #2 described RI #1 as a confused, elopement risk resident with poor safety awareness. When asked what could have been some of the consequences of RI #1, who exited the facility without staff knowledge on 02/12/17. EI #2 said bodily injury could have resulted, RI #1 could have fallen or RI #1 could have been hit by a car. EI #2 said RI #1 did not have the safety awareness to not go out in the road. ************************* On 03/05/17 at 4:05 p.m., the facility submitted an Acceptable Allegation of Credible Compliance, which documented: F 323 - Quality of Care On 02/12/17, RI #1, a resident wearing a Wander Guard, exited the facility and was found in the facility's parking lot. There are five other residents identified in the facility wearing Wander Guards. There have been no other incidents of RI #1 or other residents exiting the facility. On 02/12/17, the Director of Nursing / designee initiated an action plan when it was identified that the facility's elopement alarm protocol had not been initiated. On 02/12/17, staff who responded to the sounding alarm was in-serviced on the elopement alarm protocol. The DON / designee provided demonstration on how to properly respond to a sounding alarm, visually inspecting the general area inside and outside the door on every occurrence, including the parking lot. On 02/12/17, the DON / designee provided in-service to staff on the elopement alarm protocol. The DON / designee provided demonstration on how to properly respond to a sounding alarm, visually inspecting the general area inside and outside the door on every occurrence, including the parking lot. All staff will be in-serviced before returning to work. All staff upon hire will be in-serviced on the facility's elopement alarm protocol with demonstration on the facility's alarm system. On 02/13/17, the facility implemented Wander Guard checks weekly for functionality. Prior to this, Wander Guard checks were conducted every shift for placement by the licensed nurses. On 02/17/17 and 03/02/17, monthly elopement drills were conducted by the facility. Monthly elopement drills will be increased to include drills on each shift every month. On 03/04/17, Wander Guard checks were increased to include placement and functionality every shift by the licensed nurses. On 03/04/17, the facility's Quality Assurance Committee (Administrator, DON, SSD's, Medical Director and management company representative) reviewed the elopement policy and procedure to ensure it addressed the appropriate response to be initiated by facility staff when responding to a sounding alarm. After review, there were no needed revisions. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 323 was lowered to a D level to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice was cited as a result of the investigation of complaint/report AL 016.

Based on interviews, medical record review, review of the facility's policy titled ADMINISTRATIVE ELOPEMENT ALARMS, the Director of Nursing's (DON's) job description, and the facility's Record of Monthly Elopement Drills, the DON failed to ensure the staff implemented the ADMINISTRATIVE ELOPEMENT ALARMS on 02/12/17, when Resident Identifier (RI) #1 exited the facility without staff knowledge. The DON further failed to ensure the staff had received training on facility's ADMINISTRATIVE ELOPEMENT ALARMS. Staff interviews revealed RI #1 was last seen in the dining room on 02/12/17 around 7:20 a.m., eating breakfast. Facility staff stated they heard their alarm system sound about 7:35 a.m. The responding staff member, Employee Identifier (EI) #4, a Restorative Certified Nursing Assistant (CNA), stated he deactivated the alarm system and stepped outside the front door, but failed to check the parking lot and surrounding areas. Interviews with other staff working in the facility revealed they heard the sounding alarm, but failed to implement the facility's elopement alarm policy. The facility's ADMINISTRATIVE ELOPEMENT ALARMS directs the staff to investigate the cause of the alarm and inspect the surrounding area, inside and outside the facility on every occurrence, even if the cause appears to be immediately determined. The facility staff failed to implement policy as written. RI #1 was found in a car in the facility's parking lot by an off duty employee, EI #5, the weekend receptionist around 7:40 - 7:45 a.m. When EI #5 arrived to the facility for work on 02/12/17, she stated there was no staff observed at the front door looking out or checking the outside of the facility. RI #1 was returned to the facility without injuries. These deficient practices placed RI #1, one of six residents sampled for wandering, in immediate jeopardy of serious injury, harm or death. On 03/04/17 at 6:04 p.m., Employee Identifier (EI) #1, the facility's Administrator; EI #2, the Director of Nursing and EI #15, a corporate representative were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Administration, F 490. Findings Include: The facility's policy titled ADMINISTRATIVE ELOPEMENT ALARMS revised 07/14, documented Policy Door alarms for elopement prevention shall be thoroughly monitored to lessen the occurrence of unsupervised exit from the facility by residents. Procedure . 