Every finding on record at Treyton Oak Towers

Based on interview, record review, and review of facility policy, the facility failed to have evidence that risks, benefits, and alternate treatments were discussed with residents and/or their representatives for 2 of 5 sampled residents reviewed for unnecessary medications (Resident (R)22, and R31). The findings include: Review of the facility policy titled, Psychotropic Medication Use, revised 07/2022, revealed, 4. Residents (and/or representatives) have the right to decline treatment with psychotropic medications. a. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. 1. Review of R22's Resident Face Sheet indicated the facility admitted the resident on 09/10/2024 and re-admitted the resident on 02/17/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia with other behavioral disturbance, generalized anxiety disorder, psychotic disorder with delusions, unspecified psychosis, and adjustment disorder with anxiety. Review of R22's Care Plan, included a problem statement initiated 09/18/2024 indicating the resident was at risk for adverse side effects of psychotropic medications. Review of R22's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2025, revealed the facility assessed the resident as having short and long-term memory problems and severe cognitive impairment. The MDS also revealed R22 received antidepressant and antianxiety medications during the seven-day assessment look-back period. Review of R22's Active Orders, revealed orders for buspirone (anxiolytic), 5 milligrams (mg), twice a day, with a start date of 02/17/2025; trazodone (antidepressant) 50 mg, one-half tablet every hour of sleep (hs), related to insomnia, with a start date of 02/17/2025; and Remeron (antidepressant) 15 mg, 7.5 mg (one-half tablet) by mouth at bedtime related to weight loss with a start date of 03/27/2025. Review of R22's Resident Progress Notes for the timeframe from 09/10/2024 through 07/02/2025, revealed no documented evidence the risks and benefits of the resident's use of antidepressants or anxiolytics had been discussed with the resident and/or their representative. There was also no documentation to indicate whether the resident or representative consented to the use of these medications.2. Review of R31s Resident Face Sheet indicated the facility admitted the resident on 05/22/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of major depressive disorder and insomnia. Review of R31s Care Plan included a problem statement initiated on 05/23/2025 indicating the resident was at risk for adverse side effects of psychotropic medications related to the use of antidepressant medication for insomnia and depression. Review of R31s admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further revealed the facility assessed R31 as receiving antidepressant medication during the seven-day assessment look-back period. Review of R31s Active Orders revealed orders for fluoxetine (antidepressant) capsule 40 milligrams (mg), one tablet daily in the morning, with a start date of 05/22/2025 and trazodone (antidepressant) tablet 50 mg, one tablet daily in the evening, with a start date of 05/22/2025. Review of R31s Resident Progress Notes, for the time frame from 05/22/2025 through 07/01/2025, revealed no documented evidence that the risks and benefits of the resident's use of antidepressants had been discussed with the resident and/or their representative. Further, here was also no documented evidence the resident or representative consented to the use of these medications. 3. Review of R42's Resident Face Sheet revealed the facility admitted the resident on 12/05/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia, depression, and anxiety disorder. Review of R42's Care Plan, included a problem statement dated 12/12/2023, that indicated the resident was at risk for adverse side effects of psychotropic medications related to the use of antidepressant and antianxiety medication for depression and malnutrition. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2025, revealed the facility assessed the resident as having short and long-term memory problems and severe cognitive impairment. The MDS further revealed the facility assessed R42 as receiving antianxiety and antidepressant medications during the seven-day assessment look-back period. Review of R42's Physician Order Report dated 06/01/2025 through 07/01/2025, revealed orders for mirtazapine (antidepressant) 7.5 milligrams (mg) once a day in the evening (start date 12/26/2024); lorazepam (benzodiazepine) 0.5 mg three tablets every hour as needed for anxiety, agitation, and restlessness (start date 04/21/2025); and lorazepam 0.5 mg three tablets, four times daily (start date 05/08/2025). Review of R42's Resident Progress Notes revealed no documented evidence the risks and benefits of the resident's use of psychotropic medications had been discussed with the resident and/or their representative. There was also no documentation to indicate whether the resident or representative consented to the use of these medications. During an interview on 07/03/2025 at 12:08 PM, the Social Services Director (SSD) stated the Psychiatric Nurse Practitioner (NP) ordered the medications, and the nurses discussed the risks and benefits of the psychotropic medications with the family. She stated the contents of the nurse's conversation with the family was expected to be documented in a progress note. During an interview on 07/03/2025 at 1:31 PM, Registered Nurse (RN)1 stated orders for new psychotropic medications originated from the psychiatric physician. She stated nurses then notified the resident and their power of attorney (POA) of the new order, and the physician discussed the risks and benefits of the medication with the family. RN1 stated these conversations and interactions would be documented in the progress notes to indicate the resident or responsible party was informed. During an interview on 07/03/2025 at 9:29 AM, the facility's Psychiatric NP stated that side effects of prescribed medications were discussed with the residents or their family at the time the medication was ordered. Per the Psychiatric NP, following her visit, she communicated any medication changes to the facility staff, who were then responsible for informing the family. She stated there was no specific form used by the psychiatric team to document risk/benefit discussions. Instead, she indicated it was the facility's responsibility to obtain consent, particularly for antipsychotic medications or medications with black box warnings. During an interview on 07/03/2025 at 1:38 PM, the Medical Director (MD) stated she recalled a conversation held in January or February, regarding discussions about the risks and benefits of care decisions and recent changes to surveyor guidance. However, the MD stated she did not believe the facility had adopted the required documentation. She expressed a desire for the facility to use consent forms to ensure proper communication and compliance with updated guidelines. During an interview on 07/03/2025 at 2:11 PM, the Director of Nursing (DON) stated the nurses notified families verbally for new psychotropic medications and any medication changes, with those conversations being documented in the progress notes. She stated the psychiatric physician should discuss the risks and benefits of the medication with the resident and families, and she assumed the documentation of that conversation was in the resident progress notes. She stated her expectation going forward was for the nurse to notify families of new medications or changes and for the psychiatric provider to discuss the risks and benefits with the family. She said she expected documentation of both conversations to be in the progress notes. During an interview on 07/03/2025 at 3:40 PM, the Administrator stated it was his expectation for staff to adhere to the rules and regulations for antipsychotic and psychotropic medications.

Based on interview, record review, and review of facility policy, the facility failed to ensure allegations of abuse were reported to the Administrator and State Agencies immediately, but not later than 2 hours after an allegation of abuse was made for 2 of 4 residents reviewed for abuse prohibition, Resident (R)23 and R201. The findings include: Review of the facility policy titled, Resident Abuse, revised 06/30/2023, revealed, any alleged violations involving mistreatment, neglect, exploitation or abuse, including injuries of unknown source and misappropriation of resident property, must be reported to the employee's supervisor or directly to the Administrator immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The policy revealed, When an alleged violation, suspected case of mistreatment, exploitation or neglect is reported, or there is a substantial investigation of mistreatment or abuse, the facility Administrator, or his/her designee, will notify the following persons or agencies within the time frames specified above of such incident . 2. State Licensing and Certification Agency. 1. Review of R23's Resident Face Sheet revealed the facility admitted the resident on 01/06/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left and right side. Review of R23's Care Plan, included a problem statement dated 02/08/2024, revealing the resident had limited mobility and needed assistance related to impaired balance, weakness, and poor safety awareness/judgement. Interventions directed staff to utilize a mechanical lift for transfers from chair to bed and bed to chair transfers (initiated 02/22/2024). Review of R23's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. Further review of the MDS, revealed the facility assessed the resident as dependent on staff for chair to bed and bed to chair transfers. Review of the facility Initial Report revealed on 06/21/2024 (time not documented), a resident reported that Certified Nursing Assistant (CNA)12 slammed R23 into a wheelchair when providing care. The Initial Report revealed the facility failed to notify the Administrator of the allegation until 06/23/2024 at 2:31 PM, two days after the alleged incident. A Facsimile report revealed the facility sent the initial report of alleged abuse to the State Survey Agency (SSA) on 06/23/2024 at 4:29 PM. Review of the typed facility statement for CNA15, dated 06/24/2024, revealed on Saturday (06/22/2024), R23's roommate stated CNA12 changed R23 and when the CNA transferred the resident to a wheelchair, she slammed the resident into the seat and the resident yelled loudly. Per the statement, CNA15 stated there was a lot going on that morning and she forgot to tell the nurse. It slipped my mind. During a telephone interview on 07/02/2025 at 1:42 PM, CNA15 stated a resident told her, that on Friday (06/21/2024), CNA12 was rough with R23 and had grabbed the resident's arms when she moved the resident from the bed into a wheelchair. CNA15 stated the resident told her about the incident on Saturday (06/22/2024), when the CNA was delivering a meal, and she forgot to tell anyone about the allegation. CNA15 further stated, on Monday morning (06/24/2024), the Assistant Director of Nursing (ADON) asked her about the incident, and she told the ADON that she failed to report the allegation. Review of CNA14's written statement, dated 06/23/2024, revealed a resident told her, CNA12 slammed R23 into a wheelchair on Friday (06/21/2024). During a telephone interview on 07/02/2025 at 8:35 PM, CNA14 stated, on 06/23/2024, another resident told her about an incident that happened on Friday (06/21/2024) and she immediately notified the Assistant Director of Nursing (ADON). CNA14 stated the resident told her CNA12 was rough with R23 when the resident was transferred from the bed to the wheelchair. During an interview on 07/03/2025 at 9:47 AM, the ADON stated CNA15 failed to report the allegation to anyone on Saturday (06/22/2024), after a resident told her about the incident. The ADON stated CNA15 should have reported the allegation to the nurse immediately. During an interview on 07/03/2025 at 2:12 PM, the Director of Nursing (DON) stated it was not acceptable for staff to fail to report an allegation of abuse. She stated she expected staff to report allegations immediately to the Administrator, who was also the abuse coordinator. 2. Review of R201's Resident Face Sheet revealed the facility admitted the resident on 10/04/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of osteoarthritis of the right hand, other osteoarthritis without a current pathological fracture, psychotic disorder with behavioral disturbance, and dementia, Review of R201's Care Plan, included a problem statement dated 04/25/2022, indicating the resident had limited mobility and needed assistance with mobility related to impaired balance, weakness, poor safety awareness/impulsive, and Alzheimer's disease. Interventions revealed the resident was not ambulatory and directed staff to provide total assistance with bed mobility (initiated 04/25/2022). Review of R201's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/03/2023, revealed the facility assessed the resident as having both short and long term memory loss and severe impairment in cognitive skills for daily decision-making. The MDS further revealed the resident was dependent on staff for repositioning in bed. Review of the facility Initial Report, revealed on 12/05/2023 at 10:01 AM, the resident had edema to the right hand with purple discoloration to the fourth and fifth digits (fingers). Per the report, an x-ray was obtained at 2:53 PM and the facility received the x-ray results at approximately 4:00 PM, which indicated the resident had a nondisplaced fracture at the base of the fifth digit. The report revealed the origin of the injury and time were unknown. The report further revealed the Administrator was notified at 4:00 PM. A Facsimile report revealed the facility sent the initial report to the SSA on 12/05/2023 at 5:57 PM. During an interview on 07/01/2025 at 1:45 PM, Licensed Practical Nurse (LPN) 4 stated he notified the Director of Nursing (DON) within thirty minutes of the incident of the discoloration of R201's right hand. During an interview on 07/03/2025 at 2:12 PM, the DON stated she expected staff to report any injury of unknown source immediately. During an interview on 07/03/2025 at 3:39 PM, the Administrator stated he expected staff to report all allegations of abuse or injuries of unknown source to him immediately, and he would ensure the state agencies were notified.

Based on observation, interview, record review, and review of facility policy, the facility failed to assess fall interventions related to placing a resident's bed against the wall and related to the use of a mattress with bolsters as potential restraints for 1 of 2 sampled residents reviewed for physical restraints, Resident (R) 41. The findings include Review of the facility policy titled, Use of Restraints, revised 04/2017, revealed, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. The policy continued, 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, such as side rails are put back down, rather than climbed over, and this restricts his/her typical ability to change position or place, that device is considered a restraint. The policy specified, . 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. Review of R41's Resident Face Sheet indicated the facility admitted the resident on 11/11/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of Parkinson's disease, narcolepsy, orthostatic hypotension, and neurocognitive disorder with Lewy bodies. Review of R41's Care Plan, included a problem statement dated 11/18/2024, that indicated the resident was at risk for falls related to impaired balance, weakness, and prior falls. Interventions directed staff to place a fall mat on the right side of the bed (01/07/2025). Review of R41's Resident Progress Notes, dated 01/19/2025 at 3:54 AM revealed the resident was found on the floor on the left side of the bed. Review of R41's Resident Progress Notes, dated 01/21/2025 at 1:55 PM, revealed the resident's family member requested the resident's bed to be against the wall to create more room inside the resident's room. Further review of R41's Care Plan, revealed an updated intervention to arrange the left side of the resident's bed against the wall (01/21/2025). Review of R41's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2025, revealed the facility assessed the resident as having short and long-term memory problems and as having severe cognitive impairment. The facility further assessed R41 as dependent on staff for all activities of daily living (ADLs) and as propelled by staff using a wheelchair for locomotion throughout the facility. The MDS indicated R41 had not sustained any falls since the prior assessment. Review of R41's Resident Progress Notes, dated 05/16/2025 at 2:39 PM, revealed the resident was found on the floor next to the bed on the floor mat. Further review revealed bolsters were requested for the resident's mattress. Additional review of R41's Care Plan, revealed an updated intervention to utilize a mattress with bolsters (05/19/2025). Observation on 06/30/2025 at 12:29 PM, revealed R41 was observed on what appeared to be a concave mattress, and the resident's bed was against the wall on the left side. During an interview on 07/03/2025 at 10:01 AM, the Assistant Director of Nursing (ADON) stated placing a bed against a wall, even at a family member's request, was the same as having a full bed rail. She stated regarding restraints, an assessment should be completed to ensure resident movement was not restricted. Per the ADON, a restraint assessment should have been completed when R41's bed was moved against the wall and again when the bolster mattress was added to the bed to make sure they were not restraints. She stated the facility currently did not have restraint assessments completed for the placement of R41's bed or the use of a mattress with bolsters. During an interview on 07/03/2025 at 2:11 PM, the Director of Nursing (DON) stated, R41's bed was moved over to the wall at the request of the resident's family. The DON further stated the wall was not like a full bedrail and the reason for having the bed against the wall was to keep the resident from continuing to roll out of bed and prevent potential injury. The DON stated an assessment should have been completed prior to the resident's bed being moved against the wall. Further, the DON agreed an assessment should have been completed for R41 prior to the use of the mattress with bolsters. She stated this was important to make sure they were not restraining the resident. During an interview on 07/03/2025 at 3:40 PM, the Administrator stated if a bed was moved to keep a resident from falling out of bed, an assessment should be completed to determine if it was an enabler or a restraint.

Based on interview, record review, and review of facility policy, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days in the absence of a documented rationale for extending the use of the medication. This affected 1 of 5 sampled residents reviewed for unnecessary medications, Resident (R)42.The findings include: Review of the facility policy titled, Psychotropic Medication Use, revised 07/2022, revealed psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Review of R42's Resident Face Sheet revealed the facility admitted the resident on 12/05/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia, depression, and anxiety disorder. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2025, revealed the facility assessed the resident as having short and long-term memory problems and severe cognitive impairment. The MDS further revealed R42 received antianxiety and antidepressant medications during the seven-day assessment look-back period. Review of R42's Care Plan included a problem statement, dated 12/12/2023, indicating the resident was at risk for adverse side effects of psychotropic medications related to the use of antidepressant and antianxiety medication for depression and malnutrition. Interventions directed the pharmacist to review medications for gradual dose reduction recommendations and appropriate diagnoses. Review of R42's Physician Order Report, for the timeframe from 06/01/2025 through 07/01/2025, revealed an order for lorazepam (benzodiazepine; a psychotropic drug) 0.5 milligram (mg) tablets, three tablets every hour as needed for anxiety, agitation, and restlessness with a start date of 04/21/2025 and no end date. Review of R42's Medication Administration History, for the timeframe from 06/05/2025 through 07/03/2025, revealed staff administered lorazepam to the resident on 06/10/2025, 06/14/2025, 06/16/2025, 06/22/2025, 06/23/2025, and 06/24/2025. During an interview on 07/03/2025 at 1:38 PM, the Medical Director stated PRN psychotropic medications were rarely used, and when prescribed, were intended for short-term use. The Medical Director stated she was unaware of an active PRN lorazepam order since April of 2025 for R42. She further stated she could not recall a clinical rationale for the extended use of the PRN psychotropic medication and acknowledged the issue would need to be addressed by the facility. During an interview on 07/03/2025 at 2:38 PM, the Director of Nursing (DON) stated she was unaware of an active PRN lorazepam order for R42. She acknowledged any psychotropic medication order should be limited to 14 days, and if continued beyond that, the physician must document a clear rationale in the resident's medical record. She stated the clinical team was responsible for reviewing orders to ensure compliance with the requirement, but in this case, the issue was missed. During an interview on 07/03/2025 at 3:39 PM, the Administrator stated it was his expectation for staff to follow regulatory guidelines related to PRN psychotropic medication use.