2. Elopement drills shall be conducted and documented monthly by a nurse manager according to a schedule established and monitored by the director of nursing . The Director of Nursing's (EI #2's) JOB DESCRIPTION AND PERFORMANCE STANDARDS signed 04/27/15, documented: . Purpose of this position The purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department . Delegation of authority Authority is delegated to the individual in this position to: . Develop and implement policies and procedures for nursing care of residents . Supervise and manage all aspects of the nursing department . The primary functions and responsibilities of this position are as follow: . 2. Assume accountability for the development, organization and implementation of approved policies and procedures . 20. Assume responsibility for nursing service compliance with federal, state and local regulations . 44 Be responsible for safety of residents under his/her supervision . Refer to F 323 On 02/28/17 at 2:43 p.m., the surveyor conducted an interview with EI #3, the Licensed Practical Nurse (LPN) assigned to care for RI #1 on 02/12/17. The surveyor asked EI #3 what the facility's elopement policy directed the staff to do when an alarm sounds, EI #3 replied, We are supposed to check and look inside and outside of the building to make sure we don't see anyone. The surveyor asked EI #3 was that done by the staff on 02/12/17. EI #3 said she assumed it was. EI #3 said the staff at the door said they had it. EI #3 was asked, did she ask anyone if they checked outside. EI #3 replied, No Ma'am, I just assumed they had. A review of the facility's Record of Monthly Elopement Drill for the time period of January 2015 through February 2017, revealed the last time EI #3 participated in a facility elopement drill was during the second shift on 05/19/16. On 02/28/17 at 12:51 p.m., the surveyor conducted an interview with EI #6, one of the CNAs assigned to work on the morning of 02/12/17, on the hall RI #1 resided. EI #6 was asked, when the alarm sounded what she did. EI #6 said she continued to pass out the breakfast trays to other residents and after about a minute, the door alarm stopped sounding. In a follow-up interview on 03/02/17 at 11:57 a.m., EI #6 was asked, what did the facility's elopement policy direct the staff to do when a door alarm sound. EI #6 said the staff was supposed to go and find where the alarm was sounding, check for where the resident was who set the alarm off and do not turn the alarm off until a reason has been established as to why the alarm sounded. When asked if she did that on 02/12/17, EI #6 said no. A review of the facility's Record of Monthly Elopement Drill for the time period of January 2015 through February 2017, revealed the last time EI #6 participated in a facility elopement drill was during the first shift on 07/30/15. On 03/01/17 at 7:48 a.m., the surveyor conducted an interview with EI #8, the other CNA assigned to work on the morning of 02/12/17, on the hall RI #1 resided. EI #8 said she also heard the door alarm sounding on the morning of 02/12/17, and continued to pass out breakfast trays. In a follow-up interview on 03/02/17 at 12:06 p.m., EI #8 was asked, what did the facility's elopement policy direct the staff to do when the door alarm sounded. EI #8 said staff was to stop what they were doing, find which door alarm was sounding and go outside and make sure no one was outside that should not be. The surveyor asked EI #8 did she do that on 02/12/17. EI #8 replied, Regretfully no. A review of the facility's Record of Monthly Elopement Drill for the time period of January 2015 through February 2017, revealed the last time EI #8 participated in a facility elopement drill was during the second shift on 08/28/16 and 11/10/16. On 03/01/17 at 9:14 a.m., the surveyor conducted an interview with EI #7, a CNA working on another hall at the facility on 02/12/17. When asked if she heard the door alarm sound on 02/12/17, EI #7 replied, Yes Ma'am I did. EI #7 said there was a resident who was a wanderer on her hall, and she went to check on that resident. EI #7 said when she