Based on interview, record review, and review of facility document and policy, there was no documented evidence alleged violations were thoroughly investigated for 2 of 4 residents reviewed for abuse prohibition, Resident (R)42 and R201.The findings include: Review of the facility's policy titled, Resident Abuse, dated 06/30/2023, revealed, Each resident has the right to be free from abuse, mistreatment, neglect, and misappropriation of property. The policy revealed the section titled, V. Investigation, included, D. The investigation shall consist of: 1. Review of witness statements; 2. Interview with the person(s) reporting the incident; 3. Interviews with any witnesses to the incident; 4. Interview with the resident; 5. Interview with the resident's attending physician; 6. Review of the resident's medical record; 7. Interviews with the staff members on all shifts having contact with the resident during the period of the alleged incident. The policy revealed, Documentation of interviews: It is necessary for all interviews to document the name and title of the person being interviewed, the date and time of the interview as well as the information provided by the interviewee. 1. Review of R42's Resident Face Sheet revealed the facility admitted the resident on 12/05/2023. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of dementia. Review of R42's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/21/2025, indicated the resident had severe impairment in cognitive skills for daily decision-making and had both short and long-term memory problems. The MDS further revealed R42 required substantial/maximal assistance with activities of daily living, and the resident also received hospice services. Review of the facility Long Term Care Facility - Self Reported Incident Form Initial Report, dated 07/12/2024, revealed R42's family member contacted the facility, notifying the facility the resident's credit card had unauthorized use. The facility investigation included three transactions for which the credit card had been used. The transactions included a local liquor store, ride share, and automated teller machine (ATM) withdrawal, with locations. The information provided to the facility reflected the card had not been used for over two years. The report revealed the police theft department was notified, and a full investigation was underway. According to the report, the facility planned to interview staff members to determine whether they heard or saw anything and planned to review video footage. Review of the Police Incident Report, dated 07/12/2024, revealed The victim's [R42] wallet was stolen from their purse at listed location [facility location]. Victim [R42] in skilled nursing section at listed location. The incident report documented five items that were stolen, which included a wallet, two credit cards, personal identification, and a social security card. The incident report did not include information regarding the three unauthorized transactions and the locations of the transactions.During an interview on 07/03/2025 at 7:37 AM, the Administrator stated he did not recall the details reported to the police; however, the three transactions should have been reported to the police. After a review of the police incident report, he stated it did not appear the transactions were communicated to the police. Review of the facility Long Term Care Facility - Self Reported Incident Form Final Report/5 Day Follow Up, dated 07/17/2024, revealed staff did not notice anything that could help with the investigation and did not see anyone taking anything that belonged to another resident. The report revealed the facility was unable to determine the perpetrator. Per the report, the resident's credit card was cancelled. The report revealed the facility's investigation was inconclusive with respect to identifying who may have taken or used the resident's credit card. According to the report, the police department report was not available, but the facility hoped to hear from the bank or police department with any information and make any corrective action necessary. Further review of the facility's complete investigation revealed no documented evidence of facility staff interviews. Further, the facility's report revealed no documented evidence the facility interviewed the hospice staff assigned to R42 during the alleged theft of the credit card. During an interview on 07/02/2025 at 10:10 AM, R42's Responsible Party (RP) (RP17), revealed unauthorized purchases had been made using the resident's credit card. Per interview, RP17 reported the issue to both the nursing supervisor and the social worker. According to RP17, R42 who had memory impairment and had required full-time care since 2023, typically kept a pocketbook in a drawer accessible to caregiving staff. RP17 denied filing a police report because the facility was to conduct a thorough investigation and notify law enforcement. RP17 stated, despite expectations and assurances from staff, the outcome of the investigation was never discussed and staff responses when questioned about the outcome were vague or dismissive. Per RP17, R42 had no other visitors. Per interview, although R17 sought accountability, there was no resolution. During an interview on 07/02/2024 at 11:30 AM, the Unit Secretary stated she became aware of the incident involving R42's missing credit card when the resident's family member informed her by phone. She stated she then transferred the call to the Social Service Director (SSD) to continue the conversation. The Unit Secretary stated she did not recall the exact time of the call. She stated she did not recall ever seeing a credit card in the resident's room. In further interview, the Unit Secretary stated she was not involved in the investigation, nor did she provide a written statement. During an interview on 07/02/2025 at 10:45 AM, the Social Service Director (SSD) stated, regarding R42's missing credit card, she communicated with R42's family and the credit card company. The SSD stated R42 was non-interviewable, had a purse in her room, and her family member reported approximately $1,000 in unauthorized charges. The SSD stated, although R42's room was searched and the incident was reported to the appropriate personnel, she did not know if staff interviews, or camera footage reviews were conducted. The SSD stated she did not contact the police or receive follow-up on the investigation's outcome. She emphasized the facility was unaware the resident had a credit card until informed by the family member. During an interview on 07/02/2025 at 11:03 AM, Detective2 stated neither the family nor the nursing facility followed up with him after initially reporting the stolen items. Detective2 further stated the facility also failed to notify him the stolen credit cards were being used, which hindered his ability to act on the information. He stated, despite the ongoing misuse of the cards, no one provided transaction details or responded to his inquiry. Detective2 further stated as a result, no investigative action was taken, and he was unable to begin or complete the investigation due to the lack of communication and information from both the family and the facility. During an interview on 07/02/2025 at 11:13 AM, Registered Nurse (RN)3 stated, although she was unaware of any resident's credit card being taken and had not witnessed such incidents, she did hear about R42's missing card from another staff member. She stated R42 had dementia and staff was unaware the resident had a credit card. Further, RN3 stated, although she had provided care for R42, she was not interviewed nor asked to provide a statement regarding the incident. During an interview on 07/02/2025 at 7:42 PM, RN6 stated she had worked at the facility since May 2023. Regarding R42, she recalled hearing from other nurses that a family member had reported missing credit cards. RN6 said she was unaware a credit card was kept in R42's room and expressed that families typically did not leave such items. She also mentioned having heard suspicions involving a male staff member, who worked the 3:00 PM to 11:00 PM shift and was assigned to the resident. RN6 stated she was not interviewed in connection with the missing card. During an interview on 07/02/2025 at 7:51 PM, RN7 stated she had worked at the facility since 2010. Regarding R42, she recalled hearing the credit card had gone missing and believed it was reported by a nurse, though she could not recall which nurse. RN7 stated she did not see the card herself, did not search for the resident's belongings, and was not approached by the family regarding the incident. She stated a male staff member assigned to the resident was mentioned in connection with the missing card. RN7 further stated she was not interviewed about the incident and was unsure whether any statements from staff were obtained. During an interview on 07/03/2025 at 9:30 AM, Hospice RN8 stated she worked with R42 in July 2024 and was never contacted by the facility regarding the missing credit card. She explained if she had been informed of the missing credit card, she would have notified her manager, who would have coordinated with the facility and initiated interviews with hospice aides to gather statements. Hospice RN8 stated she learned of the incident informally through conversations among aides and was specifically told by Licensed Practical Nurse (LPN)4, that a facility employee was suspected of taking the card. She stated despite this, neither she nor the hospice aide was formally questioned. During an interview on 07/03/2025 at 9:40 AM, the Assistant Director of Nursing (ADON) explained the facility's protocol for missing items included reporting the incident, investigating, and interviewing both staff and residents. The ADON stated staff interviews were typically conducted by the SSD and documented on paper. According to the ADON, regarding R42, she was informed upon arriving at work the resident's credit card had gone missing and was later discovered to have been used. The ADON stated the card had been kept in a drawer. The ADON further stated at the time, the interim Director of Nursing (DON) and another Administrator were responsible for conducting the investigation. During an interview on 07/03/2025 at 8:40 AM, the Former Interim DON stated she had been in the role for three weeks and any incidents involving theft should have been reported and documented. She stated she did not recall any incidents of misappropriation occurring during her time at the facility and did not recall being involved in the investigation regarding R42. During an interview on 07/03/2025 at 2:10 PM, the DON explained, when a missing item was reported, the facility's protocol included initiating a report, searching for the item, notifying the Administrator, law enforcement, and the Office of Inspector General (OIG). The DON stated interviews should be conducted with residents, staff, and family members, and all details should be documented on paper. Regarding R42, the DON clarified she was not present during the investigation, as she began her role on 07/15/2024. The DON stated at that time, the interim DON was overseeing the case. She recalled R42's credit card, kept at the facility for two years without use, was discovered to be missing by the family, prompting an investigation. Per the DON, the aide suspected in the incident, a male staff member, did not return to work following the event. The DON attempted to contact the staff member and other facility staff for follow-up. The DON stated the facility should have followed through and completed a more thorough investigation. During an interview on 07/02/2025 at 1:38 PM, the Administrator stated, during the time of the investigation into the missing credit card, there was an interim DON in place. He stated the facility should have conducted interviews with all relevant staff members and collected their statements. The Administrator stated the facility's investigation report did not include any documented staff interviews, indicating a significant gap in the facility's internal investigative process. During a follow-up interview on 07/02/2025 at 2:39 PM, the Administrator stated, after searching the facility offices there was no evidence of staff interviews being conducted. During an interview on 07/03/2025 at 3:44 PM, the Administrator stated there was no evidence of staff interviews or hospice staff interviews. According to the Administrator, he did not think the facility had completed a thorough investigation. 2. Review of R201's Resident Face Sheet revealed the facility admitted the resident on 10/04/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of osteoarthritis of the right hand, other osteoarthritis without a current pathological fracture, psychotic disorder with behavioral disturbance, and dementia. Review of R201's Care Plan, included a problem statement dated 04/25/2022, indicating the resident had limited mobility and needed assistance with mobility related to impaired balance, weakness, poor safety awareness/impulsive, and Alzheimer's disease. Interventions revealed the resident was not ambulatory (initiated 04/25/2022). Further review revealed staff was to provide total assistance with bed mobility (initiated 01/04/2024). Review of R201's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/03/2023, revealed the facility assessed the resident as having severe impairment in cognitive skills for daily decision-making and as well as short-term and long-term memory problems. The MDS indicated the resident was dependent on staff for repositioning in bed. Review of the facility Initial Report, revealed on 12/05/2023 at 10:01 AM, R201 had edema to the right hand with purple discoloration to the fourth and fifth digits (fingers). An undated Final Report/5 Day Follow Up, related to R201, revealed resident interviews indicated there were no complaints with care or reports of abuse. Review of the facility's investigation related to R201, revealed there were no written statements or questionnaires completed by interviewable residents and no skin assessments for non-interviewable residents. During an interview on 07/03/2025 at 2:12 PM, the Director of Nursing (DON) stated all skin assessments and questions to the residents and staff should be completed prior to submitting the facility's Final Report/5 Day Follow Up, preferably within 24 hours to make a sound decision.During an interview on 07/03/2025 at 3:39 PM, the Administrator stated, for an investigation to be complete it should include interviews, assessments, and the root cause of what occurred.

Based on interview, record review, and facility document review, the facility failed to provide evidence that a Level I Preadmission Screening and Resident Review (PASRR) was submitted to the state's PASRR authority and failed to have evidence of the results of the assessment for 1 of 2 residents (Resident (R) #22) reviewed for PASRR. The findings included:Review of facility Resident Face Sheet indicated the facility admitted Resident #22 on 09/10/2024. According to the Resident Face Sheet, the resident had diagnoses including dementia with other behavioral disturbance, anxiety disorder, psychotic disorder with delusions, psychosis, and adjustment disorder with anxiety.Review of the quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 05/22/2025, revealed Resident #22 had severe impairment in cognitive skills for daily decision-making and had a short- and long-term memory problem per a Staff Assessment of Mental Status (SAMS) exam. The MDS also revealed Resident #22 received antidepressant and antianxiety medication during the assessment's look-back period.Review of Resident #22's Care Plan, included a problem statement initiated 09/18/2024, that indicated the resident was at risk for adverse side effects of psychotropic medications. Interventions directed staff to assess the resident and notify the physician for side effects of antidepressant medications such as sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (heart rate over 100 beats per minute), muscle tremors, agitation, headache, skin rash, photosensitivity of the skin, excess weight gain (initiated 09/18/2024); assess and notify the physician for side effects of anxiolytic medications (used to treat anxiety disorders) such as ataxia (a neurological condition characterized by poor muscle coordination), nausea, vomiting, or confusion (initiated 09/26/2024); to consult with the psychiatric physician as needed (initiated 09/18/2024); and for the pharmacist to review medications for gradual dose reduction recommendations and appropriate for the diagnosis (initiated 09/18/2024).Further review of Resident #22's diagnoses list revealed the resident's diagnoses of dementia with behavioral disturbances, psychosis, psychotic disorder with delusions and adjustment disorders with anxiety were all present on admission and dated 09/10/2024 and a diagnosis of generalized anxiety disorder dated 01/31/2025.Review of Resident #22's Active Orders, contained an order for buspirone (anti-anxiety) 5 milligram (mg) twice a day with a start date of 02/17/2025; trazodone (antidepressant) 50 mg 1/2 tablet once every evening with a start date of 02/17/2025; and Remeron (antidepressant) 7.5 mg at bedtime related to weight loss with a start date of 03/27/2025.Review of facility document titled Nursing Facility Application, dated 09/13/2024, for Resident #22 revealed a PASRR Level I was completed by MDS Coordinator (MDSC) #16. The Nursing Facility Application did not indicate the results of the PASRR Level I or if the document was submitted.During an interview on 07/03/2025 at 11:59 AM, MDSC #16 stated Resident #22 was admitted to the facility as private pay and not from the hospital. MDSC #16 stated she was the one that entered the initial assessment information into the PASRR system; however, she did not receive confirmation that the assessment was accepted or an alert for a Level II to be completed.During an interview on 07/03/2025 at 12:08 PM, the Social Services Director (SSD) stated she was the coordinator for the PASRR Level IIs. She stated a liaison initiated or completed the information needed for the PASRR Level I while a resident was in the hospital, and if a resident needed a Level II, she went into the PASRR system and put in a request for a Level II. The SSD stated the facility did not print anything out to show if the assessments were received by the PASRR office as complete or if the Level I was positive or negative. She stated if the facility did not hear anything from the PASRR department, they assumed everything was okay.During an interview on 07/03/2025 at 2:11 PM, the Director of Nursing (DON) stated there were two people who completed PASRRs. The DON stated that before admission to the facility, a liaison entered information into the PASRR system and obtained a PASRR. The DON stated her expectation was that the PASRR process be completed as it should be, so that the facility was in compliance with the regulations.During an interview on 07/03/2025 at 3:40 PM, the Administrator stated he knew a PASRR was done on admission and if the resident had psychiatric issues, but he did not know a lot about the process.

Based on observation, interview, record review, review of facility document and policy, the facility failed to complete a root cause analysis and determine appropriate interventions to reduce the risk of further falls for 1 of 3 residents reviewed for accidents, Resident (R)41. R41 sustained a fall on 01/30/2025 at 8:10 AM; however, there was no documented evidence the facility attempted to determine the root cause. Subsequently, R41 sustained another fall on 01/30/2025 at 9:44 PM.The findings include: Review of the facility's policy titled, Falls - Clinical Protocol, revised 04/2013, revealed the section titled, Cause Identification, included, 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. The policy revealed the section titled, Treatment/Management, included, 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). The policy revealed the section titled, Monitoring and Follow-Up, included, . 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Review of R41's Resident Face Sheet revealed the facility admitted the resident on 11/11/2024. According to the Resident Face Sheet, the resident had a medical history including diagnoses of Parkinson's, progressive supranuclear ophthalmoplegia, narcolepsy, orthostatic hypotension, and neurocognitive disorder with Lewy bodies. Review of R41's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2025, revealed the facility assessed the resident as having severe impairment in cognitive skills for daily decision-making and both short and long-term memory problems. The facility further assessed the resident as dependent on staff for all activities of daily living (ADLs), and assessed the resident as using a wheelchair for locomotion throughout the facility, propelled by staff. The MDS indicated R41 had not had any falls since the prior assessment. R41's Care Plan, included a problem statement dated 11/18/2024, revealing the resident was at risk for falls related to impaired balance, weakness, and prior falls. Interventions directed staff to assess and report any decrease or loss of function status, decreased balance, or decreased range of motion to the physician (11/18/2024); assist with glasses as needed (11/18/2024); keep the resident's bed in the resident's preferred position (11/18/2024); keep the call light within reach and remind/encourage the resident to ask for assistance (11/18/2024); encourage the resident to wear non-skid socks and/or properly fitting footwear when transferring or any time when out of bed to minimize risk of slipping (11/18/2024); keep room free of clutter and obstacles (11/18/2024); neurochecks as ordered (11/18/2024); pharmacy review of medications to identify any which may increase fall risk (11/18/2024); and see psychotropic care plan related to possible side effects of psychotropic medications (11/18/2024). Additional interventions directed staff to place nonskid socks when in bed (12/09/2024); to place a fall mat to the right side of the bed (01/07/2025); and place the left side of the bed against the wall (01/21/2025). Review of 41's Resident Progress Notes, dated 01/30/2025 at 8:10 AM, revealed a call was placed to the resident's family member notifying them the resident had been found on the floor with no injury. The Resident Progress Notes revealed no documented evidence staff attempted to determine the root cause and evaluate for appropriate interventions or the need for new interventions to reduce the risk for future falls. Review of R41's Care Plan, revealed no new interventions were put into place after the fall. Review of R41's Facility Event Summary Report for the timeframe from 12/01/2023 to 07/01/2025, revealed no documented evidence of a fall event for this fall. Review of R41's Resident Progress Notes, dated 01/30/2025 at 9:44 PM, revealed a staff member entered the resident's room to provide R41 medications and found the resident on the floor on the right hip. R41's head was leaning against the bed. Per the Resident Progress Notes, the bed was in the lowest position, the floor mat was in place at the right side of the bed, and the call light was in place. Review of R41's Facility Event Summary Report for the timeframe from 12/01/2023 through 07/01/2025, revealed a fall event dated 01/30/2025 at 10:20 PM. According to the Report, R41 experienced a fall and there was redness and a skin tear noted to R41's knees. The Report revealed the interdisciplinary team (IDT) reviewed the event and determined the root cause was the resident was exhibiting increased restlessness, and a referral was made for hospice services. However, R41's Care Plan revealed no new interventions were put into place immediately following the fall. R41's Care Plan was updated on 05/19/2025 with an intervention for a Immersus mattress (mattress designed to protect high fall risk patients) with bolsters. During an interview on 07/02/2025 at 1:54 PM, Registered Nurse (RN)10 stated R41 was at risk for falls and currently had a fall mat. He stated when a resident sustained a fall, he would look around the room to determine the reason for the fall, especially for residents who could not state what happened. RN10 stated after a resident sustained a fall, the nurses reviewed the resident's care plan and put in a new intervention to try to prevent the resident from falling again and to keep the resident safe. He stated regarding falls, nurses should put an intervention into place and update the care plan immediately and not wait for the IDT to meet. During an interview on 07/03/2025 at 10:01 AM, the Assistant Director of Nursing (ADON) stated R41 was a fall risk, especially on admission. She stated the process for a fall was for the nurse to assess the resident for injury and document the fall on the 24-hour report sheet. Per the ADON, the management team reviewed falls in the morning meeting. The ADON stated fall interventions depended on the root cause analysis and what the resident was doing at the time of the fall. During an interview on 07/03/2025 at 2:11 PM, the Director of Nursing (DON) stated the process for a fall was for the nurse to ask the resident what happened, assess the resident for injuries, and then look for the root cause. Per the DON, the nurses were to implement an immediate intervention, then the IDT would meet and look at the intervention put in place and if needed change the intervention. During an interview on 07/03/2025 at 3:40 PM, the Administrator stated nurses should determine the root cause of a fall to help protect the resident. The Administrator said if a resident continued to fall, then staff needed to try another intervention.

Based on observation, interview, record review and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for wound care, Resident (R)41. During observation of R41's wound care on 07/02/2025, Registered Nurse (RN)11 did not remove his soiled gloves or wash his hands after cleaning the resident's wound, and prior to beginning treatment to the wound bed, which was a clean process.The findings include:Review of the facility's policy titled, Wound Care, undated, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy revealed, . 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water. 12. Remove dry gauze. Apply treatments as indicated. 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing.Review of R41's Resident Face Sheet indicated the facility admitted the resident on 11/11/2024. According to the Resident Face Sheet, the resident had a medical history including diagnoses of Parkinson's, and neurocognitive disorder with Lewy bodies.Review of R41's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/06/2025, revealed the facility assessed the resident as having severe impairment in cognitive skills for daily decision-making and both short and long-term memory problems. The MDS further indicated the resident had one Stage 2 pressure ulcer. Review of R41's Care Plan, included a problem statement dated 04/10/2025, which stated the resident had an actual skin impairment of a Stage 2 pressure ulcer on the coccyx. Interventions directed staff to provide treatment as ordered (initiated on 04/10/2025).Review of R41's Active Orders, revealed an order dated 04/09/2025, for MediHoney (antibacterial wound treatment) paste topical with instructions to clean coccyx wound with normal saline, pat dry, apply MediHoney with calcium alginate (wound dressing) to site and cover with foam dressing twice a day and as needed. During a wound care observation on 07/02/2025 at 10:25 AM, of RN11 performing wound care for R 41, the nurse placed a barrier on the bedside table and washed his hands. RN11 then donned gloves and retrieved the wound care supplies from the treatment cart, placing them on the barrier. He then donned a gown for enhanced barrier precautions (EBP). RN11 washed his hands, donned gloves, and removed the soiled dressing from R41's coccyx wound. He then doffed his gloves, washed his hands, and donned clean gloves. RN11 cleaned the wound with normal saline and 4 x 4 gauze and patted the wound dry with a 4 x 4 gauze dressing. RN11 then failed to doff his soiled gloves and wash or sanitize his hands. RN11 proceeded to open a cotton tipped applicator and apply MediHoney ointment to the wound bed while wearing the soiled gloves. RN11 then applied a one-inch square of calcium alginate over the wound and covered the wound with a dated and initialed border dressing while wearing the soiled gloves. RN11 then doffed his gloves, washed his hands, removed the EBP personal protective equipment, and threw away the soiled items in the trash. During the observation, after cleaning the wound with normal saline and a 4 x 4 gauze and drying the wound, RN11 did not remove his soiled gloves before beginning treatment to the wound bed, which was a clean process. RN11 further did not change gloves or wash his hands at any point during the remainder of the wound care treatment, until the end, when he was removing his EBP personal protective equipment and throwing away the trash. During an interview on 07/02/2025 at 2:36 PM, RN11 confirmed he should have changed his gloves and sanitized his hands in between dirty and clean aspects of the dressing change. RN11 stated he could not recall whether he did that or not during the dressing change.During an interview on 07/03/2025 at 2:11 PM, the Director of Nursing (DON) stated it was her expectation for the nurse to change gloves between dirty and clean processes. During an interview on 07/03/2025 at 3:40 PM, the Administrator stated it was his expectation for the nurses to follow the rules and regulations for infection control regarding wound care.

Based on interview, record review, and review of the facility's video footage and policies, it was determined the facility failed to protect one (1) of seven (7) sampled residents (Resident #1) from neglect. On 01/26/2024 at approximately 7:50 PM, Resident #1 (R1) sustained a witnessed fall out of his/her wheelchair. R1 had a history of blood clots and had been receiving blood thinning medication (Eliquis, Plavix and Aspirin) prior to the fall on 01/26/2024. The resident sustained an injury to his/her head and right side of face. R1's nurse, Licensed Practical Nurse (LPN) #1 documented that she had notified the on-call physician and received orders to perform neuro checks per the facility's protocol, and to apply a cold pack to the affected area of the resident's face. However, when LPN #1's documented progress notes and neurological (neuro) check assessment findings were compared to the facility's video footage, it was determined the LPN failed to complete the neuro checks, and apply the cold pack as ordered. Per the facility's protocol, LPN #1 should have assessed R1 thirteen (13) times over the course of the night. Interviews with staff, and the Medical Director revealed LPN #1 neglected to re-assess and evaluate R1's mental/neurological status and notify the medical provider of those changes. Registered Nurse, (RN) #2 assessed the resident and documented on 01/27/2024, at 8:52 AM, that R1 was not responding appropriately; was unable to follow commands; and had a blood pressure (B/P) reading of 192/102. R1 was transferred to the hospital and diagnosed with bilateral subarachnoid hemorrhage (bleeding in the area surrounding the brain which if left untreated, could lead to permanent brain damage or death), and a right orbital blowout (fracture of one [1] or more of the bones that make up the eye socket) fracture. The facility's failure to take immediate action and have a system in place to ensure residents were protected from neglect is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 02/22/2024 at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600). The Immediate Jeopardy was determined to exist on 01/26/2024. The facility was notified of Immediate Jeopardy (IJ) on 02/22/2024. An acceptable Immediate Jeopardy Removal Plan was received on 02/24/2024, which alleged removal of the Immediate Jeopardy on 02/23/2024; however, the State Survey Agency (SSA) validated Immediate Jeopardy was removed on 02/24/2024, prior to exit on 02/24/2024. Non-compliance remained in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect and Exploitation (F600) at a Scope and Severity (S/S) of a D; while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's, Resident Abuse policy dated 01/24/2024, revealed each resident had the right to be free from abuse, mistreatment, neglect, and misappropriation of property. Per review, all employees were expected to follow the policy, and failure to do so would result in immediate termination. Continued review revealed the definition of Neglect was the failure of the facility, it's employees or service providers to provide the necessary goods and services for a resident to avoid physical harm, pain, mental anguish, or mental distress. Further review of the policy, revealed employees were to be trained as part of their orientation and through ongoing sessions regarding issues related to abuse. Review of the facility's, Neurological Assessment policy dated February 2014, revealed the purpose of the procedure was to provide guidelines for a neurological assessment which included providing the assessment: upon physician's order; following an unwitnessed fall; subsequent to a fall with a suspected head injury; or when indicated by the resident's condition. Review of the policy's general guidelines revealed when assessing a resident's neurological status, frequent vital signs should always be performed. Per policy review, particular attention was to be paid to widening pulse pressure (difference between systolic and diastolic pressures), which might be indicative of increasing intracranial pressure (ICP), and any change in vital signs or neurological status (in a previously stable resident) to be reported to the physician immediately. Continued review revealed the steps in the procedure were for nursing to: perform neurological checks with the frequency ordered or as per the protocol; determine the resident's orientation to time, place, and person; observe the resident's patterns of speech and speech clarity; take the resident's temperature, pulse, respirations, blood pressure, check his/her pupil reaction and determine motor ability; determine sensation in the resident's extremities; check the resident's gag reflex, and smile related to facial drooping, check eye opening, verbal and motor responses using the Glasgow Coma Scale (GCS, a scale used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients). Additionally, review revealed the above procedure information was to be recorded in the resident's medical record and the information regarding any change in a resident's neurological status reported to the physician, and the information reported in accordance with the facility's policy and professional standards of practice. Review of the facility's Neurological Flow Sheet protocol undated, revealed nursing documentation of a resident's vital signs and neuro checks was to be performed: every (q) fifteen (15) minutes for one (1) hour; q thirty (30) minutes for one (1) hour; q one (1) hour for four (4) hours; then q four (4) hours for twenty-four (24) hours. Continued review revealed documentation neuro assessments were to be completed as the policy indicated. In addition, further review of the neurological flow sheet in italic text revealed the direction of nurses to Progress along this time schedule ONLY if signs were stable and review further revealed nursing staff were to Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!!. Review of the facility's, Change in a Resident's Condition or Status policy statement dated February 2014, revealed the facility was to promptly notify the resident's attending physician, and his/her representative (sponsor) of changes in the resident's medical/mental condition and/or status. Further review revealed a significant change of condition was defined as a decline or improvement in a resident's condition. Review of the facility's, Licensed Practical (Vocational) Nurse Position Description undated, revealed the characteristic duties and responsibilities included making observations and reports of pertinent information related to the care of a resident; and conducting self in a professional manner in compliance with the unit and facility policies. Continued review revealed the Licensed Practical Nurse's (LPN's) Minimum Performance Standards in the area of assessment was to provide documentation of resident observations and accurately reflect the resident's status, and the LPN's knowledge of unit documentation policies and procedures. Further review revealed the LPN's Minimum Performance Standards also included ensuring changes in a resident's physical/psychological condition (changes in laboratory [lab] data, vital signs, and mental status), were reported appropriately. In addition, the Evaluation Of Care section revealed observations related to the effectiveness of nursing interventions, and medications, were reported as appropriate and documented in the resident's progress notes. Review of LPN #1's personnel record, revealed she signed acknowledging the receipt and understanding of the facility's, Handbook Acknowledgement Form; Employment Agreement; Prevention and Reporting; as well as acknowledgement of policies specific to abuse/neglect and responsibilities related to the LPN's employee Job Description, on 06/21/2022. Per continued review of LPN #1's personnel record revealed it included a facility Termination Form, dated 02/05/2024, with the LPN's last day worked noted as 02/01/2024, for violation of unsatisfactory performance, no neuro-checks as ordered, signed by the Director of Nursing (DON). Additionally, further review of the personnel records revealed a Complaint Form was electronically filed to the Kentucky Board of Nursing (KBN) on 02/06/2024, regarding the allegation of neglect and falsification of medical records of the respondent nurse, LPN #1. Review of Resident #1's clinical record revealed the facility admitted the resident on 11/10/2023, with diagnoses including cerebral vascular accident (CVA); atrial fibrillation (A-Fib) and was on Eliquis (anticoagulant); coronary artery disease (CAD). Further review revealed the resident received aspirin and Plavix (prevent blood clots). Diagnoses included dementia; and aphasia following cerebral infarction. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated severe cognitive impairment. Review of R1's Progress Note dated 01/26/2024 at 9:00 PM, documented by LPN #1 revealed the resident had experienced an unwitnessed fall at hours of sleep (HS). Per review, upon assessment R1 was lying on the floor prone (lying flat on the stomach), with the right side of his/her face having visible edema to the right eye and cheek. Continued review revealed R1 complained of pain to the affected area (right side of the face); however, denied pain elsewhere. Further review revealed Neuro checks were initiated and continued per protocol without abnormalities observed. Record review revealed an order was received to hold R1's HS Eliquis tonight only and apply a cold compress to the affected area of the face. Additional record review revealed R1's Physician's Orders contained no orders written for the telephone orders given by the Medical Director regarding performing neuro checks or applying a cold compress to R1's affected area. Review of R1's progress note dated 01/27/2024 at 6:28 AM, documented by LPN #1 revealed the resident remained in bed throughout the shift while Neuro checks performed as scheduled resulting within normal limits. Continued review of the progress note revealed edema to the right side of Resident #1's face decreased; however, visible bruising was observed to the resident's right eye. Review of R1's progress note, completed by Registered Nurse (RN) #2 on 01/27/2024, at 8:52 AM, revealed the resident was not responding appropriately, was unable to follow commands, and had a blood pressure (B/P) reading of 192/102. Further review revealed the resident was transferred to the hospital and diagnosed with bilateral subarachnoid hemorrhage and a right orbital blowout fracture. Review of R1's Hospital Records dated 01/27/2024 at 10:43 PM, revealed the resident presented to the emergency department (ED) per Emergency Medical Services (EMS) personnel after he/she was found down at the nursing home. Continued review revealed nursing reported to the EMS personnel that R1's last known normal state of consciousness was at 8:00 PM last night (01/26/2024), when staff assisted the resident to bed. Further review revealed this morning around 9:00 AM, staff went and checked on R1 and found him/her lying on the floor. Review further revealed upon EMS' arrival, R1 was almost entirely aphasic (loss or impairment of the power to use or comprehend words) with altered mental status (AMS). Additional review revealed at baseline, R1 was alert, conversational, and ambulated with wheelchair. Continued review of R1's hospital, notes dated 01/27/2024, revealed the resident had right periorbital ecchymosis (discoloration of the skin resulting from bleeding underneath) and edema with traumatic chemosis (swelling of the tissue lining the eyelids and surface of the eye from accumulation of fluid); his/her right pupil measured four (4) millimeters (mm), and the left pupil three (3) mm, equally reactive to light. Review further revealed imaging results revealed a bilateral subarachnoid hemorrhage (SAH) (Left >Right) in the setting of taking Aspirin/Plavix/Eliquis medication, and right orbital floor blowout fracture, post fall. Review of R1's hospital Palliative Note, dated 02/01/2024, revealed the resident's fall injury prognosis was indicative of long-lasting residual effects with persistent altered mental status (AMS), decreased responsiveness, and inability to eat, requiring a feeding tube for long-term nourishment replacement. Further review revealed the Discharge disposition orders revealed R1 was discharged back to the nursing home facility on 02/19/2024. Review of the facility's, Initial Report investigation, dated 02/02/2024 at 7:24 PM, revealed the description of the incident revealed R1 fell in his/her room on 01/26/2024, in which he/she sustained injury to his/her head, and the fall was witnessed by his/her roommate who called for help. Review of the statement from the Certified Nursing Assistant (CNA), on duty at the time of the fall, revealed based upon positioning of R1's body, it appeared as if he/she might have gotten up from his/her wheelchair and attempted taking steps before falling. Continued review revealed the Medical Director was notified of the fall, and neuro checks were to be initiated along with application of an ice pack to the affected area. Review of the Initial Report documentation revealed nursing progress notes indicated Pt. (patient) remained in bed throughout shift while neuro checks performed as scheduled resulting within normal limits (WNL), edema to right side of face decreased but visible bruising to right side of eye. Per continued review of the Initial Report, at 8:52 AM on 01/27/2024, the nurse (RN #1) went to R1's room to administer his/her morning medication, and upon assessment the resident was not responding appropriately and was unable to follow commands. Further review of the Initial Report revealed the ED, initiated a search for documentation of the neuro checks, and when unable to find the documentation, despite searching facility records, hospital records and the shred it bin, a review of video tape for the evening and early morning hours until EMS transported the resident to hospital was conducted. The review of the video tape revealed LPN #1 had not completed the neuro checks as documented; therefore, was suspended from duty pending the investigation. Review of the facility's, Final Report/5 Day Follow-Up investigation dated 02/08/2024 at 4:47 PM, revealed the video tape review was considered the primary witness and step of the investigation. Per review, the video tape of the hours beginning just prior to the fall, through the time R1 was transported from the facility by ambulance at 9:00 AM on 01/27/2024, revealed LPN #1 entered the resident's room at the time of the fall, and four (4) additional times after the fall. Review of the summary of interviews on the Final Report/5 Day Follow-Up revealed the Director of Nursing (DON) spoke with LPN #1, to ask her what she did with the neuro check documentation from R1's fall. Continued review of the summary of interviews documentation revealed LPN #1 stated she passed the neuro check information on to the next nurse and the information was placed on the physician's board that contained resident important information, such as lab results, neuro -checks, and imaging results, etc. Continued review of the final report, dated 02/08/2024, revealed LPN #1 stated R1's assessment was within normal limits except for the hematoma to his/her eye area, and she notified the physician who gave new orders for neuro checks and to place an ice pack to the hematoma. Per the review of LPN #1's statement the DON asked her if the neuro checks had truly been completed and the LPN stated yes. Continued review revealed the DON then informed her according to the video the neuro checks were not completed, and LPN #1 then stated she had checked on R1 during the night and there had been no change to his/her baseline. Further review revealed the DON informed LPN #1 of what the camera footage had shown; however, LPN #1 did not offer any explanation after being told that by the DON. At that time, the DON informed LPN #1 the facility had to separate her employment effective immediately. In addition, the facility concluded Resident #1's neuro-checks had not been completed, following the facility's review of the video recording of LPN #1's performance during the shift in question. Review of the facility's, Video Footage provided and viewed on 02/16/2024 at 11:30 AM, revealed it was footage from 01/26/2024, of the East hallway, where Resident #1 resided and of the nurses' station. Further review revealed the video footage began just prior to the fall at approximately 7:00 PM, through the time when EMS transported R1 from the facility at approximately 9:00 AM on 01/27/2024. Continued review of the video revealed it was determined LPN #1 entered R1's room at the time of the fall (7:50 PM) and four (4) additional times, at 8:31 PM, 10:50 PM, 12:17 AM, and 5:56 AM. However, per review of the facility's protocol, LPN #1 should have assessed R1 thirteen (13) times over the course of the night shift following the fall. In addition, further review of the video footage revealed LPN #1 entered R1's room at 12:17 AM and exited at 12:19 AM, but no further footage of the LPN entering the resident's room again until 5:56 AM. However, review of the progress note documented by LPN #1 on 01/27/2023 at 6:28 AM, revealed R1 remained in bed throughout her shift, and neuro checks were performed as scheduled and resulted in the LPN noting the neuro check were WNL (within normal limits). Per review of the documented progress note compared to the facility's video footage revealed one (1) set of vital signs completed at the time of R1's fall. Continued record review revealed however, no documented evidence of LPN #1's neuro check assessments. Review of R1's roommate, R7's medical record revealed the facility assessed the resident to have a BIMS score of thirteen (13) which indicated he/she was cognitively intact and interviewable. During interview with R1's roommate, R7 on 02/16/2024 at 9:45 AM, the roommate stated the evening of R1's fall, R1 had been his/her normal self the entire day, sitting up in the wheelchair which had been placed beside R1's bed. He/She stated R1 had been laughing and cutting up while visiting with his/her son. The roommate stated however, at approximately 7:30 PM or 8:00 PM, as soon as R1's son left, the roommate heard a loud thump and observed R1 lying face down on the floor in front of his/her bed. R7 stated he/she screamed out for help, and everyone came running and got R1 back onto the bed using a mechanical lift. The roommate stated he/she had not noticed any blood, but the side of R1's face was swollen, and something was not right, The roommate stated R1 had not been the same since the fall. He/she stated R1 just lays there and stares out, no joking or cutting up like before. During an interview with R1's Family Member (F1), on 02/20/2024 at 12:32 PM, he stated he was informed about R1's fall on 01/26/2024, and was told the resident was fine and sleeping. Per the interview, he stated he received a call from the facility the next morning and was told the resident was unresponsive, his/her blood pressure was very high, and EMS was called to transfer the resident to the ED. F1 stated he rushed to the facility and arrived the same time as the ambulance. Further, he stated, It was really bad. F1 stated the entire right side of R1's face was swollen and his/her right eye was black/blue and swollen shut. He stated the resident was unconscious and was not responding to him. He added the EMS personnel made the decision to divert from transferring R1 to the local hospital to a trauma center due to the resident's condition and extent of his/her injuries. The Family Member stated R1 remained unconscious for eight (8) to nine (9) days after sustaining the fall, and even now weeks after the fall, the resident was only awake for maybe one (1) hour out of the day. He stated R1 also could not talk, or communicate, and had to have a feeding tube placed to keep him/her alive. During an interview with CNA #6 on 02/21/2024 at 9:08 AM, she stated she had been aware of R1's fall prior to starting her shift on 01/26/2024 at 7:00 PM. CNA #6 stated at the time she assisted R1 back to bed with other staff, she observed no bleeding; however, she had observed swelling to the right side of his/her face and around the right eye. She stated but of most importance after the fall, R1 was not communicating that much. CNA #6 stated the night R1 fell , he/she showed no response to being turned and did not laugh after his/her roommate made his/her normal comment. The CNA stated at approximately 1:00 AM, she notified LPN #1 of a change in R1's condition that included increased swelling and discoloration to the right side of the resident's face and eye. She stated that cognitively, the resident was not acting the same as normally. She stated she could not recall an ice pack being applied to R1's face/eye throughout the rest of the shift. During an interview on 02/19/2024 at 2:43 PM with LPN #3, he stated R1 could communicate his/her needs appropriately prior to his/her fall on 01/26/2024. LPN #3 stated he had worked 7:00 AM till 7:00 PM the day of R1's fall incident, and had given report to the oncoming night nurse, LPN #1 at approximately 7:00 PM, with nothing new to report, nor changes in condition or any problems from his shift. LPN #3 stated while he was charting at the nursing station at approximately 7:45 PM-7:50 PM, he heard a resident call out for help, saying there was an emergency. He stated at that time, he responded and observed R1 in his/her room, lying face down towards the door at the end of his/her bed, and his/her wheelchair was next to the bed. LPN #3 stated he called out for the assigned nurse, LPN #1 and she responded from the room next door, took control of the situation with CNA #2 who was assigned to care for R1. LPN #3 further stated he felt R1 should have gone out to the hospital with that type of fall and injuries sustained, and normally, from his experience as a nurse, the nurse would recommend sending a resident out for further evaluation with any head injuries and/or hematomas. During an interview on 02/19/2024 at 3:17 PM, RN #2 stated on 01/27/2024 at approximately 7:00 AM, she was the oncoming nurse and received report from LPN #2 that R1 had fallen the previous evening, and the resident had bruising and swelling to the right side of his/her head and face. She stated LPN #1 informed her that she immediately started neuro checks of R1 and performed them up until 6:00 AM - 6:30 AM. Per RN #2, the LPN reported all the neuro checks had been normal, and at the time of shift report, RN #2 was to take over performing the neuro checks of R1 every four (4) hours. RN #2 stated after receiving report, LPN #1 handed her R1's neuro check log sheet at approximately 7:10 AM, and she looked at it and it appeared to have been filled out and complete, so she had no questions or concerns. The RN stated at approximately 7:30 AM, she started her morning rounds; however, she did not perform a formal assessment of R1 on her first round. She stated she just peeked in R1's room to ensure the resident was in a safe position, with his/her bed in the low position, and he/she had his/her oxygen on, and the call light was within reach. In a continued interview with RN #2 on 02/19/2024 at 3:17 PM, she stated her next morning round was at approximately 8:00 AM - 8:30 AM, when she performed her medication pass. Per RN #2, at approximately 8:30 AM, she entered R1's room with the resident's medications and observed R1 was not his/her normal self. She stated R1 did no respond and was unable to communicate, so vital signs were taken and she noted the resident's blood pressure was highly elevated and she observed swelling and bruising to the right side of R1's face and eye. RN #2 stated at that time she notified the physician and requested to send R1 out to the hospital for evaluation. The RN stated it had not been the scheduled time per the facility's protocol to perform R1's neuro checks, she documented the results of her assessment and physician notification in a progress note. She stated she made copies of her progress note to send with EMS personnel and put the original neuro check paper log in the medical records bin to be scanned into R1's profile. RN #2 stated the next morning a nurse from the hospital called and stated they had not received any documentation or neuro check documentation from the facility, and it was important because the physicians needed to know R1's baseline and time with change of events. RN #2 stated she retrieved the original paper neuro check log from the medical records bin and faxed it to the hospital as requested, along with other record information for R1, then returned the original documents back into the medical records bin or might have possibly placed it in the shred bin, she was just not sure. During an interview on 02/20/2024 at 1:02 PM, the Advanced Practice Registered (APRN), stated upon R1's admission in November 2023, the resident had a history of a stroke and was on blood thinners (Eliquis), related to a history of blood clots. Per the APRN, typically R1, at baseline, would answer yes/no questions appropriately. Per the APRN, she stated she was made aware of the resident's fall the next day. The APRN stated if the resident was on a blood thinner, she would consider various factors such as resident history, medication regimen, current clinical status, code status and seriousness of fall, to make the decision whether to transfer a resident out for further evaluation. She stated if a resident had a fall with a head injury it would be of high importance for nurses to perform neuro checks and reassess the resident as much as possible. Further, the APRN stated, on 02/20/2024 at 1:02 PM, that performing the neuro checks and reassessing the resident was important in order to detect and report even the slightest change in the resident's neurological status, such as increased blood pressure, increased sleeping and/or decreased communication, and possiblity of bleeding, to prevent any delay in the resident receiving the care he/she needed. The APRN stated a nurse neglecting to perform the neurological checks and not informing the physician of any type of change in condition, could cause a delay in resident care; and therefore, the brain bleed could become bigger and if not stopped, could lead to the worst neurological outcome. The APRN stated she could see a difference in R1 since his/her fall, which included not being verbal, his/her alertness came and went, there being more right sided swelling and deficit decline as well as now requiring a feeding tube for nutrition. Further interview revealed the APRN truly felt it was neglect of R1 when he/she had not received the necessary care and services required. During an interview with the Assistant Director of Nursing (ADON) on 02/19/2024 at 9:00 AM, she stated she was made aware of R1's fall and transfer to hospital on 01/29/2024, per LPN #3's report. She stated after being notified of R1's fall she began looking into the incident and started the investigation process with the DON and ED, as her normal procedure with any incident. The ADON stated on 01/30/2024, after interviewing LPN #1 about R1's neuro check findings, and the LPN's claim that she had completed the neuro checks and took care of the resident, and handed off the neuro check log to RN #2 the following morning. She said at that time she spoke with RN #2, and the RN claimed having possession of the neuro check log sheet from LPN #1, and reviewing the log on the morning R1 was transferred out of the facility. The ADON stated RN #2 told her she had sent (faxed) a copy of the neuro check log to the hospital per their request, and then proceeded to put the neuro check log sheet in the shred bin. She stated after the interview with RN #2, she and the ED searched the shred bin and the medical records bin for the neuro check log; however, found nothing. The ADON stated after continued discussion with the team, and having no evidence of the neuro check log or any other documents noted by LPN #1 related to R1's fall on 01/26/2024. In a continued interview with the ADON, on 02/19/2024 at 9:00 AM, she stated she and the ED initiated a review of the video tape footage for the evening shift on 01/26/2024 of the care provided for R1's care and LPN #1's performance. The ADON stated she and the ED reviewed the video footage and determined LPN #1 had not completed the neuro checks according to the facility's protocol. The ADON stated the ED notified the Medical Director, and DON of the results and contacted the appropriate parties. She further stated she had been involved with the education and implementation of neuro checks, change in residents' condition, the procedure to follow for a fall and post-fall procedures, as well as the monitoring of nursing performance to ensure accuracy and proficiency. Per the ADON's interview, she stated LPN #1 was fully aware of the facility's policies and procedures through the on-hire and continuing education; therefore, LPN #1 failed in her nursing duties by not performing R1's neuro-checks, not performing a complete and thorough assessment of the resident after a fall, and by not notifying the physician of R1's change in condition. The ADON stated she felt LPN #1 failed to triage and implement the facility's education of policies and procedures. She stated LPN #1 also failed in her nursing skills for R1 from the beginning to the end, and ignored the seriousness of the resident's injuries, treating it as if nothing happened. The ADON stated therefore, an unfortunate outcome occurred for R1, and affected not only the resident but the entire facility. She further stated it was neglect of R1 when the resident did not receive the necessary care and services he/she required. During an interview with the Director of Nursing (DON) on 02/19/2024 at 9:17 AM, she stated on 01/29/2024 she was informed of Resident #1's fall, that she and the ADON started the investigation process to gather the appropriate evidence to establish a root cause analysis (RCA) of resident's incident/fall under investigation. The DON stated per policy and procedure, nursing staff were educated/trained and aware of the importance to start neuro-checks and once the resident was safe and secure to inform the physician immediately of the type of fall, resident's appearance and assessment of his/her current status, as well as the result of their injuries and any pertinent medical information such as history and current medication regimen the physician would need to know for decision making and orders. The DON stated, after staff interviews, review of the video footage, and no evidence of documentation, it was evident of LPN #1's failure of following facility policy and procedures and neglecting nursing standards of practice and performance. Therefore, DON stated after discussion with the ED, and MD, determination was made on 02/05/2024 that LPN #1 falsified documentation and neglected resident care and safety. It was neglect of Resident #1 when he/she did not receive the necessary care and services required. During an interview on 02/21/2024 at 1:07 PM, the Medical Director stated she was R1's physician and had a good relationship with the resident. The Medical Director stated the night of R1's fall she received a call from LPN #1, somewhere between 8:00 PM - [TRUNCATED]