saw that the resident was in his/her room, she went back to passing out the breakfast trays on her hall. In a follow-up interview on 03/02/17 at 11:50 a.m., EI #7 was asked, what did the facility's elopement policy direct the staff to do when the door alarm sounded. EI #7 said she did not know what the facility's policy said. A review of the facility's Record of Monthly Elopement Drill for the time period of January 2015 through February 2017, revealed EI #7 had not participated in a facility elopement drill. On 03/02/17 at 10:17 a.m., a telephone interview was conducted with EI #4, a Restorative Certified Nursing Assistant. EI #4 was asked, what the facility's elopement policy directed the staff to do when a door alarm sounded. EI #4 said, go toward the door and see what was going on. The surveyor asked EI #4 how far he went beyond the front door on 02/12/17. EI #4 said he really did not go far at all. EI #4 said he just stood on the outside of the door and looked around. EI #4 said he did not see anybody so he went back in the building. A review of the facility's Record of Monthly Elopement Drill for the time period of January 2015 through February 2017, revealed the last time EI #4 participated in a facility elopement drill was during the first shift on 09/05/16. On 03/01/17 at 2:41 p.m., the surveyor conducted an interview with the DON, EI #2. The surveyor asked EI #2 what the facility's policy directed staff to do when a door alarm sounds. EI #2 replied, Look around the area and go outside to check the area for anyone that went outside. EI #2 said the area to be checked would include the parking and that was not done when the alarm sounded on 02/12/17. In a follow-up interview on 03/04/17 at 1:07 p.m., EI #2 was asked, when the door alarm sounds, what should staff do. EI #2 said staff should investigate the area inside and outside of the facility, including the parking lot. The surveyor asked EI #2 was that done on 02/12/17. EI #2 replied, No. The surveyor asked EI #2, what specifically should the staff have done. EI #2 replied, Investigate the outside area before turning the alarm off. ************************* On 03/05/17 at 4:05 p.m., the facility submitted an acceptable Allegation of Credible Compliance, which documented: F 490 - Administration On 02/12/17, the facility failed to implement the elopement alarm protocol. On 03/04/17, the Director of Nursing (DON) was educated by the present Administrator on the facility's elopement alarm protocol. On 03/04/17, the Quality Assurance Committee (Administrator, Medical Director, and management company representative) reviewed with the DON the elopement alarm protocol. On 03/04/17, the management company representative ensured the elopement alarm policies and procedures had been reviewed to see if they were being implemented correctly, and education had been conducted with the DON. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to a D level to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice was cited as a result of the investigation of complaint/report AL 016.

Based on interview and document review, the facility failed to update the care plan following a fall in order to prevent future falls by Resident Identifier (RI) #4, a resident identified by the facility as a high risk for falls. RI #4 sustained a fall from her geri chair on 9/12/10, which resulted in the fracture of two ribs, the [MEDICAL CONDITION] clavicle, and [MEDICATION NAME] spine compression fractures at T12 and T7. A review of the 9/12/10 fall investigation revealed an intervention of keeping the resident in view of staff when RI #4 was in the geri chair. A review of RI #4's medical record revealed the facility failed to add the recommended intervention or any additional interventions to the resident's plan of care in order to prevent a reoccurrence. On 12/31/10, the resident was found on the floor in her room (unattended) after a fall from the geri chair, which resulted in a fracture to RI #4's left hip. The facility failed to incorporate the 12/31/10 fall investigation's recommended intervention or any new intervention to the resident's plan of care in order to prevent a reoccurrence. This affected one of two residents sampled for falls. Findings Include: The facility's "Nursing MDS (Minimum Data Set)/Comprehensive Care Plan," dated July 2009, included the following: "Policy An interdisciplinary approach to identification of problems and developing solutions provide individualization and coordination of resident care..... Procedure Interdisciplinary Approach ... 