Based on interview, observation, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to provide a safe environment for four (4) of thirty-six (36) sampled residents (Residents #2, #20, #38 and #108). The facility admitted Resident #38 with a known history of falls, and assessed the resident to be at high risk for falls and had poor cognitive memory. Resident #38 had five (5) falls in four (4) weeks. Staff educated the resident, who had poor cognitive memory, to remember to use the call light to call for the immediate intervention with the fall. The resident had a fall on 05/06/2021. However, the facility did not implement a new intervention until 05/20/2021, after the resident had a fall on 05/18/2021, which resulted in a fracture to the left clavicle. In addition, the facility failed to provide a safe environment for Residents #2, #20 and #108. Resident #2 sustained a skin tear during personal care provided by staff wearing jewelry. The facility assessed Resident #20 as a two (2) person assist, required a gait belt and gripper socks. Staff transferred the resident with one aide and no equipment, the resident fell and sustained a laceration. The facility assessed Resident #108 as a two (2) person assist for transfers. However, staff transferred the resident with one aide; the resident had a fall during the transfer. The findings include: Review of the facility's policy, Falls and Fall Risk Managing, revised March 2016, revealed staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident's fall and to try to minimize complications from a fall. According to the Minimum Data Set (MDS), the definition of a fall included the unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an external force (push from another resident). When a fall occurred despite initial interventions, the facility would implement additional or different interventions. In addition, if the underlying causes could be identified or complement additional or different interventions the facility would try various interventions based on the assessment until the falls were reduced, stopped or until the reasons for the continuation of the falls were identified as unavoidable. In addition, the staff would monitor the resident's response to the new interventions intended to reduce falls or the risk of falls. Review of the facility's policy, Fall Risk Assessment Policy, undated, revealed the nursing staff along with others would seek to identify and document the resident's risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Upon admission, the facility would identify the resident's falls within the past ninety (90) days; the resident's risk of falls; assess underlying medical conditions which increased the risk of injury of falls; Activity of Daily Living (ADL) capabilities, and cognition which may increase the resident's risk of falls; and, modify fall risk factors and interventions to minimize the risk factors which were not modifiable. Review of the facility's policy titled, Accident and Incidents-Investigating and Reporting undated, revealed all accidents and incidents involving residents on the facility's property shall be investigated and reported to the Administrator (ADM). The management team shall promptly initiate and document the investigation of the accident or incident. The Director of Nursing (DON) ensured the Administrator received a copy of the report. The Charge Nurse was promptly notified of any change in condition to a resident. Review of the facility's policy titled, Safety and Supervision of Residents, undated, revealed safety risks and hazards were identified on an ongoing basis through a combination of employee training, monitoring and reporting process, Quality Assurance and Performance Improvement (QAPI) reviews of the incidents and accidents. Further review of the facility's policy revealed when accident hazards were identified QAPI shall evaluate and analyze the cause and develop a way to mitigate the hazards. Additionally, this policy revealed employees were trained on potential accident hazards and demonstrated competency on how to identify and report them. Review of the facility's, Employee Handbook dated 2019, revealed under the Appearance/Uniform tab; excessive jewelry was not permitted. 1. Record review revealed the facility admitted Resident #38, on 04/09/2021, with the diagnoses of Cerebral Infarction, Dementia, and weakness. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) with a score of fourteen (14) and deemed the resident was interviewable. The facility assessed the resident with a history of falls prior to the admission, and the resident had one (1) fall since admission to the facility. Further review revealed the MDS Care Area Assessment (CAA) triggered for falls risk and care planning for fall risk. Review of Resident #38's History and Physical, dated 04/12/2021, revealed the facility admitted the resident for therapy after treatment for an acute mild stroke. The provider assessed the resident with [CONDITION(S)], confusion, and difficultly holding attention. Review of the Physician's Order's, 04/09/2021, revealed the resident received [MEDICATION(S)] (blood thinner) two point five (2.5) milligrams (mg) twice a day and received [MEDICATION(S)] (diuretic) twenty (20) mg every morning. Review of the Fall Risk Assessment, dated 04/10/2021 at 1:23 AM, revealed the resident scored an eleven (11). The assessment score of ten (10) or higher revealed a high risk for falls. Review of the Baseline Care Plan, dated 04/12/2021, revealed the facility initiated the baseline care plan for care related to an acute infarction. The interventions to meet the immediate needs of the resident included: place the bed in low position, place nonskid socks to feet when not wearing appropriate footwear, and one person assist with transfers, ambulation, and toileting. Review of the Saint Louis University Mental Status (SLUMS) examination, dated 04/30/2021, revealed the facility assessed the resident for cognitive impairment and dementia with a total score of thirteen (13) out of thirty (30). The score of 13 revealed the resident exhibited dementia. Review of the facility's Event Report, dated 04/10/2021 at 12:00 PM, revealed Registered Nurse (RN) #1 documented Emergency Medical Staff (EMS) observed Resident #38 fall after the resident stood up from a sitting position in the wheelchair. The facility staff's new interventions included to remind the resident to use the call light and ask for assistance, and signs were posted in the room. Interview with RN #1, on 06/15/2021 at 2:18 PM, revealed the RN had provided care for Resident #38 since admission. The RN stated the resident presented on admission with severe confusion, lack of safety awareness and short term memory loss. RN #1 stated on admission, the resident often attempted to get up from the w/c, transfer to the toilet without help, and staff frequently reminded the resident to use the call bell. However, the resident remembered at the moment of instruction and forgot when staff left the room or area because of the resident's confusion. The RN revealed the EMS staff observed the resident stand from the w/c and fall forward while in the resident's room on 04/10/2021 at 12:00 PM. Further interview revealed the resident sustained a skin tear from the fall and did not know if the facility's fall protocol included to start a new intervention after a fall, but she knew the completion of the Event Report required a new intervention after the fall until the managers reviewed the report. The RN stated the facility's basic interventions for all residents on admission included a low bed, gripper socks, and use of the call bell for assistance. RN #1 further revealed after the initial three (3) interventions, the only other intervention the facility could do included to remind the residents to use the call bell for assistance, verbally and they posted signs in the room. Continued review of the facility's Event Report, dated 04/10/2021 at 12:00 PM, revealed RN #1 noted staff determined the resident did not call for assistance and the immediate intervention the RN placed included to remind the resident to not get up without staff's assistance. However, the resident's admission diagnoses included a cerebral infarction (stroke) and dementia; and, RN #1 stated the resident had severe confusion, lacked safety awareness, and could not remember due to short term memory issues. Further review revealed the facility closed the event and did not update the care plan until 04/26/2021, sixteen days (16) after the fall. Review of the Nurse's Progress Note, dated 04/11/2021 at 3:23 AM, revealed staff assessed the resident with confusion and redirected the resident to sit down in the w/c multiple times because the resident would stand up from the w/c. Interview with Family #10, on 06/15/2021 at 3:33 PM, revealed the facility reported the resident had a fall by the white laundry hamper in the resident's room. The family reported they washed and returned the clean clothes for the resident and picked up the laundry several times a week. Family #10 stated when they visited the day of the fall, the resident focused, and apologized for the smell in the room of the soiled cloths in the hamper. The family revealed the resident explained staff removed the resident's soiled sleep pants and placed the soiled pants into the hamper without bagging or rinsing out the pants. The family revealed the resident had memory issues but would understood the pants would start to stink and probably went to the hamper to rinse the pants out before the family came. Review of the facility's Event Report, dated 04/21/2021 at 6:02 AM, revealed Licensed Practical Nurse (LPN) #3 documented Resident #38 had a fall and the resident across the hallway observed the fall and activated the call bell to alert staff. The resident, who alerted staff, reported Resident #38 pushed the white laundry hamper and slipped between the basket and the bed. The LPN noted the resident did not lock the wheels to the chair. LPN #3 noted the w/c was the only intervention used prior to the fall. Review of Nurse's Progress Note, dated 04/21/2021 at 2:38 AM, revealed the nurse observed the resident attempt to self-transfer to use the bathroom. Further review revealed the nurse encouraged the resident to use the call bell for assistance. However, the nurse noted the resident remained alert with periods of confusion. Record review revealed the facility admitted Resident #18, (Resident #38's) on 12/08/2020, with the diagnoses of Diabetes, Heart Failure, and Hypertension. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) with a score of fourteen (14) and deemed the resident interviewable. Interview with Resident #18, on 06/14/2021 at 2:00 PM, revealed he/she alerted staff that Resident #38 had a fall on 04/21/2021. The resident stated he/she observed Resident #38 try to get into the laundry hamper by the resident's bedside. Resident #18 stated the resident stood up while he/she held onto the basket, the hamper slid, and the resident fell . Observations, on 06/14/2021 at 2:30 PM, revealed a white laundry hamper remained between the bed and the outer wall next to Resident #38's bed. Interview with LPN #3, on 06/12/2021 at 7:07 PM, revealed Resident #38 would constantly stand up out of the chair, attempt to transfer, or attempt to walk without staff. The LPN revealed staff would verbally redirect and educate the resident to call for assistance with the activation of the call light. LPN #3 stated the resident's memory could be good one day and bad the next day so verbal reminders for the resident to call for help did not work, but staff still tried with the resident's poor safety awareness. The LPN stated the facility placed gripper socks, kept the bed low, ensured the call bell was within reach, signs were in the room, and staff checked on residents at night with rounds when they peered into rooms as they passed. Review of the facility's Event Report, dated 04/21/2021 at 6:02 AM, revealed LPN #3's immediate intervention included to remind the resident to call the nursing staff for assistance and secure the call bell to the resident's chair. However, the facility closed the Event Report and updated the care plan on 04/26/2021, five (5) days after the event and added a device called a Reacher (equipment to aide the resident to reach for item) to the resident's fall interventions. According to the facility's policy, the facility's investigation would find the underlying cause and implement additional or different interventions to prevent additional falls related to the investigations findings. However, observations revealed the white laundry hamper remained next to the resident's bed and accessible to the resident. Observation, on 06/14/2021 at 1:20 PM, revealed the Reacher laid on the resident's table and his/her cell phone laid on the opposite side of the table away from the resident. During the interview, the cell phone rang, the resident got up from the wheelchair, attempted to walk, and reach the phone instead of the use of the Reacher, which was in front of the resident. Review of the facility's Event Report, dated 05/03/2021 at 10:15 AM, revealed RN #1 documented staff found Resident #38 on the floor on his/her back in front of his/her sink in the resident's room. This incident was noted as an unwitnessed fall. Further review revealed the resident reportedly had attempted to wash his/her hands at the sink. The interventions prior to the fall included the w/c, call light and nonskid shoes. The nurse's intervention to further reduce the occurrence of a fall included to encourage the resident to use the call bell. However, the facility's policy stated the facility would implement additional or different interventions to prevent additional falls. Review of the facility's second Event Report, dated 05/03/2021 at 4:15 PM, (two falls on the same day) revealed according to RN #1, staff found Resident #38 with a walker on top of him/her with the resident on his/her back on the floor at the entrance to the room. The facility's previous interventions implemented included the call bell, w/c and walker prior to the fall. RN #1 assessed the resident with no injuries, and placed the resident back into his/her wheelchair. Continued review of the facility's Event Reports revealed the facility's immediate intervention on, 05/03/2021 at 10:15 AM, was the resident's sink was not low enough for the resident to access, but sanitizer was available on the wall. Interventions for the fall 05/03/2021 at 4:15 PM included to clip the call bell to the resident's wheelchair, place oxygen to the resident, and reinforced to the resident to use the call light for assistance for the immediate new intervention to prevent further falls. Further review revealed the facility closed the event on 05/06/2021 and updated the intervention on 05/06/2021. The interventions included to encourage the resident to wash his/her hands before and after meals. However, the event report noted the sink was not low enough for the resident with a wheelchair and observations reveal the sanitizer dispenser height did not allow the resident to reach it from the wheelchair. Interview with RN #1, on 06/15/2021 at 2:18 PM, revealed staff continually reminded the resident to use the call bell for assistance because there were no other interventions to start for Resident #38 or with residents who could not remember to call for help. RN #1 stated the resident used his/her own walker, which staff left in his/her room. The RN stated the resident used the walker for therapy and used a w/c for any other needs. However, she stated the resident had used a walker when he/she lived in the independent living apartment and probably just used the walker like he/she always did. The RN revealed the walker was folded and put in the corner of the room. Continued review revealed the resident did not remember his/her limitations with ambulation and balance and despite the constant reminder to call for help the resident would get up. The RN stated the facility could not prevent falls in the facility and they did all they could for Resident #38. Review of the Provider Progress Note, dated 05/03/2021, revealed the resident had an examination after a non-injury fall. During the examination, the resident remarked that he/she got mad because he/she did not know why he/she had fallen. The provider noted the resident had poor decision and safety awareness. Further review revealed the provider noted the plan included to encourage the resident to use the call light. Review of Nurse's Progress Note, dated 05/05/2021 at 5:14 AM, revealed LPN #2 supervised the resident at the nurse's station because the resident attempted several times to get out of the bed without help. LPN #2 noted the resident remained confused at times, continent of bladder and bowel with occasional periods of incontinence. Review of the facility's Event Report, dated 05/06/2021 at 5:45 PM, revealed RN #2 documented staff heard a clunk and at the same time the resident across the hall from Resident #38 called out for help. RN #2 noted the resident's previously observed activity included dining in his/her room with dinner at the bedside. Further review revealed staff found the resident at the doorway, on the floor, and the resident's wheelchair remained at the resident's bedside. RN #2 assessed that the resident had reinjured the skin tear on his/her left elbow. The facility's previously implemented interventions included the w/c and nonskid socks/shoes before the fall. The nurses returned the resident to the wheelchair and attached the call bell. Continued review of the event report, dated 05/06/2021, revealed RN #2's implemented new interventions to further reduce the occurrence of a fall included to encourage the resident to be out of the room while awake and added signs in the room to call for help. However, the facility had implemented to post signs on 04/26/2021. The facility closed the event and updated the care plan on 05/20/2021, fourteen (14) days after the event, and two (2) days after the resident had a fall and fractured his/her clavicle. The facility's policy stated the facility would implement additional or different interventions to prevent additional falls. Interview with Resident #18, on 06/14/2021 at 2:00 PM, revealed he/she yelled for help when Resident #38 fell by the door. The resident stated (Resident #38) went to the closet door in his/her wheelchair, stood up at the door, and attempted to open the doors and fell backward. The resident stated that he/she believed the resident attempted to get cloths from the closet to dress for the night. Resident #18 reported the facility did not interview him/her after the witnessed falls he/she reported. Interview with RN #2, on 06/17/2021 at 1:42 PM, related to the fall on 05/06/2021, revealed she did not remember the resident or the incident and therefore could not discuss the event. Interview with Family #10, on 06/15/2021 at 3:33 PM, revealed the facility notified the family of each fall, without notification of what immediate intervention the facility initiated to address the reason for the fall. In addition, the family member stated the facility did not notify them of any updated care plan interventions. Family #10 stated the resident had injuries with the falls other than on 05/18/2021. The family member stated they met several times with the clinical floor staff, the Director of Nursing (DON), and twice with the Administrator about concerns for Resident #38's safety, the number of falls in a short amount of time, and the report from staff that the resident continually attempted to get up by himself/herself. Continued interview revealed they discussed staffing concerns because when they visited the resident, staff's slow response to the resident's request for help to the bathroom would lead the resident to go to the bathroom without assistance. The family member stated the facility discussed the implemented fall prevention interventions of a low bed, visual cue card to ask for help, and kept reminding the resident to call for assistance. Furthermore, the family member stated the staff expressed to the family no other interventions could be done for the resident except to constantly remind the resident to call for help, and that the facility could not prevent all falls. However, the family member revealed the resident had memory issues, which could be good at one time, bad the next time, and they often found the resident without his/her hearing aids in, or they were not turned on, which only furthered the issue of safety. Family #10 stated the resident's quality of life and care needs were not being met by the facility. Review of the Nurse's Progress Note, dated 05/09/2021 at 6:02 PM, revealed the family reported to staff the hearing aids placed in the resident's ears were not turned on and had to provide verbal instructions to staff on how to turn on the device. Review of the facility's Event Report, dated 05/18/2021 at 3:15 AM, revealed LPN #2 was notified Resident #38 had fallen when Resident #38's roommate activated the call bell and alerted staff about the fall. Further review revealed staff found the resident on the floor, lying on his/her left side and faced the dresser in the room. LPN #2 noted a large hematoma to the resident's left side of his/her head, left hand swelling, and left clavicle swelling with complaints of pain. The facility sent the resident out to the emergency room for an evaluation. Interview with LPN #3, on 06/12/2021 at 7:07 PM, revealed she last saw the resident at 12:30 AM with medication round. LPN #3 stated the resident remained in bed asleep, and at the time of the fall the aides continued care for the assigned residents. The LPN stated the resident had been confused on the the evening of the fall and she had kept the resident at the nurses' desk to monitor. The roommate notified staff at 3:15 AM that the resident had a fall. The LPN revealed she found the resident on the floor, between both residents' beds and faced toward the dresser while he/she moaned in pain. The LPN stated her assessment concluded the resident either dislocated or fractured his/her arm. LPN #3 revealed the facility admitted the resident with a high risk for falls, poor cognition, poor safety awareness, and multiple falls had occurred before 05/18/2021. The LPN stated each nurse completed an event report, started a new intervention at the time of the fall, documented on the event report the event questions, new intervention, and the next day the DON or ADON reviewed the event report. Continued interview revealed the ADON and DON reviewed the report and determined if the intervention met the resident's safety need, if not it remained their decision what intervention to start and to put the intervention on the care plan the next day. The LPN revealed the facility did not notify her of new interventions or care plan updates. She stated the information was usually passed in report, with the exception of the fall mat after 05/18/2021. The LPN revealed the resident could toilet, however the resident was not on a toilet schedule. LPN #3 revealed staff's intervention of reminders and redirection to use the call bell or ask for help didn't work because the resident would not remember after staff gave the education. Attempts to interview CNA #4 as the event witness on 05/18/2021 were unsuccessful with three attempts to contact. Review of the Emergency Visit Hospital Report, dated 05/18/2021 at 5:12 AM, revealed Resident #38's diagnoses included a distal left clavicle fracture with inferior displacement, scalp hematoma, bruise to the left hand, and fall. Further review revealed Orthopedics recommended non-surgical treatment, to place a left arm sling on at all times except when in the shower, and to follow up two (2) to four (4) weeks for x-ray to evaluate the healing process of the fracture. Review of the Provider's Progress Note, dated 05/19/2021, revealed the resident fell on [DATE] which resulted in a left clavicle fracture, left head bruise and left arm pain. The provider plan noted the resident continued to have poor safety awareness and explained to the family that falls could happen at any time and recommended the resident continue to room with his/her roommate for safety reasons. Interview with CNA #9, on 06/15/2021 at 3:15 PM, revealed the facility admitted Resident #38 after he/she had a stroke. The aide revealed the resident was more confused than the aide experienced with the resident's last admission. The aide revealed she would not leave the resident in his/her room because the resident would try to go to the bathroom, change the bed, get his/her cloths, and try to walk like when he/she had in the independent apartment. The aide stated residents with poor cognition often get busy when staff left them alone in a room. CNA #9 revealed to tell the resident with poor memory to use the call bell or call for help did not work because the next second the resident would not remember. The aide revealed the resident could go to the bathroom and when he/she had to go to the bathroom, he/she went to the bathroom, and she found this as the main reason the resident would be up out of the chair. The aide revealed the resident must have had a job which required him/her to get up really early because the resident always fell in the early morning when he/she would try to go the bathroom and get dressed for the day. However, the aide revealed the facility did not inquire to her about the resident's habits, she did not report the observations, the resident did not have a toilet schedule, or an early morning routine before he/she fell and broke the arm. Interview with LPN #4, on 06/17/2021 at 11:00 AM, revealed Resident #38 required stand by assistance of one staff. The LPN revealed the resident required redirection to call for staff. LPN #4 revealed the resident was forgetful and the resident could not remember to use the call bell. The LPN stated the resident got up with staff all the time before the fall and after the fall he/she did not get up without help. The LPN revealed she cared for the resident when she worked and did not receive information from staff or management for new interventions after a fall. The LPN revealed she did not review the resident's care plan for new interventions. But the main interventions included low bed and a fall mat if the resident fell out of bed. LPN #4 revealed the facility expected the nurse to start an appropriate intervention immediate to try to prevent another fall. The LPN revealed to tell Resident #38 to use the bell or call for help would not be appropriate. Further interview revealed if staff did not start a new and appropriate intervention it meant the facility did not keep the resident safe. The LPN revealed the facility expected staff to keep residents safe. However, the nurses needed to have interventions for the staff to follow to keep the residents safe. Interview with the Physical Therapist, on 06/14/2021 at 2:30 PM, revealed the therapy assessed Resident #38 as a high risk for falls, unsteady, poor strength, and maximum assist when the facility admitted the resident. The therapist revealed the SLUMS exam revealed the resident scored on the level for dementia. Further interview revealed the resident presented as very confused for the first month of admission, did not follow direction, command, and did not understand he/she had a stroke that effected his/her body. The therapist revealed the department relayed assessment findings and concerns to the nursing staff as appropriate or with the fall management meeting once a week. The therapist revealed the facility's admissions were more acute and they admitted higher acuity residents with cognitive issues. The therapist revealed the facility opened the admission policy which lead to the changes in population which probably related to resident falls. Interview with the Rehabilitation Director, on 06/19/2021 at 2:00 PM, revealed the resident could not hear without hearing aids and therefore could not hear if staff provided redirection for safety concerns. The Director stated that she and staff observed the resident without the hearing aids when staff met with the resident for therapy, and the therapists put the aids for the session. Interview with the Assistant Director of Nursing (ADON), on 06/20/2021 at 11:12 AM, revealed the admission nurse completed the focus care plans for residents. The ADON revealed the fall protocol for the facility included to assess the fall risk at admission and start the baseline care plan with the basic intervention for all residents with a fall risk which included to keep the bed low, have the call bell in reach, and to have gripper socks on when shoes were not in place. The ADON revealed when the resident experienced a fall, the nurse assessed the resident for injury and started a new intervention immediately. The ADON revealed a resident who fell five (5) times within a month of admission meant the resident had ineffective interventions. Further interview revealed repeated reminders to use the call bell could not remain an effective intervention if it did not work the first time and usually was ineffective with residents with memory issues. The ADON revealed the facility's intervention included an immediate response. However, the fall team meeting occurred once a week and the facility reviewed the fall interventions by staff, added other interventions, and monitored the resident. The ADON revealed the administrator expected all staff to follow policies to care for the residents. Interview with the DON, on 06/23/ at 4:00 PM, revealed she had not identified issues with falls in the facility. However the ADON reviewed the event report for the falls in the facility. The DON revealed if the resident fell it meant the staff did not follow the resident's care plan. Further interview revealed the staff completed an event report and started a new intervention at the time of the fall. She stated the ADON reviewed the event including the intervention, and updated the residents' plan of care if it had not been already done. The DON revealed the ADON met with therapy once a week to review the event reports and they made changes to residents' care at the meeting. The DON revealed she changed the facility's meetings to three (3) times a week because she identified the need to address resident care more than once a week. She stated she did not realize Resident #38 had five (5)falls in a month's time, before the resident broke his/her shoulder. The DON stated that the resident should not have fallen that many times. The DON revealed she expected staff to follow policy. Interview with the Administrator, on 06/24/2021 at 2:32 PM, revealed the facility had not identified quality of care concerns in the areas of falls, injury or to maintain a safe environment. He stated if the facility found any issues it would have been addressed them and educated staff. However, the resident had the right to decline treatment. He stated his responsibility to the residents and staff included to do everything he could do to meet every regulation he was required to meet. The Administrator stated the facility audited care provided by staff to the residents, by the system. He stated by system he meant when a treatment or service had not been provided, the facility's system notified staff the care need had not been completed. 2. Review record revealed the facility admitted Resident #2 on 06/04/2019 with diagnoses of Alzheimer's, Dementia without behaviors and [CONDITION(S)]. Review of Resident #2's Minimal Da [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan timely with effective interventions to prevent recurring falls for one (1) of thirty-six (36) sampled residents, Resident #38. Record review revealed Resident #38 fell on [DATE], 04/21/2021, 05/03/2021 twice, 05/06/2021. Continued review revealed the care plan revisions did not occur timely and the resident fell again on 05/18/2021. The facility transferred Resident #38 to an acute care facility where the resident was diagnosed with a fractured clavicle. The findings include: Review of the facility's policy, Comprehensive Person-Centered Care Plans (CCP), revised 2016, revealed a CCP included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. Care plans are revised as information about the residents and the resident's condition changes. Review of the policy Falls and Fall Risk Managing, revised March 2016, revealed the facility staff identified interventions related to the resident's specific risks. When a fall occurred the facility implemented additional or different interventions. In addition, if the underlying causes could to be identified or corrected, the facility would try various interventions based on the assessment until the falls were reduced, stopped or until the reason for the continuation of the falls were identified as unavoidable. In addition, the staff would monitor the residents response to the new interventions intended to reduce falls or risk of falls. Clinical record review revealed the facility admitted Resident #38, on 04/09/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed the resident as an extensive one person assist with transfer and toileting, and used hearing aids devices. Review revealed the facility developed a focus care plan for a risk of falls and communication. Review of Resident #38's CCP, dated 04/19/2021, revealed the facility developed a fall focus for impaired balance, weakness, poor safety awareness, and use of psychological medication. The fall focus interventions implemented on 04/19/2021 included assess/report decreased status, balance or motion, bed low, call light in reach with the staff to encourage the use and ask for assistance, encourage non-skid socks or footwear with transfers, room free of clutter, pharmacy reviews, and to see [CONDITION(S)] care plan for possible side effects. Record review of facility event, dated 04/10/2021, revealed the facility report by RN #1 included staff witnessed the resident fall when he/she stood up from the wheelchair without assistance. Record review of the Resident #38's care plan revealed the facility revised the interventions related to the 04/10/2021 fall on 04/26/2021 for visual cue to call for assistance. The revision occurred sixteen (16) days after the fall. Record review of facility event, dated 04/21/2021, revealed the facility report by LPN #3 included an unwitnessed fall occurred and found the resident on the floor at the laundry hamper by the bed. Observations, on 06/14/2021 at 2:30 PM, revealed a white laundry hamper remained between the bed and the outer wall next to the Resident #38's bed. Record review of Resident #38's care plan revealed the facility revised the interventions related to the 04/21/2021 fall on 04/26/2021 to include a tool to reach with called a Reacher. The revision occurred five (5) days after the fall. Record review of facility event, dated 05/03/2021, revealed the resident fell at 10:15 AM and at 4:15 PM. RN #1 reported at 10:15 AM revealed an unwitnessed fall of the resident at the sink. The resident reported an attempt to wash his/her hands but the sink was not low enough for the resident to reach from the wheelchair. RN #1 report at 4:15 PM revealed a witnessed fall by another resident, Resident #38 fell in front of the door with a walker found on top of the resident. Record review of the Resident #38's care plan revealed the facility revised the interventions related to the 05/03/2021 fall on 05/06/2021 to include to encourage to wash hands before and after a meal. The facility revised the care plan three (3) days after the fall. Review of the event evaluation, dated 05/06/2021, revealed the facility evaluated the 4:15 PM fall on 05/03/2021 and concluded the walker needed to be removed from the immediate area when not in use by staff or therapy. However, review of the care plan revealed the facility did not revise the fall care plan to reflect the plan. Record review of facility event, dated 05/06/2021, revealed RN #2 reported the resident fell at the base of the door to the room. The resident had walked away from the wheelchair which remained at the resident's bedside. Record review of the Resident #38's care plan revealed the facility revised the interventions related to the 05/06/2021 fall on 05/20/2021 which included to encourage the resident to be out of the room while awake and fall mat. However, the resident fell on [DATE] and fractured his/her left clavicle. The facility did not revise the care plan until after the resident fell which resulted with an injury. Interview with LPN #3, on 06/12/2021 at 7:07 PM, revealed when resident's fall the facility policy included to start a new intervention to decrease the potential for a fall. The LPN revealed she put the intervention for Resident #38 on the event report. The LPN revealed she could put the new intervention on the care plan they started. However, she let the Assistant Director of Nursing (ADON) or Director of Nursing (DON) review the intervention on the report sheet and if they decided they wanted to keep it then the care plan could then revised. The LPN revealed the revision of a care plan after a fall ensured the resident's new intervention documented the care the resident required to prevent a fall. The LPN revealed the facility should revise the care plan by the next day of a residents fall because it left the opportunity for falls to continue and then the resident would get hurt. Interview with RN #1, on 06/15/2021 at 2:18 PM, revealed the facility expected staff to start a new intervention immediately after a resident fell . The RN revealed Resident #38 fell the first day after admission and on 05/03/2021 under her care. The RN revealed she documented the new intervention in the event report and then the care plan should be revised. However, the RN revealed to have difficulty with the electronic program with access and navigation and therefore lets the managers revise the care plan. The RN revealed the revision to the actual care plan needed to occur within one to two days to decrease the chance of another resident fall. The RN revealed 5 to 16 days as to long to revise a care plan and it put the resident's safety at risk. The RN further revealed the facility reviewed the falls once a week. Interview with the MDS coordinator, 06/20/2021 at 9:30 AM, revealed she revised care plans quarterly and with significant changes. She revealed she did not revise care plans after the resident fell in the facility. She revealed she did not attend the fall committee meeting every week. She revealed the clinical nursing staff were responsible to revise the care plan for new intervention for a fall and she had no involvement with the process. Interview with the Assistant Director of Nursing (ADON), on 06/20/2021 at 11:12 AM, revealed the facility committee for falls met once a week to review the fall event reports for the facility. The ADON revealed the facility committee only met once a week and several weeks were missed last month. The ADON revealed the resident's revisions after a fall occurred immediately after the resident fell and should be completed by the staff. The ADON revealed with the weekly review the committee reviewed the new intervention and would decide if the intervention met the root cause and revised the care plan further if necessary. The ADON revealed the clinical team had not audited the care plans for timely or appropriate revisions. Interview with the DON, on 06/23/2021 at 4:30 PM, revealed she expected staff to revise the resident care plans at all the time of a fall to ensure resident remained as safe as the facility attempt. The DON revealed she knew some staff had difficulty using the electronic care plan program. The DON revealed she assigned the fall event review and care plan revisions for the fall review process to the ADON. The DON revealed the fall committee which consisted of the ADON and the Therapy Director met once a week for review and revisions of care. The DON revealed she was unaware of issues with revisions of the care plan in required to the length of time or staff not completing the revision the day of the incident. However, she was aware the fall committee had not met for several weeks in a row. The DON revealed the clinical team did not complete audits of resident care plans in order to identify issues. The DON revealed to have identified areas of education needs with staff which included care planning and revision of the care plan. Interview with the Administrator, on 06/24/2021 at 2:52 PM, revealed the facility did not identify issues for revisions of resident care plans. He revealed the facility revised the resident care plans with any significant change. He revealed the resident had a right to refuse the care plans. He revealed with the discussion of quality of care the resident had a right to fall and the facility could not prevent a fall.