2. The interdisciplinary Care Plan is reviewed, revised and updated quarterly and more frequently if warranted by a change in resident's condition...." RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's "Fall Risk Assessment" tool identified RI #4 as "High Risk" for falls on 3/11/10 with a score of 17, on 6/14/10 with a score of 17, on 9/16/10 with a score of 17, and on 12/2/10 with a score of 18. The "Fall Risk Assessment" tool coded scores with 10 or more points as high risk. RI #4's Fall Care Plan included under the "Problem" section dated 3/12/10 as follows: "Fall Resident is at risk for falls related to weakness, use of [MEDICAL CONDITION] medications, and [MEDICAL CONDITION] disorder. ..." Approaches included: "...Geri chair when up..." An Annual MDS, with an assessment reference date of 6/14/10, identified RI #4 with a short-term memory problem and modified independence in cognitive skills for daily decision-making. There was no record of falls or fractures within the previous 180 days. An "Incident Report," dated 9/12/10, at 9:50 AM, documented a witnessed fall by RI #4. The report was completed and signed by Employee Identifier (EI) #15 a (Licensed Practical Nurse) on 9/12/10 and was signed as reviewed on 9/13/10 by EI #1 (the Administrator) and EI #14 (the Director of Nursing). The report included the following: "... Summary Resident sat up in geri chair and fell over the front right side. ... Interventions to Prevent Reoccurrence: ... Keep in view of staff when in geri chair." Radiology reports ordered by the hospital's emergency room (ER) physician on 9/12/10 for RI #4, dated 9/13/10, revealed: "... Findings: There are fractures of the fourth and sixth right ribs. ...; ... There are also compression fractures at T12 and T7. ... [MEDICATION NAME] spine compression fractures. ...; ... There is a [MEDICAL CONDITION] clavicle. ..." A Quarterly MDS, with an assessment reference date of 9/13/10, was completed for RI #4 and signed by the interdisciplinary team members on 9/13/10. The MDS documented RI #4 had a short-term memory problem and modified independence in cognitive skills for daily decision-making. The MDS also revealed RI #4 had fallen within the last thirty days and had sustained a fracture in the last 180 days. Neither the Fall Care Plan in RI #4's medical record nor that used in the Certified Nursing Assistant's (CNA) Care Plan/Activities of Daily Living (ADL) Book for RI #4 listed any new approaches following the completion of the 9/13/10 Quarterly MDS. Specifically there was no approach to keep the resident in view of staff when she was in the geri chair. A Quarterly MDS, with an assessment reference date of 12/13/10 documented RI #4's score of 6 out of 15 possible points on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The MDS identified one fall, which resulted in a major injury (bone fractures, ...), since the prior assessment. Neither the Fall Care Plan in RI #4's medical record nor that used in the CNA Care Plan/ADL Book for RI #4 listed any new approaches following the completion of the 12/13/10 Quarterly MDS. An "Incident Report," dated 12/31/10, documented an unwitnessed fall by RI #4 on 12/31/10 at around 7:40 AM. The report included the following: "... Summary Sensor alarm was sounding resident was found on floor, had fell out of geri-chair. ... Interventions to Prevent Reoccurrence: Resident is to be out of room when in geri-chair. ..." Radiology reports ordered by the hospital's ER physician on 12/31/10 for RI #4, dated 1/1/11, revealed: "... Opinion: Nondisplaced subcapital fracture left hip. ..." A review of RI #4's Fall Care Plan in the medical record and in the CNA Care Plan/ADL Book revealed no interventions were added following the 12/31/10 fall investigation. EI #16 (a CNA) was interviewed on 5/20/11 at 10:30 AM. When asked to review the "300 Hall Assignment Sheet" for the First Shift on 12/31/10, EI #16 was able to verify she was assigned to provide care for RI #4 for that time. EI #16 said she looked at RI #4's Care Plan in the CNA Care Plan/ADL Book to know how to provide care for the resident. When asked if RI #4 was supposed to be left alone in her room, EI #16 said she did not know. When asked why RI #4 was left alone in her room, EI #16 said she did not know. When asked if she was aware that RI #4 was to be in staff view at all times when she was up in the geri chair, EI #16 said she did not know that. EI #16 was asked why did she not know and if there was anything in the resident's Care Plan about keeping RI #4 in staff view when she was up in the geri chair. EI #16 reviewed RI #4's Fall Care Plan and said she did not see anything about it. When asked if anyone told her or if she saw any instruction on the Care Plan to keep RI #4 outside of her room when in the geri chair, EI #16 said no. EI #15 (a Licensed Practical Nurse) was interviewed on 5/20/11 at 11:00 AM. When asked to review the 9/12/10 incident report of RI #4's fall, EI #15 verified she had completed the report. When asked what were the interventions listed on the incident report for RI #4's fall on 9/12/10, EI #15 said checking for a UTI, which was done the night before, and keep in view of staff when in geri chair. EI #15 was asked what was done with the interventions to prevent reoccurrence on the incident report. EI #15 said if it is an order, the nurse completing the incident report would write the order. EI #15 said interventions for the Care Plan are given to EI #6 (a Licensed Practical Nurse)/Restorative Nurse. EI #15 said she either gives the incident report directly to EI #6 or she puts it in EI #6's box. When asked if she saw the recommended intervention from the 9/12/10 fall on RI #4's Care Plan, EI #15 said no, she did not. When asked if she saw the recommended intervention from the 12/31/10 fall on RI #4's Care Plan, EI #15 said no. EI #6 (a Licensed Practical Nurse/Restorative Nurse) was interviewed on 5/20/11 at 11:15 AM, when asked what were her responsibilities at the facility, EI #6 replied: Restorative duties; MDS sections G, H, J, P, O; Bowel/Bladder Assessments, and Falls. EI #6 said she conducted investigations to determine why the resident fell and to see if an intervention had been implemented or to change the intervention as appropriate for the resident. When asked who was responsible for updating the Care Plan to include the recommended intervention from the 9/12/10 incident report of RI #4's fall, EI #6 replied it should have been herself. When asked who was responsible to update RI #4's Care Plan and add the intervention from the 12/31/10 fall, EI #6 said she did not know she was supposed to put those on the Care Plan unless it was an order. EI #14 (the Director of Nursing) was interviewed on 5/20/11 at 12:30 PM with access to copies of RI #4's Care Plan from the medical record and the CNA Care Plan/ADL Book. EI #14 was asked what interventions were in place for RI #4 on her Care Plan and CNA Care Plan prior to the fall on 9/12/10. EI #14 reviewed and said: - Sensor mat to bed/chair. - Lock brakes on bed. - Side rails up times two. - Marissa lift for transfers. - Geri chair when up. When asked what was the intervention added to the Care Plan after RI #4's fall on 9/12/10, EI #14 said she did not see it. When asked what was put in place for RI #4's Plan of Care after the 12/31/10 fall, EI #14 said she saw nothing. EI #14 was asked why the 9/12/10 fall's intervention to prevent reoccurrence was not implemented and added to RI #4's Plan of Care. EI #14 said EI #6 (the Restorative Licensed Practical Nurse) forgot to do it. EI #14 said it was EI #6's responsibility to add the intervention to the Care Plan.

Based on interview and document review, the facility failed to supervise Resident Identifier (RI) #4, a resident identified by the facility as a high risk for falls. RI #4 sustained a fall from her geri chair on 9/12/10, which resulted in the fracture of two ribs, the fracture of the right clavicle, and thoracic spine compression fractures at T12 and T7. A review of the 9/12/10 fall investigation revealed an intervention of keeping the resident in view of staff when RI #4 was in the geri chair. A review of RI #4's medical record revealed the facility failed to put the recommended measure in place or any additional interventions to prevent a reoccurrence. On 12/31/10, the resident was found on the floor in her room (unattended) after a fall from the geri chair, which resulted in a fracture to RI #4's left hip. The facility further failed to implement the recommended intervention following the investigation of the 12/31/10 fall or any new intervention to prevent a reoccurrence. This affected one of two residents sampled for falls. Findings Include: RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's "Fall Risk Assessment" tool identified RI #4 as "High Risk" for falls on 3/11/10 with a score of 17, on 6/14/10 with a score of 17, on 9/16/10 with a score of 17, and on 12/2/10 with a score of 18. The "Fall Risk Assessment" tool coded scores with 10 or more points as high risk. RI #4's Care Plan included a problem with an onset date of 3/12/10 as follows: "Fall Resident is at risk for falls related to weakness, use of psychotropic medications, and seizure disorder. ..." Approaches included: "Geri chair when up." An Annual Minimum Data Set (MDS), with an assessment reference date of 6/14/10, identified RI #4 with a short-term memory problem and with modified independence in cognitive