Based on observation, interview and review of facility policy, it was determined the facility failed to serve food in a sanitary manor. Observations during the survey revealed dietary staff cross contaminated food with improper hand hygiene during meal services. In addition, wash/rinse temperatures and sanitization chemical levels were not documented. The findings include: Review of the facility's policy titled, Environmental Sanitation/Infection Control, revised 2014, revealed pathogenic organisms could be transferred to hands from a variety of sources and then moved from hand to food during preparation and service. Employees involved in the storing, preparing, distributing and serving of food should wash their hands frequently using proper cleaning procedures to prevent food contamination and the spread of food borne illness. Further review revealed the policy described proper hand washing techniques as water turned on, hands rinsed under clean, soap applied and all surfaces of the hands and fingers were rubbed together vigorously with friction for at least twenty (20) seconds, giving particular attention to the area under the fingernails, between the fingers/fingertips and surfaces of the hands and arms. Hands were to be properly washed before and after entering the food preparation area. Single use gloves were to be donned when working with food and between glove changes, when engaging in food preparation, handling clean equipment and serving utensils, switching between cooked and raw food, handling soiled dishes, and equipment or utensils. Observation of Dietary Aide #3, on 06/08/2021 at 11:50 AM, revealed she continuously touched her gloved hands to her pant legs. In addition, she rested her hands on her pant legs when she bent over to see the meal tickets on trays. She also touched the top of the plate with her gloved hand while she plated food to balance the plate in her hand. Dietary Aide #3 was also observed, with the same gloves on, to move spaghetti back on to the plate which had slid off. While Dietary Aide #3 continued to plate food with the same pair of gloves she reached under the steam trays and rummaged through a storage container to look for a particular utensil and then went back to plating food. Observation revealed that at no time throughout this process did she change her gloves or wash her hands. Unable to interview Dietary Aide #3, as she left after her shift on 06/08/2021 and did not return to work. Interview with the facility's Chef, on 06/12/2021 at 8:00 AM, revealed when staff plated food their hands should have been washed, dried and gloves put on. He also stated cross contamination could be caused by: duty changes without proper hand hygiene; failure to wash hands properly; work done with cooked and uncooked food; and, food that had not been cooked properly. He stated gloved hands should not touch staffs' clothes and then touch food, because of the potential for cross contamination. Interview with the Dietary Service Director (DSD), on 06/12/2021 at 8:35 AM, revealed she worked at the facility for four (4) years but had been in the industry for many years. The DSD stated proper hand hygiene and sanitation were extremely important while in the kitchen because improper practice could result in food borne illnesses or death to residents who were already high risk. Continued interview with the DSD on 06/12/2021 at 8:35 AM, revealed it was proper practice to change gloves every time staff went in and out of the pantry area. She stated the staff's gloves should have been changed and her hands washed after she looked through the containers prior to handling food again. Continued interview revealed it was also the expectation when staff plated food their hands would be off of the plate, otherwise that was unsanitary. 2. Review of the Pot and Pan Sink Sanitizer Chart provided by the facility for the three-compartment sink, on 06/12/2021 at 8:00 AM, revealed the facility used Oasis 146 Multi-QUAT Sanitizer- 200 to 400 parts per million (ppm), 75 degrees quaternary (consists of four (4) units) test strip. Charting was to be done three (3) times daily by staff, in the AM, NOON and PM, to document that the checks fell into the correct perimeters for sanitization, and initialed by staff who ran the test. Review of the Tracking Chart for February 2021, revealed no documentation on 02/19/2021, 02/22/2021 and 02/25/2021 thru 02/28/2021. Review of the Tracking Chart for March 2021, revealed staff did not initial the document on 03/05/2021, 03/08/2021, 03/12/2021 and 03/13/2021. Further review revealed the Chart was not completed from 03/18/2021 thru 03/28/2021. Review of the Tracking Chart for April 2021, revealed staff did not initial it on 04/02/2021 through 04/06/202; nor on 04/08/2021, or 04/10/2021 through 04/12/2021. In addition, tracking was not documented as completed from 04/16/2021 through 04/19/2021. Nor on 04/24/2021, 04/25/2021, 04/29/202 and 04/30/2021. Review of the Tracking Chart for May 2021, revealed staff did not initial it on 05/01/2021 through 05/03/2021, nor on 05/05/2021 and 05/07/2021 thru 05/10/2021. The chart was not completed on 05/14/2021 thru 05/17/2021 nor for 05/27/2021 and 05/28/2021. In addition, 05/21/2021 through 05/24/2021 and 05/28/2021 thru 05/31/2021 were blank. Interview with the facility's Chef, on 06/12/2021 at 8:00 AM, revealed the three-compartment sink was used to wash, sanitize and rinse pots and pans. He stated the rinse sink required 180 degrees for the water temperature and the sanitizer was required to be at least 200 ppm. The chart was reviewed with the Chef and he stated the missing log information should have been reported to the Dining Services Director (DSD) upon discovery. He also stated the facility was short staffed and that could have contributed to the incomplete logs. Further interview revealed some staff were cross trained in the kitchen, but generally they worked in the same type of area, for example someone who did pots and pans could be cross trained how to run the dishwasher but would not be trained to prepare food. The Chef stated he should have checked the logs to ensure they were completed properly; It is on the Chef, every shift chemicals should be tested ., especially when the Pot and Pans staff did not do it. He also stated residents could get sick if dishes were not cleaned within the required chemical range. Continued interview with the DSD, on 06/12/2021 at 8:35 AM, revealed in reference to the logs for the three-compartment sink, she conducted audits to ensure paperwork was completed, but she would not go back and fill in blanks because that would not be the proper way to keep records. Interview related to the blank slots on the Chart, revealed staff did not document the results, it was just verbal feedback. She reported the logs were important to have as proof the staff tested the water to ensure it was at the appropriate sanitation level to prevent food borne illnesses.

Based on interview and record review it was determined the facility failed to ensure nursing staff had appropriate competencies and skill sets upon hire and annually to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Record review revealed the facility failed to document orientation/competency assessments. The findings include: Review of the facility's policy, Competency of Nursing Staff, revised October 2017, revealed all nursing staff must have met the specific competency requirements of their respective licensure and certification. Continued review revealed the facility and resident-specific competency evaluations would be conducted upon hire, annually and as needed based on the facility's assessment. Further review revealed licensed nurses and nursing assistants employed or contracted by the facility would participate in a facility-specific, competency-based staff development and training program; and would demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. Review of the facility's assessment, dated November 24, 2020, revealed the facility would train staff to be competent in the range of skills necessary to meet the needs of the existing and anticipated resident population. Continued review revealed there was a recommendation for the facility to provide a staff person, under the supervision of the Director of Nursing (DON), as least part time, who could plan, execute and document ongoing training/competency programs for all staff members at least monthly throughout the year. Further review revealed a part-time staff development coordinator would be in place by March 01, 2021 with monthly education beginning April 2021. Additional review of the facility's assessment revealed staff competencies necessary to have met the needs of the residents included: resident rights, person centered care, basic nursing needs, medication management, communication, identification of change of condition, dementia care, customer service, and mechanical lift training. Interview with the Administrator, on 06/23/2021 at 10:54 AM, revealed the online education program was not utilized for newly hired employees until their yearly anniversary date. The facility failed to provide documentation on two (2) new hires, a Certified Medication Technician (CMT#2) and Licensed Practical Nurse (LPN #4) regarding the online education program the facility utilized to help maintain employee competency. Per request from the State Survey Agency (SSA), the facility provided a list of newly hired employees since March 2021. Review of the list revealed the facility hired nine (9) new persons, but could only produce one (1) Competency Based Orientation checklist completed for a Certified Nurse's Assistant (CNA). Review of the checklist revealed the staff member had previous experience on performance objectives but there was no documented evidence the CNA demonstrated and/or return demonstrated the skills necessary to determine competency. Interview with the Director of Nursing (DON) on 06/22/2021 at 10:41 AM revealed she expected new staff to demonstrate or return demonstrate the performance objectives on the checklist and without this, the facility could not ensure their staff were competent. Interview with CNA #20, on 06/23/2021 at 5:02 PM, revealed she was not shown how to use a mechanical lift device before she used it to lift a resident. She stated it was different than other facilities I've worked at. I had to ask my own questions, like do the hooks go here? Interview with Certified Medication Tech (CMT) #2, on 06/15/2021 at 12:00 PM, revealed she was a newly certified CMT (2 months) and began working in the facility in April 2021. She revealed she did not receive onboarding orientation or an orientation checklist and was on a medication cart on her first day. She stated she was not familiar with the facility's electronic health record system and received no training on the computer. Interview with LPN #2, on 06/15/2021 at 11:50 AM, revealed he knew he had a new staff member to train when he came in to work and saw their name on the schedule. He revealed he did not receive any formal training on how to train new employees. LPN #2 stated he trained new staff based on his own experiences. Additionally, he stated he did not complete any computer training with newly hired staff. Interview with LPN #4, on 06/16/2021 at 5:52 PM, revealed she was a newly licensed LPN and began working at the facility on 02/22/2021. LPN #4 stated she had not been provided a training checklist upon hire, and that the training wasn't what I needed. Further interview with LPN #4, on 06/17/2021 at 8:30 AM, revealed she did not know how to discontinue medication orders in facility's electronic health record (EHR). Interview with Registered Nurse (RN) #3, on 06/17/2021 at 9:15 AM, revealed she knew she had a new staff member to train when that staff member's name showed up on the schedule. She stated she was not given any training or direction on what or how to train new employees, and that when she trained a new employee she taught them what she knew from experience. RN #3 stated new hires only get a few days training with the EHR. Interview with the Activities Director, on 06/18/2021 at 10:30 AM, revealed she had not received any training on resident abuse this year. She stated in years past she received training on abuse identification, prevention and reporting requirements at least annually. She also stated the Former Administrator provided training that included drills on the seven (7) types of abuse, and that there was an education fair in the facility's courtyard last summer. Interview with the Director of Human Resources, on 06/17/2021 at 11:30 AM, revealed she provided only general orientation information and was not involved in clinical orientation. She stated the Department Directors were responsible to bring completed training documents to her and ensure staff were trained. Interview with Quality Assurance (QA), on 06/16/2021 at 11:23 AM, revealed currently there was no staff educator in the facility but the facility had discussed it. He stated the Assistant Director of Nursing (ADON) completed some education and the facility had planned a large competency fair but it was postponed due to the SSA (State Survey Agency) entering the building. He stated he had participated in the on-boarding process in the past but had not recently. Continued interview revealed that in the past the new hires utilized an orientation checklist but he was not sure of the current process. He stated that he did not follow up with new staff to ensure they received adequate orientation, but he believed the DON and ADON performed that task. He revealed the ADON had been doing some in-services and one on one (1:1) training with some staff. Additionally, he stated he did not know who was leading orientation and training. Interview with the ADON, on 06/16/2021 at 3:15 PM, revealed she was newly hired to the facility (2 months) and she did not follow up to ensure new staff received adequate training. She stated she believed the DON completed that task. The ADON stated she had not seen a competency, routine but the facility has discussed completing competency audits for everyone. She revealed she was not sure if the trainer received any direction before training new hires. Continued interview revealed she was not sure if training for the agency staff was completed in the facility, if any. Interview with the DON, on 06/22/2021 at 10:41 AM, revealed she gave newly hired employees a competency checklist to be completed while on the floor receiving orientation. She stated she had multiple roles in the facility therefore, she could not check every checklist for completeness and had not received every checklist back. She stated normally new hires received three (3) days on the floor unless they expressed additional time was needed or a concern was identified. The DON revealed she expected the trainers to come to her with concerns of any new hires. Additionally, she revealed when the ADON was hired they split the education up and started identifying concerns such as licensed staff not signing out medications timely/not being signed out at all, uniform concerns, attendance issues, resident showers and some infection control concerns. She stated staff did not have a classroom day when the EHR was reviewed and all new staff received computer training while on the floor. Further interview revealed the facility did not have a staff development coordinator (educator) but she believed the facility would benefit from one. She continued competencies were to be completed with a new hire and annually with facility staff. Interview with the Administrator, on 06/23/2021 at 10:54 AM, revealed newly hired staff have general orientation and complete floor orientation. He revealed the facility ensured their staff were competent by completed background checks and validating their license or certification. Continued interview revealed he had not identified any orientation concerns from staff, residents, or family. Further interview revealed all new hired employees received computer training on the floor. He stated he expected staff to learn the processes and systems for the facility along with the EHR. Additionally, he revealed the facility did not have an educator nor had there been discussion to get a staff educator. He stated the facility was too small, therefore a staff educator could not be justified. He stated the Social Services person, ADON, DON and the QA Nurse could all educate, depending on the topic and although it may not be the easiest, it was manageable. The Administrator provided typed documentation that stated, CNA licenses are checked prior to hire to ensure active certification and per 42 C.F.R. 483.152 lists the required training to obtain a license.

Based on interview, record review, and facility policy review it was determined the facility failed to be administered in a manner that enabled it to use facility resources effectively and efficiently to attain or maintain the highest practicable physical, mental, or psychosocial wellbeing of each resident. Record review and interview revealed the facility failed to provide training, orientation, and competency to new and desisting staff per facility policy. The findings include: Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the Administrator ensured compliance with applicable standards and regulatory guidelines, provided orientation and training and retained sufficient qualified staff to provide services. Review of the facility's position description for Director of Nursing (DON), revised 02/1994, revealed the DON was responsible for effective overall management of the nursing department and coordination with other disciplines to provide quality care. Further review revealed the DON provided orientation and education programs for nursing service personnel and ensured all personnel demonstrated the abilities required to function appropriately in their positions. Review of the facility's assessment, dated 11/24/2020, revealed there was a recommendation (unknown who made the recommendation) for the facility to provide a staff person, under the supervision of the Director of Nursing (DON), as least part time, who could plan, execute and document ongoing training/competency programs for all staff members at least monthly throughout the year. Additionally, the assessment revealed a part-time staff development coordinator would be in place by 03/01/2021 with monthly education beginning 04/2021. Interview with the Quality Assurance (QA) Nurse, on 06/16/2021 at 11:23 AM, revealed currently there was no staff educator in the facility but the facility had discussed it per the facility's assessment with the previous management. Interview with the DON, on 06/22/2021 at 10:41 AM, revealed the facility did not have a staff development coordinator (educator) but she believed the facility would benefit from one. Continued interview revealed she was aware what a facility assessment was but had not been asked to review it since being employed at this facility. Interview with the Administrator, on 06/24/2021 at 3:27 PM, revealed no concerns had been brought to his attention regarding the facility assessment and the facility assessment could be amended at any time. Continued interview revealed he was aware per the facility assessment that a part time educator was needed but the facility was small, census wise, therefore a staff educator position could not be justified. Additionally, he revealed staff development is something management completes as a group but he leads the staff development program.

Based on interview, record review, and facility policy review it was determined the facility failed to review and update the facility's assessment. The facility failed to ensure to hire a part-time staff educator to coordinator, plan, execute, and document ongoing training and competency programs for all staff members at least monthly throughout the year. The facility failed to ensure newly hired staff received and completed required training and competencies for resident care and safety. In addition, the facility failed to complete yearly annual training for employed staff greater than one (1) year. The findings include: Review of the facility's policy, undated, revealed the facility completed the assessment annually and updated to determine the capacity to meet the needs and competently care for the residents. The assessment stated the designated team would meet to ensure the facility had the resources available to meet specific needs of the residents. The assessment included the breakdown of the training, licensure, education, skill level, and measures of competency for all personnel. The assessment was intended to help the facility plan for and respond to changes in the need of the resident population to determine staff training. Review of the Facility Assessment, dated 11/24/2020, revealed the facility assessed the residents over the previous twelve (12) months and planned the next 12 months with staff competencies necessary to meet the needs of the facility's residents. The competencies included: Resident Rights, Person Centered Care, Basic Nursing Needs, Identification of Change of Condition, and Dementia Care. The facility assessment concluded additional competencies and specific needs included mechanical lift training, and advanced dementia care. The assessment identified a list of prioritized needs which included staff competencies. Review of the Facility Assessment Action Plan, dated 11/24/2020, revealed the facility assessment included the need to train facility staff to insure competency in the skills necessary to meet the needs of the resident population and those competencies identified by regulation. To achieve this, the assessment revealed the facility would provide a staff person under supervision of the Director of Nursing, no less than part time, who would plan, execute, and document ongoing training and competency programs for all staff members, at least monthly throughout the year. The staff development coordinator would be in place by 03/01/2021 with monthly education beginning April 2021. Review of the staff roster revealed the facility did not list a part time staff educator coordinator. Record review revealed the facility employed nine (9) new employees, but could only produce one (1) Competency Based Orientation checklist completed for a Certified Nurse's Assistant (CNA). Review of the checklist revealed the staff member had previous experience on performance objectives but there was no documented evidence the CNA demonstrated and/or return demonstrated the skills necessary to determine competency. Interview with the Director of Nursing (DON) on 06/22/2021 at 10:41 AM revealed the facility could not ensure new staff were competent. In addition, the facility could not produce competency annual training for staff for April 2020 through April 2021, which was the month the facility identified as their annual training month. Interview with the Quality Assurance (QA) Coordinator, on 06/16/2021 at 11:23 AM, revealed he participated with the completion of the facility's assessment. He revealed the facility did not have a staff educator. He revealed the facility assessed the need for the a part time staff educator to ensure all training requirements were met for regulatory requirement and the facility had identified a change of resident population. Continued interview revealed the assessment was completed in November 2020 with the goal to hire the part time educator. He stated he could not organize and ensure staff met all competency and training requirements. Further interview revealed he pieced training together when he could and he did not follow up with staff to ensure the staff were trained on the floor. In addition, he revealed he did not know who lead staff education and competency training. The QA further revealed the facility's assessment was irrelevant at this time, but had not known of any revision. Interview with the Assistant Director of Nursing (ADON), on 06/16/2021 at 3:15 PM, revealed she was newly hired to the facility and did not participate with the facility assessment. However, she knew staff training and competencies were required but she did not follow up to ensure new and regular staff completed the required training. She revealed she was unaware the assessment included to hire a part time educator to ensure the facility met compliance and staff received the required training. The ADON revealed she did not know if staff were competent or had completed any training and competencies which a staff educator, even on a part time basis, would ensure the staff provided safe and competent care to the residents. Interview with the Director of Nursing (DON), on 06/22/2021 at 10:41 AM, revealed she and the ADON split the training of the staff. She revealed with all the required duties for her and the ADON, it was difficult to manage the staff's educational and orientation needs for the required competencies. The DON stated the facility did not have a staff development coordinator, but the facility would benefit from one. She stated staff's competencies were to be completed with a new hire and annually with facility staff. The DON stated staff should be determined to be competent before providing care to the residents. Interview with the DON, on 06/23/2021 at 4:30 PM, revealed she was not employed when the facility's assessment was completed and she did not have an opportunity or been provided a copy to review the assessment. The DON revealed the facility's assessment was the guide for the facility to care for the residents from beginning to end, and it included staff education and competencies. She stated she was unaware the assessment included a part time staff coordinator to help with education and the completion of competency check off for staff. The DON revealed the QA Coordinator, ADON and she tried to meet the educational needs of the facility. However, nobody was in control of the training of the facility and while the three (3) of them tried to keep it under control they all had so many responsibilities with more piled on daily it was out of control. The DON stated if the facility could not meet the assessment then it needed to be reviewed and revised or, she needed the staff development coordinator to meet the staff education and competency requirements because the facility was not in compliance. Interview with the Administrator, on 06/23/2021 at 10:54 AM, revealed the facility did not have an educator nor had there been discussion to get a staff educator. He stated the facility was too small, therefore a staff educator could not be justified. He stated the Social Services, ADON, DON, and the QA Nurse could all educate depending on the topic. He stated although it may not be the easiest, it was manageable. In addition, the Administrator stated newly hired staff did not require education and competency check off at hire because the staff's certificate or licensure ensured they were competent and it was only required after a year of employment. The Administrator provided a typed documentation which stated, CNA licenses are checked prior to hire to ensure active certification and per 42 C.F.R. 483.152 lists the required training to obtain a license. Further interview with the Administrator, on 06/24/21 at 2:52 PM, revealed the facility's assessment was completed annually and could be revised at any time when the facility determined the assessment required revisions. However, the facility's assessment had not been revised after April 2021 for a staff education coordinator. He revealed he could not justify a position for a staff development coordinator because the census for the facility dropped with the pandemic and as a non-profit facility it was just not justifiable. However, the assessment was completed November 2020. The Administrator stated he oversaw the staff development program for the facility.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment. Observations of the residents' multiple-use shower room revealed unsanitary conditions. The findings include: Review of the facility's policy titled, The Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2018, revealed the resident-care equipment, including reusable items and durable medical equipment was cleaned and disinfected according to the current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, and that durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Observation, on 06/16/2021 at 7:40 AM, revealed the facility had one shower room. In the shower room it was observed to have a shower chair and toilet bucket which contained visible urine, a white wash cloth smeared with feces, a hair tie, and a white cap as identified by Certified Nursing Assistant (CNA) #1. CNA #1 identified body wash in a gallon container which sat on the floor, almost full, without the cap. The container was observed on the floor in the shower. Interview, on 06/16/2021 at 7:45 AM, with CNA#1, revealed after a resident's shower, the used shower chair and toilet bucket should be emptied, and the shower chair and toilet bucket should be cleaned and disinfected with the shower room's red-tipped hose which also dispensed a disinfectant spray. Interview, on 06/16/2021 at 8:15 AM, with CNA #15, revealed the person who showered a resident was responsible for cleaning and disinfecting all DME and other equipment used to shower a resident. CNA #15 stated this should be done immediately after the shower, once the resident was safely returned to his/her room. Additionally, CNA #15 stated failure to clean and disinfect equipment immediately after use provided risk for infection. Interview on 06/16/2021 at 8:00 AM with the Infection Control/Quality Assurance (ICQA) Nurse revealed it was important to clean the facility's multi-use resident equipment, such as shower chairs with toilet buckets, right after use, and doing so prevented residents' exposure to potentially infectious pathogens and equipment. Interview with the Director of Nursing (DON), on 06/23/2021 at 4:30 PM, revealed she expected the residents' shower room to be cleaned by staff. The DON revealed the residents' shower room was a community room, and the equipment should be cleaned after use by a resident, and was to be kept clean at all times. Interview with the Administrator, on 06/24/2021 at 2:32 PM, revealed the facility had not identified any issues or received reports from the ICQA nurse.