skills for daily decision-making. RI #4 required limited assistance for bed mobility, but needed extensive assistance for eating and personal hygiene. RI #4 required total dependence upon staff for transfer, locomotion, dressing, toileting, and bathing. A two person assist was needed for transfers, which were done using a mechanical lift. The resident was incontinent of bowel and bladder. There was no record of falls or fractures within the previous 180 days. In addition, under the MDS section titled "Stability of Conditions," RI #4 was checked for: "Conditions/diseases make resident's cognitive, ADL (Activities of Daily Living), mood or behavior patterns unstable--(fluctuating, precarious, or deteriorating)." An "Incident Report," dated 9/12/10, documented a witnessed fall by RI #4 on 9/12/10 at 9:50 AM. The report was completed and signed by Employee Identifier (EI) #15 (a Licensed Practical Nurse) on 9/12/10 and was signed as reviewed on 9/13/10 by EI #1 (the Administrator) and EI #14 (the Director of Nursing). The report included the following: "... Summary Resident sat up in geri chair and fell over the front right side. Alarm was in place and functioning. Resident hit head and got a skin tear on R (right) leg. ... Physician Orders: Send to (Name of hospital) ER (emergency room ) Interventions to Prevent Reoccurrence: O (check) for UTI (Urinary Tract Infection). Keep in view of staff when in geri chair." Radiology reports ordered by the hospital's ER physician on 9/12/10 for RI #4, dated 9/13/10, revealed: "... Findings: There are fractures of the fourth and sixth right ribs. ...; ... There are also compression fractures at T12 and T7. ... Thoracic spine compression fractures. ...; ... There is a fracture of the distal clavicle. ..." A Quarterly MDS, with an assessment reference date of 9/13/10, was completed for RI #4 and signed by the interdisciplinary team members on 9/13/10. The MDS documented RI #4 had short-term memory problems and modified independence in cognitive skills for daily decision-making. RI #4 required extensive assistance for bed mobility, eating, personal hygiene, and bathing. RI #4 required total dependence upon staff for transfer, locomotion, dressing, and toileting. The resident was incontinent of bowel and bladder. The MDS also revealed RI #4 had fallen within the last thirty days and had sustained a fracture in the last 180 days. In addition, the MDS noted RI #4's conditions/diseases made the resident's cognitive, ADL, mood or behavior patterns unstable (fluctuating, precarious, or deteriorating). Neither the Fall Care Plan in RI #4's medical record nor that used in the Certified Nursing Assistant's (CNA) Care Plan/Activities of Daily Living (ADL) Book for RI #4 listed any new approaches following the completion of the 9/13/10 Quarterly MDS. Specifically there was no approach to keep the resident in view of staff when she was in the geri chair. A Quarterly MDS, with an assessment reference date of 12/13/10 documented RI #4's score of 6 out of 15 possible points on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. RI #4 was able to eat independently. RI #4 needed extensive assistance for personal hygiene. RI #4 required total dependence upon staff for bed mobility, transfer, locomotion, dressing, toileting, and bathing. A two person assist was needed for transfers. The resident was incontinent of bowel and bladder. The MDS identified one fall, which resulted in a major injury (bone fractures, ...), since the prior assessment. Neither the Fall Care Plan in RI #4's medical record nor the Falls Care Plan in the CNA Care Plan/ADL Book listed any new approaches following the completion of the 12/13/10 Quarterly MDS. An "Incident Report," dated 12/31/10, documented an unwitnessed fall by RI #4 on 12/31/10 at around 7:40 AM. The report included the following: "... Summary Sensor alarm was sounding resident was found on floor, had fell out of geri-chair. All of left side was touching the floor. Skin tear to left forearm and redness to left side and lower back. Out to (Name of hospital) ER for evaluation. ... Interventions to Prevent Reoccurrence: Resident is to be out of room when in geri-chair. ..." Radiology reports ordered by the hospital's ER physician on 12/31/10 for RI #4, dated 1/1/11, revealed: "... Opinion: Nondisplaced subcapital fracture left hip. ..." A review of RI #4's Fall Care Plan in the medical record and in the CNA Care Plan/ADL Book revealed no interventions were added following the 12/31/10 fall investigation. EI #16 (a CNA) was interviewed on 5/20/11 at 10:30 AM. When asked to review the "300 Hall Assignment Sheet" for the First Shift on 12/31/10, EI #16 was