Based on interview, record review and facility policy review, it was determined the facility failed to develop and implement a Baseline Care Plan (BCP) for one (1) of thirty-nine (39) sampled residents, (Resident #196). Resident #196 was admitted to the facility from a Personal Care Home (PCH) after it was determined resident required a higher level of care. The facility failed to initiate a baseline care plan to ensure resident's activity of daily living needs were met. The findings include: Review of the facility's policy titled, Baseline Care Plans revised 04/01/2021, revealed a baseline care plan must be developed within forty-eight (48) hours of a resident's admission including instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Review of Resident #196's clinical record revealed the facility admitted the resident on 06/07/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospice comprehensive assessment and plan of care dated 05/25/2021 revealed resident is now requiring hand feeding and is wheelchair bound, signed by a physician on 05/20/2021. Review of an agency assessment and care plan dated 04/14/2021, revealed the resident needed assistance with feeding and drinking and client will need to be fed, assist with cutting up food and encourage liquids. The facility only provided page eleven (11) of twelve (12) of the Baseline Care Plan created 06/07/2021 and did not have guidelines to meet resident's mealtime needs. Observation on 06/12/2021 at 9:30 AM, revealed Agency Sitter #1 for Resident #196 was in the room and was upset as she picked food out of resident's hair and off of his/her clothes. Interview with Agency Sitter #1 on 06/12/2021 at 9:30 AM, revealed she was hired by the resident's Power of Attorney (POA) and spouse to ensure resident had a smooth transition from the Personal Care Home (PCH) to the Skilled Nursing facility. She revealed Resident #196 was unable to feed him/herself and was supposed to be fed by staff. Interview with Resident #196's POA, on 06/16/2021 at 3:20 PM, revealed resident was moved to the facility because he/she needed a higher level of care than what a PCH could provide. Interview with Certified Nursing Assistant (CNA) #10 on 06/12/2021 at 10:15 AM, revealed on this day for breakfast she took resident's tray in the room, set it up and explained to resident what was on the tray, then left resident alone. Continued interview with CNA revealed she was not informed by the facility or sitter she was supposed to shadow the sitter. She revealed the care plan listed the resident as set up only at mealtime. Interview with Registered Nurse (RN) #1, on 06/19/2021 at 11:30 AM, revealed she worked at the facility for two and one half (2.5) years. She revealed whatever staff member handled the admission would put doctor orders in the computer and complete the baseline care plan. Interview with the Assistant Director of Nursing (ADON), on 06/20/2021 at 12:20 PM, revealed she was not sure what would be needed for a new hospice resident and her only involvement in a new admission would be to help get the assessments done. She revealed the baseline care plan was completed by the nurse on duty when a new admission came in. She also revealed the baseline care plan could be updated as needed when the resident's needs changed. Interview with the Director of Nursing (DON), on 06/22/2021 at 1:47 PM, revealed the nurse on duty when a new resident came in would be responsible for the admissions process to include the baseline care plan. She further revealed someone from the management team would assist with the required assessments. The DON also revealed there was a problem with the computer system that did not allow the baseline care plan to include hospice information because it was a template style program and only had certain options. Additionally, the DON revealed a person down in Human Resources got the paperwork for new admissions but that was not effective practice. In her opinion the facility needed a person in Skilled Nursing who was responsible for the paperwork and that was why the facility needed an Admission Coordinator. It would be important to have the Hospice Care Plan upon admission because it provide an in depth look at resident's needs. Interview with Administrator on 06/24/2021 2:52 PM , revealed he expected staff to meet the needs of the residents the best they can. He further revealed it was his responsiblity to do everything he could to ensure the needs of the residents and their family's were met through compliance with the regulations. The Administrator reported no baseline care plan concerns had been brought to him.

Based on interview, record review, and policy review it was determined the facility failed to report potential or identified abuse for one (1) of thirty-six (36) sampled residents (Resident #2). The facility initiated an investigation for an injury of unknown origin, but failed to immediately report to the administrator, and other required officials. On 04/22/2021 at 7:00 AM, Licensed Practical Nurse (LPN) #2 conducted a weekly skin assessment on Resident #2 and found a bandage on the resident's lower right leg. LPN #2 completed a facility Event at 9:54 AM and documented that the resident did not know what happened. This event was not processed as an injury of unknown source. However, the facility did not report to this management and the State Survey Agency (SSA) timely. The findings include: Review of the facility's Abuse and Neglect policy dated 02/2019, revealed the definition of an injury of unknown source was defined as an injury in which the source of the injury was unknown and the injury was suspicious because of the extent of the injury. Continued review of the Abuse and Neglect policy revealed the Administrator would be notified immediately of any allegation or suspicion of abuse and a thorough investigation would be conducted. Review of Resident #2's clinical record revealed the facility admitted Resident #2 on 06/04/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident to require the physical assistance of one (1) person to bathe, and the extensive assistance of one (1) staff for bed mobility, transfers, to toilet and for personal hygiene. Review of Resident #2's Progress Notes revealed Licensed Practical Nurse (LPN) #2 documented, on 04/22/2021 at 9:54 AM, a late entry for an incident that happened at 7:00 AM. The Note stated, This nurse went to perform weekly skin assessment and noted a dry dressing to right leg. Night shift nurse did not know anything about the dressing on resident's leg. Removed the dressing and noted a skin tear 3.5 cm (centimeter) x 4 cm with bruising 6 cm x 10 cm with minimal red blood drainage, no signs or symptoms of infection. Resident did not know how the skin tear happened. Review of the facility's Event Report completed by LPN #2 on 04/22/2021 at 9:40 AM, revealed the LPN documented the occurrence as unable to determine for contributing factors. It was also documented that Resident #2 did not know what happened. Interview with LPN #2 on 06/18/2021 at 11:40 AM, revealed the resident could not tell him what happened. LPN #2 stated CNA (Certified Nursing Assistant) #13 was on night shift and had provided personal hygiene care for the resident but he did not see staff member do it, and that he could not say if (CNA #13) actually did it. LPN #2 stated he reported it up the chain and he was not sure what happened after that. The LPN stated he could not recall the last time he completed abuse training and he could not recall if abuse training was completed after this incident. LPN #2 stated he was unsure if this constituted abuse. The LPN stated whoever caused the injury did not immediately report it. Interview with Registered Nurse (RN) #3, on 06/16/2021 at 10:15 AM, revealed LPN #2 did a skin assessment on Resident #2 at the start of his shift on 04/22/2021 at 7:00 AM. The RN stated he found a skin tear that had been bandaged. RN #3 stated she did not know anything about it. She stated it possibly could have been caused by CNA #13 when she gave the resident a bath the prior night. However, CNA #13 was already gone for the day and they were not able to talk to her. Unsuccessful attempt on 06/16/2021 at 9:36 AM, to reach Certified Nursing Assistant (CNA) #13. A voice message was left. CNA #13 did not call back. Another attempt was made on 06/17/2021 at 9:50 AM; the phone number was no longer in service. Interview with the Assistant Director of Nursing (ADON), on 06/16/2021 at 3:30 PM, revealed on 04/22/2021 when she came on shift, she overheard LPN #2 tell the Director of Nursing (DON) about a new skin tear to Resident #2. She stated that she and the DON went to Resident #2's room and looked for anything that could have caused the skin tear, but they did not find anything and the resident could not tell them how he/she got the skin tear. Continued interview revealed CNA #13 admitted that she caused the injury to the resident and that most likely her rings cut the resident. She further revealed it was suspicious that the CNA covered the wound and did not report it to her nurse. The ADON said she was not sure this was considered abuse. Continued interview with the ADON on 06/16/2021 at 9:36 AM, revealed an injury of unknown origin did fall in the abuse category and should have been reported immediately. She stated she was not informed of this case immediately. The ADON stated she formally found out about the incident at 9:30 AM on a conference call and she was not sure if it had been reported to the Administrator. She stated she was not sure if it was reported to Adult Protective Services or to the State Survey Agency as the DON would be responsible for reporting. The ADON revealed an investigation should not be stopped when the source was found because that would not be a complete investigation. Continued interview revealed that a complete investigation was the only way to ensure the same thing did not happen again. She stated residents would be at risk of continued harm if no interventions were put in place to keep the residents safe. Interview with the DON, on 06/22/2021 at 1:47 PM, revealed an injury of unknown origin would be investigated thoroughly by the facility and would include interviews with staff and interviews with residents. However, no interview statements were provided. The DON stated she did not know the facility's process for an abuse investigation. She stated she used the facility's policy and some interview forms as pointers, but she did not complete any interview forms. The DON stated she completed skin assessments and interviews with residents, but she did not document them because she was too busy. She also stated the Administrator was the Abuse Coordinator and he was involved in all abuse investigations. Continued interview with the DON on 06/22/2021 at 1:47 PM, revealed she was notified right away about this event. However, interviews with LPN #2 and the ADON reported the DON was notified on 04/22/2021 when she reported to work. She reported it was not until the next day when she reviewed the Progress Notes, that she found it had been documented as an injury of unknown origin and she conducted an investigation as such. The DON stated she did not report the incident to the Administrator and in turn it was not get reported to State Survey Agency. Further interview with the DON on 06/22/2021 at 1:47 PM, revealed she did not determine the cause of the skin tear until 04/22/2021 around noon when she talked with CNA #13. The DON stated that CNA admitted she caused the skin tear when she provided care to the resident and that perhaps her ring got caught on the resident's skin. The DON stated she believed CNA #13 did not report the skin tear for fear of loss of her job. Interview with the Medical Director (MD) on 06/23/2021 at 9:30 AM, revealed she had worked at the facility for eleven (11) years. She reported the facility usually reported things to the Nurse Practitioner (NP) and then the NP ran it by her. The MD revealed she could not recall this incident but that it should have been reported to the NP and an investigation should have been completed. She also stated a halted investigation could have resulted in another resident being harm. Interview with the Administrator on 06/20/2021 at 9:40 AM, revealed he was the Abuse Coordinator and he completed all abuse investigations. He stated he followed the process in the regulations and based on the allegation he had two (2) hours to report some cases and twenty-four (24) hours to report others to the State Survey Agency. Although the Event that occurred on 04/22/2021 was documented as an injury of unknown origin at 7:00 AM, the facility did not discover until lunchtime that CNA #13 had caused the skin tear. Further interview with the Administrator revealed he did not believe the resident's injury was of unknown origin. He stated he believed the investigation was complete and handled properly. Further interview revealed this injury was not reported to State Survey Agency and a five (5) day report was not completed.

Based on observation, interview, record review and policy review it was determined the facility failed to develop and implement a person centered Comprehensive Care Plan (CCP) for two (2) of thirty-six (36) sampled residents to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for Residents #20 and #108. Record review revealed Resident #108's care plan interventions were not implemented regarding transfer resident. Record review revealed that Resident #20 was improperly transferred by one (1) Certified Nurse Assistant (CNA), when resident was care planned for a two person assist. Resident did not have on proper footwear or non-slip socks. The findings include: Review of the facility's policy, Comprehensive Assessment and the Care Delivery Process, revised December 2016, revealed a comprehensive assessment was conducted to assist in developing person-centered care plans. Continued review revealed monitoring results and adjusting interventions were included. Review of the facility's policy, Comprehensive Person-Centered Care Plans (CCP), revised 2016, revealed a CCP included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Continued review revealed the CCP described the services that were to be furnished to maintain the resident's abilities, incorporate identified problem areas and associated risk factors, reflect treatment goals, timetables and objectives in measurable outcomes, identify the professional services that were responsible for each element of care, aid in preventing or reducing decline in the resident's functional status and/or levels, and reflected current recognized standards of practice for problem areas and conditions. Further review revealed the CCP identified problem areas and their causes while the Interdisciplinary Team (IDT) developed interventions targeted and meaningful to the resident. The IDT included the resident and the resident's legal representative. 1. Review of resident's clinical record revealed the facility admitted Resident #20 on 07/31/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Quarterly Minimum Data Set (MDS) dated [DATE], revealed resident had a Brief Interview Mental Status (BIMS) of ten (10) out of fifteen (15) moderate cognitive impairment. Resident was assessed for bed mobility and transfer as an extensive assistance of two staff. Resident was also assessed to have impairments to the upper and lower extremity of one side of the body and required a wheelchair. Review of Resident #20's Comprehensive Care Plan last revised 05/12/2021, revealed resident was an assist of two (two) staff for transfers with use of a gait belt (created 08/12/2020, revised 05/12/2021) no new intervention put in place for incident on 04/22/2021. Resident's care plan also revealed resident was encouraged to wear non-skid socks and proper fitting footwear when transferring (created 08/12/2020). Resident's care plan review revealed, on 08/12/2020, the facility imitated focus problem of self-care deficit related to generalized weakness, impaired balance and cognitive deficits. The facility initiated, on 03/05/2021, the approach of no shoes and this focus remained a part of her care plan. Review of Resident #20's Progress Notes completed by Registered Nurse (RN) #2 on 04/22/2021 at 2:45 PM, revealed CNA was transferring resident from chair to bed. Resident was sliding and CNA lowered resident to the floor. No injuries were noted. Nurse Practitioner (NP) and family notified of resident's non injury fall. Review of facility Event MR#5986-01 completed by RN #2 on 04/22/2021 at 2:43 PM, revealed at 2:20 PM, CNA #11 transferred a resident and the resident started to slide and was lowered to the floor. The Event revealed resident had a wheelchair, call light within reach and bed in lowest position as interventions prior to event. Non-skid socks were added as a new intervention although that intervention was already supposed to be in place based on the care plan. Continued review of facility Event MR#5896-01 revealed the Health Care Risk Manager (HCRM), Assistant Director of Nursing (ADON), the Director of Nursing (DON) completed an evaluation of this event and found CNA #11 assisting resident during a transfer from wheelchair to bed, resident feet began to slide, CNA lowered resident to the floor. Wheelchair brakes were locked. Shoes were not applied prior to transfer, resident wearing slippery socks. Resident has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention: Staff was reeducated regarding safe footwear during transfers. Staff reeducated regarding following most current plan of care. Review of CNA #11 Powerful Moment (coaching) done on 05/03/2021 by the ADON was triggered because staff assisted fall -resident was lowered to floor due to improper footwear being put on resident. CNA #11 was reeducated on facility gait belt policy: gait belts must be used with all transfers. Resident must be wearing appropriate footwear (non-skid socks, socks/shoes) prior to starting transfer. Ensure most current care plan was being followed. Interview with CNA #11 on 06/23/2021 at 2:20 PM, revealed she had been at the facility for about three (3) months but had worked in the profession for thirty (30) years. She revealed when she started at the facility she was trained by another CNA but could not recall whom it was. She stated she was told by that CNA, Resident #20 was a stand and pivot for transfer. CNA #11 revealed she trained with the other CNA for three (3) or four (4) days and could not recall if they used a check off list to show what she had trained on. She revealed it was her responsibility to know what the care plan showed for each resident and it was important to follow the care plan to ensure the resident's safety. Interview with Licensed Practical Nurse (LPN) #4 on 06/17/2021 at 11:00 AM revealed, she knew how to do a Baseline Care Plans but did not believe it was her job to do Comprehensive Care Plans, she revealed those should be done by the RNs. She revealed she does not know how to revise a Care Plan and as she understood it LPNs were not allowed to do Care Plans in the nursing home. LPN #4 revealed initial assessments and Care Plans were supposed to be done by the RNs. She also revealed there was always an RN on shift and it was the RN's job to review the Care Plan. The Care Plans should have been created in a way to keep the resident safe. If Staff did not follow the Care Plan the resident's needs were not met. LPN #4 revealed she did not know the Care Plan policy. Interview with ADON on 06/20/2021 at 10:00 AM, revealed she does not have much to do with care plans. The MDS Coordinator is usually the staff member who updated care plans. Revisions could be made to care plans at any time. The facility usually waited for residents to get adjusted to the facility before the Comprehensive Care Plan was done. The facility has fourteen (14) days to complete the care plan. CNA's can look at the care plan on the computer and nurses can check on Matrix under the care plan tab. She revealed if the care plan was not followed there could be injury to residents, dignity concerns and skin issues. CNAs document when they have provided care to a resident and the ADON reviews it to ensure resident's needs were met. If there was a decline in the resident's health, the ADON would address that with the CNAs and it was the same practice for nurses. The ADON revealed the facility had not identified any concerns with care plans. Interview with the DON, on 06/22/2021 at 10:44 AM, the MDS Coordinator was responsible for creating Care Plans. She revealed she had to sign off on them because she was an RN but she had not had time to review them. She expected staff to follow all policies and to follow the Care Plan when care was provided to residents. She also revealed she had not had time to audit care plans but the ADON performed clinical rounds to check on residents to ensure they were neat, clean and their needs were met; she had not reported any concerns to the DON. Interview with the ADM, on 06/20/2021 at 9:40 AM, revealed staff show they were qualified to work at the facility because they were certified or licensed. Staff also go through orientation. He expected all staff to follow the care plan and the facility policies and to provide the best care they could to the residents. 2. The facility admitted Resident #108 on 10/22/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #108 was assessed by a Brief Interview for Mental status (BIMS) exam and the resident's BIM score was ten (10). Continued review revealed he/she was an extensive assist with transfers. Review of event report, dated 04/21/2021 at 8:01 PM, revealed Resident #108 was transferring from wheelchair to bed when a laceration was obtained. Per report the Certified Nursing Assistant (CNA) #13 said the resident was trying to self-transfer into bed when she entered the room and resident was about to fall and the CNA caught resident. She did not know what caused the laceration. Per report, Resident #108 stated CNA #13 kept telling the resident to stand up, and that they could stand up. The resident said that they told the CNA that they could not stand, and that they only had socks on. The CNA continued to assist resident to bed without shoes on while the resident slid. The resident did not recall how she received the laceration. Review of the care plan, dated 05/14/2021, revealed that Resident #108 was to wear non-skid socks or properly fitted footwear and a gait belt for any transfers. Continued review revealed that a walker was also care-planned to be used with one (1) person assist for all transfers. Unable to interview Resident #108 due to resident no longer being in facility. Unable to interview Certified Nursing Assistant (CNA) #13 after repeated attempts, on 06/16/2021 at 3:00 PM and on 06/18/2021 at 2:58 PM with no answer and a message left on voicemail. No return phone call received at this time. Interview with Certified Nursing Assistant (CNA) #14, on 06/18/2021 at 9:15 AM, revealed Resident #108 was a one (1) person assist for transfers and she never knew of the resident trying to get up without assist. She stated the care plan was very important because it told you know what a resident can and cannot do. The nurse needed to be updated too if something changed with a resident so the nurse can update care plan. Interview with CNA #10, on 06/18/2021 at 9:50 AM, revealed Resident #108 was a one (1) person assist and the resident never tried to get up on their own. She said the care plan was very important, especially if it was the first time that you were caring for a resident. You need to know how a resident transfers and that their care was a priority. Interview with Registered Nurse (RN) #1, 06/19/2021 at 11:20 AM, revealed every resident was different and the care plan directed how to care for each resident. Staff should follow the care plan and if something needed to be changed let the MDS coordinator or nurse know. Interview with Registered Nurse (RN) #3, on 06/19/2021 at 8:12 AM, revealed that after the incident with Resident #108, CNA #13 was not reeducated on proper transfer as related to care plan till the Director of Nursing did it the following day. She stated at that time the CNA was still saying that the resident had slipped and she had caught resident. Interview with the Assistant Director of Nursing (ADON), on 06/18/2021 at 2:10 PM, revealed CNA #13 should have followed the care plan. She said the staff knew how to use the care plan and should also receive direction at shift report on how a resident transferred. If care plan was not followed, it can cause unsafe care to be provided and could cause all kinds of injuries. She also revealed that everyone was to follow the care plan all the time and that everyone was responsible for resident safety. Interview with the Director of Nursing (DON), on 06/23/2021 at 11:21 AM, revealed Resident #108 told her when she interviewed him/her the day after the incident, the resident told CNA #13 they could not stand up, but the CNA got the resident up anyway and the resident slipped and hit their leg on the bed. The DON reeducated CNA #13 about proper transfers and following the care plan and then terminated her after investigating incident. The DON stated the care plan should be followed when transferring residents and the CNA should also listen to the resident's request. She stated the care plan should have been followed in the incident with Resident #108. Interview with the Administrator (ADM), on 06/19/2021 at 10:54 PM, revealed that he expects the care plan to be followed while respecting the resident's rights. He stated he did not know anything about the incident with Resident #108.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to maintain the resident's rights to receive care and services in a dignified manner for one (1) of thirty-six (36) sampled residents (Resident # 97). Observation revealed staff toileted Resident #97 and failed to close the bathroom and main room door while the resident toileted. The findings include: Review of the facility's policy, Quality of Life Dignity, dated February 2020, revealed the facility provided care for each resident in a manner that promoted and enhanced his/her sense of well-being, sense of worth, and self-esteem at all times. The facility's staff promoted, maintained, and protected residents' privacy, which included bodily privacy, while staff provided assistance with personal care. The facility's staff expectation included to not engage in demeaning practices and care which compromised the resident's dignity and staff were to treat cognitively impaired residents in a dignified manner. Review of the facility's policy, Resident Rights, dated March 2017, revealed staff treated all residents with respect, dignity and promoted a dignified existence in the facility. Review of the clinical record revealed the facility admitted Resident #97, on 06/02/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) examination score of thirteen (13) and determined the resident was interviewable. Interview with Family #11, on 06/08/2021 at 3:34 PM, revealed Resident #97 had a dignified, distinguished, and accomplished life. The family member revealed the resident could toilet with assistance, but wore a pull up for accidents. Family #11 further stated Resident #97 wanted to maintain a dignified life in the facility as he/she did at home. Interview with Family #7, on 06/10/2021 at 11:18 AM, revealed Resident #97 called out or banged on furniture to get help for toileting assistance prior to admission. Family #7 revealed the resident could make his/her needs known and was able to toilet for bladder/bowel with assistance. In addition, the family member stated Resident #97 remained a person of pride and would be humiliated when incontinent, which the family member stated was the reason the resident would attempt to get up out of the chair after attempts to get staff to the room by banging items. Observation, on 06/11/2021 at 12:30 PM, revealed Resident #97 sat on his/her toilet in the bathroom. The bathroom door and door to the room remained open. Therapy staff walked back and forth from the room next door and peered into the room. Certified Nursing Assistant (CNA) #11 sat in a chair across from the bathroom and vocally encouraged the resident to complete the toilet session. Resident #97 sat on the toilet, clothes lowered to his/her ankles, and upper clothes pulled to his/her upper mid body exposing the resident's private area. Interview with Certified Nursing Assistant (CNA) #11, on 06/11/2021 at 12:32 PM, revealed she normally closed the doors for privacy. The aide stated the rights of a resident included providing privacy for dignity and the facility expected staff to always maintain the resident's rights. The aide revealed she would not want to be exposed with the door open and would not feel good if it happened. The aide further stated the facility did not require her to complete video education of residents' rights or complete a post test. CNA #11 further revealed the facility expected staff to provide an environment to maintain a resident's dignity. According to the facility's policy, staff would treat all residents with respect, dignity and promote a dignified existence in the facility. Interview with CNA #18, on 06/14/2021 at 9:07 AM, revealed staff maintained residents' dignity by covering residents to prevent exposure. The aide revealed staff-maintained dignity with closed bathroom and room doors when providing personal care. CNA #18 stated she would not want other people looking at her while she completed private activity as it was a time for peace, privacy, and dignity. The aide revealed the facility expected all staff to promote dignity to all residents. Interview with Registered Nurse (RN) #1, on 06/15/2021 at 2:18 PM, revealed when staff toileted residents the doors to the bathroom and main room remained closed as this allowed for privacy for the resident. RN #1 stated to not provide privacy would be uncomfortable and an embarrassment to the resident. The nurse further stated the facility educated staff on dignity, and expected all staff to always maintain the rights of residents, and to follow policy. Interview with the Assistant Director of Nursing (ADON), on 06/20/2021 at 11:12 AM, revealed the ADON identified some care staff had become frustrated with residents with cognitive deficits who 'hit' the call bell frequently and were counseled. The ADON revealed the staff provided dignity by following the resident's care plan. Further interview revealed the facility expected staff to treat residents with dignity and respect at all times. Interview with the Director of Nursing (DON), on 06/22/2021 at 10:44 AM, revealed the facility assigned staff initial training and yearly training for resident rights which included dignity of the resident. Further interview with the DON, on 06/23/2021 at 4:30 PM, revealed the facility expected staff to follow all policies, treat residents with respect and dignity, provide care and services as the care plan directed, and to ensure the residents remained safe. The DON revealed the facility needed to provide in depth education for care of residents with cognition deficits for approach and insight. The DON revealed the facility expected residents to always have a dignified experience in the facility. However, the DON had identified a lack of knowledge with staff with cognitive impaired resident's care. Interview with the Administrator, on 06/24/2021 at 2:32 PM, revealed the facility had not identified issues with resident rights or dignity. The Administrator revealed notices for residents' rights, for residents and families, were located on the walls and given in admission packs. He stated staff honored resident's requests and refusals.

Based on observation, interview, facility policy review, and review of manufacturer's recommendations, it was determined the facility failed to have an effective system to maintain an infection control program to ensure a safe environment and to help prevent the development and transmission of infection for four (4) of six (6) sampled residents, Resident #11, #26, #28, and #238. Observation and interview revealed the facility utilized a hand held meter to collect blood to test the International Normalized Ratio (INR) levels of residents. Staff cleaned the outside of the meter, but not where the test strip was inserted. Observation revealed the meter was soiled at the test strip insertion site. The facility used the same meter for the residents on standard precautions and the residents on isolation precautions. There were no meters dedicated to the isolation rooms. The same meter was used to test Resident #28 and #238, who were in contact isolation for [MEDICAL CONDITION], and Resident #11 and #26 who were not in contact isolation. The facility's failure to have an effective system in place to maintain an infection control program to ensure a safe environment, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 03/20/19, and was determined to exist on 03/20/19. The facility was notified of the IJ on 03/20/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 03/21/19, which alleged removal of the IJ on 03/22/19. The State Survey Agency (SSA) verified the IJ was removed on 03/22/19, prior to exit on 03/22/19. The Scope and Severity was lowered to an E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, General Infection Control, dated 09/01/18, revealed it was the policy of the facility to provide care and services related to Infection Control in accordance to state and federal regulation. Review of the facility's policy, Infection Prevention and Control and Surveillance Program, dated 09/01/18, revealed the facility ensured the Infection Control Program was designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. It provided a safe, sanitary, and comfortable environment, and helped prevent the development and transmission of disease and infection, in accordance with state and federal regulations, and national guidelines. In addition, the facility would provide infection prevention and control training upon hire and ongoing throughout the year as needed for proper cleaning and disinfection of equipment. Review of the facility's Infection Prevention and Control Program, revised (MONTH) (YEAR), revealed the infection prevention and control program was a facility-wide effort involving all disciplines and individuals, and was an integral part of the quality assurance and performance improvement (QAPI) program. The elements of the infection prevention and control program consisted of coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Review of the facility's manual, CoaguChek XS System, User Manual for Self-Testing, Version 2.0, revised (MONTH) 2009, revealed the system had built-in quality control functions in the meter and test strips. When the quality control (QC) test ran, the letters QC flashed on the display, followed by a checkmark and the meter continued to run the blood test. If the quality control failed, the meter displayed an error message. The manual contained Important Notes About Blood Testing, which included to always keep the test strip guide and meter clean. Observation of the Medication Room, with Registered Nurse (RN) # 2, on 03/20/19 at 2:10 PM, revealed the upper wall cabinet stored a black zippered case containing the INR meter. Interview with the RN #2, during the Medication Room observation on 03/20/19 at 2:20 PM, revealed the nurse identified the INR meter was used to test the blood coagulation levels for residents taking blood thinners, such as [MEDICATION NAME]. She stated the machine was typically used in the early morning hours to obtain the INR levels in preparation to notify the physician for medication adjustments to maintain therapeutic levels. The RN stated staff used bleach wipes on the meter to clean on the outside; however, she really did not use the meter. She was not sure, but believed this was the only meter in the facility. Per interview, the RN was not sure about the manufacturer's recommendation for cleaning. She searched the medication room for the manual but was not able to locate it and stated she would have to ask the Risk Manager where the manual was located. Observation of the meter and interview with the Infection Preventionist/Healthcare Risk Manager, on 03/20/19 at 2:40 PM, revealed the facility had one (1) meter for use, which was used on all residents, including residents in isolation. He stated the meter was taken from one room to the next. During observation and interview with the Risk Manager, the surface under the cover of the meter was soiled with a tan stain where the test strip was inserted. Further interview revealed there were currently four (4) residents receiving INR checks and two (2) of the four (4) residents were in contact isolation. Review of Resident #11's clinical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Coagulation testing with the facility's meter was completed on 03/07/19, and the next coagulation testing was due 03/21/19. Review of Resident #26's clinical record revealed the facility readmitted the resident on 01/15/19, with the [DIAGNOSES REDACTED]. The resident's coagulation testing with the facility's meter was completed on 03/18/19, and the next scheduled test was due 03/22/19. Review of Resident #28's clinical record revealed the facility admitted the resident on 02/08/19, with [DIAGNOSES REDACTED]. The resident's coagulation testing with the facility's meter was completed on 03/19/19 and 03/20/19. The next scheduled test was due on 03/21/19. Record review revealed Resident #28 was in contact isolation for [MEDICAL CONDITION]. Review of Resident #238's clinical record revealed the facility readmitted the resident on 03/18/19, with [DIAGNOSES REDACTED]. The resident's coagulation testing with the facility's meter was completed on 03/19/19, and scheduled for additional testing on 03/21/19. Record review revealed Resident #238 was in contact isolation for [MEDICAL CONDITION]. Interview with RN #2, on 03/20/19 at 2:56 PM, revealed she saw the pad where the test strip was inserted into the machine and it had what appeared to be blood and a tea colored staining. She stated the test strip area was dirty in appearance. Interview with Licensed Practical Nurse (LPN) #2, on 03/20/19 at 3:00 PM, revealed the INR meter was cleaned with bleach wipes, and the entire meter was cleaned except where the blood went into the machine. In addition, she stated there was only one (1) INR meter available for use on the floor, which was stored in the medication room. Interview with RN #1, on 03/20/19 at 3:01 PM, revealed the INR machine was used on the residents to obtain PT/INR laboratory values and to make sure they were in therapeutic range with their medications. She stated she was told not to clean directly where the blood strip was inserted because it would cause the machine to malfunction. She stated the INR meter should be cleaned for three (3) minutes with a bleach wipe and staff must get all of the blood off. Staff was to clean the meter before and after each use. She could not recall when she was in-serviced on the meter. Interview with LPN #1, on 03/20/19 at 3:07 PM, revealed she was hired nearly ten (10) months ago and did not receive any training on the use of or the cleaning of the INR meter, and had not watched anyone clean it. Continued interview with the Infection Preventionist/Healthcare Risk Manager, on 03/20/19 at 4:20 PM, revealed when he was hired, he received training on how to use and clean the INR meter by the Director of Nursing (DON). He stated the facility did verbal training, which included how to use the INR meter and instructed staff to use bleach wipes to clean the meter. He further stated an in-service for all nursing staff was completed in (YEAR), and nurses were trained upon hire by other nursing staff using a checklist. However, review of the facility's new hire nurse orientation checklist revealed it did not include orientation on the proper use and cleaning of the coagulation meter. Further interview with the Infection Preventionist/Healthcare Risk Manager, on 03/20/19 at 4:20 PM, revealed the meter self-calibrated and was a multi-use device and the facility only had one to use on all residents, including the residents in isolation. The Risk Manager stated he opened the lid where the strip with blood was inserted and identified a tea colored and tan colored stain was on the meter. He cleaned the meter where the strip was inserted, which was easy without much effort. The insertion site cleaned to a white color and the electronic strip was visible afterward as it was more transparent, which could not be seen before. Per interview, the meter was primarily used on the night shift, but day shift would need to use it if a test was not completed, or if one was ordered during the day shift. He stated PT/INR levels were ordered for a couple of residents currently in isolation for [MEDICAL CONDITION] and the facility did not have any additional coagulation meters to dedicate to the isolation rooms. He did not supervise staff as they cleaned equipment, nor did any auditing or monitoring, as the DON monitored the nursing staff. He was not aware of any documentation for the cleaning of the meter and was concerned if the meter was not properly cleaned, there could be cross contamination and the spread of infection. He revealed the elderly were at a higher risk and were more susceptible for infection. Telephonic interview, via speakerphone between the Administrator and the Manufacturer's Representative, in the presence of the Surveyor, on 03/22/19 at 5:02 PM, revealed if the meter was not cleaned, it might result in an error message, and failure to follow procedures might cause malfunction of the meter. She stated it was up to the facility to create a policy on the frequency of cleaning for the meter to prevent the spread of disease. The meter should be inspected on a regular basis. She revealed there were no error logs on these meters. She stated this particular model did not print the resident's laboratory results but the last one hundred (100) laboratory results were stored and could be recalled using the memory button. She stated if staff saw blood then it should be cleaned and the recommendation for cleaning the outside was 70% alcohol. She stated this particular meter was an older model, purchased in (YEAR). Interview with the Administrator, on 03/22/19 at 8:16 PM, revealed there was no policy for the meter, the facility went by the manufacture's manual. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility discontinued using the [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) meter on 03/20/19, and began using a contracted laboratory for completing PT/INR testing. 2. The Director of Nursing (DON)/Risk Management Nurse educated all licensed nurses on 03/21/19, on the discontinuation of the PT/INR meter and the need for all ordered PT/INR testing to be completed by the contracted laboratory. 3. A Quality Assurance Performance Improvement (QAPI) meeting was held on 03/21/19, with the Medical Director to discuss the survey findings and the Allegation of Compliance that had been implemented. 4. On 03/21/19, the facility notified all attending physicians and Advance Practice Nurse Practitioners (APRN) that PT/INR testing would be completed by the contracted laboratory. 5. The DON/Risk Management Nurse would monitor PT/INR testing performed by the contracted laboratory weekly for two (2) weeks, then monthly for two (2) months, then quarterly thereafter to determine that all PT/INR testing was completed as ordered. The SSA validated the facility implemented the following actions: 1. Observation, on 03/20/18 at 6:00 PM, revealed the facility removed the PT/INR meter from use. Interview with Registered Nurse (RN) #1, on 03/22/19 at 3:54 PM, revealed the facility removed the meter from use on 03/20/19. Interview with the Administrator, on 03/22/19 at 5:41 PM, revealed the facility removed the meter from use and utilized laboratory services for the PT/INR testing. Record review revealed the contracted laboratory completed PT/INR testing for residents. 2. Interview with Registered Nurse (RN) #1, on 03/22/19 at 3:54 PM, Licensed Practical Nurse (LPN) #7 at 3:58 PM, RN #2 at 4:05 PM, LPN #8 at 4:25 PM, LPN #3 at 4:58 PM, RN #4 at 3:55 PM, LPN #1 at 5:20 PM, LPN #6 at 5:42 PM, and LPN #4 at 6:10 PM, revealed on 03/21/19, they were educated regarding the laboratory doing the INR testing, as it was no longer done in house. Interview with the DON, on 03/22/19 at 3:20 PM, and the Risk Management Nurse at 4:30 PM, revealed licensed nurses were educated on the INR testing changes. Record review revealed licensed nurses were educated by 03/21/19. 3. Interview with the Administrator, on 03/22/19 at 5:49 PM, revealed a QAPI meeting was held on 03/21/19, and the Medical Director attended via telephone. The discovery of the Immediate Jeopardy was discussed, and the Allegation of Compliance was approved by the Medical Director. Record review revealed a QAPI meeting was held on 03/21/19, and the Medical Director attended via telephone. 4. Interview with the DON and the Administrator, on 03/22/19 at 3:20 PM, revealed the attending physicians and the nurse practitioners were educated on the INR testing changes. Review of the QAPI Agenda, dated 03/21/19, revealed all medical practitioners were notified of the PT/INR testing changes. 5. Interview with the Administrator, on 03/22/19 at 5:49 PM, revealed the DON/Risk management Nurse would monitor to ensure PT/INR testing occurred as ordered. The auditing would be conducted weekly for two (2) weeks, then monthly for two (2) months, then quarterly.