able to verify she was assigned to provide care for RI #4 for that time. EI #16 said she looked at RI #4's Care Plan in the CNA Care Plan/ADL Book to know how to provide care for the resident. EI #16 was asked who left the resident alone in her room on the morning of 12/31/10. EI #16 said Third Shift got RI #4 up because the resident was trying to get out of bed. EI #16 further said she thought RI #4 had been in the Day Room and she did not know who put the resident back in her room. EI #16 said she was in the Dining Room when RI #4 fell . When asked if RI #4 was supposed to be left alone in her room, EI #16 said she did not know. When asked why RI #4 was left alone in her room, EI #16 said she did not know. When asked if she was aware that RI #4 was to be in staff view at all times when she was up in the geri chair, EI #16 said she did not know that. EI #16 was asked why did she not know and if there was anything in the resident's Care Plan about keeping RI #4 in staff view when she was up in the geri chair. EI #16 reviewed RI #4's Fall Care Plan and said she did not see anything about it. Following RI #4's fall on 12/31/10, EI #16 said the nurse told her the resident had a left hip fracture, to keep her positioned right, and not to roll RI #4 too far over on that hip. When asked if anyone told her or if she saw any instruction on the Care Plan to keep RI #4 outside of her room when in the geri chair, EI #16 said no. EI #15 (a Licensed Practical Nurse) was interviewed on 5/20/11 at 11:00 AM. When asked to review the 9/12/10 incident report of RI #4's fall, EI #15 verified she had completed the report. When asked what were the interventions listed on the incident report for RI #4's fall on 9/12/10, EI #15 said checking for a UTI, which was done the night before, and keep in view of staff when in geri chair. EI #15 was asked what was done with the interventions to prevent reoccurrence on the incident report. EI #15 said if it is an order, the nurse completing the incident report would write the order. EI #15 said interventions for the Care Plan are given to EI #6 (a Licensed Practical Nurse)/Restorative Nurse. EI #15 said she either gives the incident report directly to EI #6 or she puts it in EI #6's box. When asked if she saw the recommended intervention from the 9/12/10 fall on RI #4's Care Plan, EI #15 said no, she did not. When asked if she saw the recommended intervention from the 12/31/10 fall on RI #4's Care Plan, EI #15 said no. EI #15 was asked if she thought the 12/31/10 fall was an avoidable fall. EI #15 replied it looked that way. EI #6 (a Licensed Practical Nurse/Restorative Nurse) was interviewed on 5/20/11 at 11:15 AM, when asked what were her responsibilities at the facility, EI #6 replied: Restorative duties; MDS sections G, H, J, P, O; Bowel/Bladder Assessments, and Falls. EI #6 said she conducted investigations to determine why the resident fell and to see if an intervention had been implemented or to change the intervention as appropriate for the resident. When asked who was responsible for updating the Care Plan to include the recommended intervention from the 9/12/10 incident report of RI #4's fall, EI #6 replied it should have been herself. When asked who was responsible to update RI #4's Care Plan and add the intervention from the 12/31/10 fall, EI #6 said she did not know she was supposed to put those on the Care Plan unless it was an order. EI #6 was asked how long she had been doing Care Plans and what training she had received. EI #6 said she had done the Care Plans for a year or longer, but she was still learning. EI #6 also said she really had not received any training about Care Plans, but was trying to train herself. EI #14 (the Director of Nursing) was interviewed on 5/20/11 at 12:30 PM with access to copies of RI #4's Care Plan from the medical record and the CNA Care Plan/ADL Book. EI #14 was asked what interventions were in place for RI #4 on her Care Plan and CNA Care Plan prior to the fall on 9/12/10. EI #14 reviewed and said: - Sensor mat to bed/chair. - Lock brakes on bed. - Side rails up times two. - Marissa lift for transfers. - Geri chair when up. When asked what was the intervention added to the Care Plan after RI #4's fall on 9/12/10, EI #14 said she did not see it. When asked what was put in place for RI #4's Plan of Care after the 12/31/10 fall, EI #14 said she saw nothing. EI #14 was asked why the 9/12/10 fall's intervention to prevent reoccurrence was not implemented and added to RI #4's Plan of Care. EI #14 said EI #6 (the Restorative Licensed Practical Nurse) forgot to do it. EI #14 said it was EI #6's responsibility to add the intervention to the Care Plan.