Every finding on record at Trinity Glen

Based on record review and resident and staff interviews, the facility failed to provide care in a safe manner when Resident #4 rolled off the left side of her bed during incontinence care and required transfer to the hospital for medical evaluation. This was for 1 of 4 residents reviewed for accidents (Resident #4).Findings included:Resident #4 was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia, left side paralysis following stroke, and muscle weakness.Resident #4's care plan last updated on [DATE] revealed a focus area of risk for falls related to left side weakness and paralysis. Interventions included two-person physical assistance with bed mobility and using a lift for transfers.Review of the care guide (a guide that explains to staff members what and how much assistance each resident requires) last reviewed on [DATE] showed Resident #4 was a two staff assist rolling left and right, bed to chair transfers and used an extra-large sling with the lift.A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #4 was cognitively intact and had range of motion impairment on one side of her upper and lower extremities. The MDS also indicated Resident #4 was dependent rolling left and right.A review of Resident #4's quarterly Interdisciplinary Team (IDT) risk assessment dated [DATE] revealed she was at moderate risk for falls.A review of Resident #4's physical therapy evaluation dated [DATE] showed Resident #4 was dependent rolling left to right and was unable to sit on edge of bed unsupported.During an interview with the Rehabilitation Manager on [DATE] at 7:45am, she stated Resident #4 was recently reevaluated on [DATE] for a decline in strength and functional mobility. The Rehabilitation Manager stated Resident #4 was unable to support herself and was dependent on staff for bed mobility due to her left side paralysis and weakness. During an interview with Resident #4 on [DATE] at 10:34 am she stated on [DATE], she rolled off the left side of her bed onto the floor while Nurse Aide (NA) #1 was providing care. Resident #4 stated she usually had two nurse aides turning her in bed, but sometimes only one would come in. Resident #4 indicated that when there was only one nurse aide, she usually turned on her left side and reached over to the side chair with her right hand and steadied herself that way. Resident #4 stated, on the day she fell, she thought the chair may have moved causing her to lose her balance. Resident #4 reported she didn't hit her head on anything but did hurt her right knee when she landed on the floor. Resident #4 indicated she went to the hospital because her knee hurt but nothing was broken. Resident #4 reported she had taken Tylenol for discomfort but had not needed anything else.During an interview with Nurse Aide #1 (NA #1) on [DATE] at 6:45am she stated on [DATE] during 3rd shift (7:00pm to 7:00am) at approximately 6:00am, she was providing incontinent care for Resident #4. NA #1 stated she usually worked on a different hall and had worked with Resident #4 a couple times prior. NA #1 stated she was aware that Resident #4 was dependent on staff for rolling left and right but she had cared for her by herself before by rolling Resident #4 on her left side and letting her hold onto the side chair with her right hand for support. NA #1 reported she could have asked the other nurse aide on the hall for assistance but thought the other nurse aide was already assisting another resident at that time. NA #1 stated she thought the side chair moved causing Resident #4 to lose her balance which allowed her to continue rolling left and off the left side of the bed onto the floor. NA #1 stated Resident #4 didn't hit her head and, initially, didn't complain of any pain anywhere. NA#1 stated she stepped out into the hallway and called for Nurse #1 to come help before returning to Resident #4.During an interview with Nurse #1 on [DATE] at 6:55am, she stated she was working 3rd shift on [DATE] and was near the nurse's station around 6:00am when NA #1 called out for assistance. Nurse #1 stated she arrived at Resident #4's room and found her lying face down on the left side of her bed. Nurse #1 reported that Resident #4 was alert and oriented and stated she didn't hit her head, and she was not complaining of any pain at that time. Nurse #1 stated she completed a full assessment, including vital signs, and found no abnormalities. Nurse #1 stated she and NA #1 used the lift to put Resident #4 back in her bed. Nurse #1 stated Resident #4 complained of some right knee pain after she was back in her bed, and she was transported to the hospital for evaluation. Nurse #1 indicated that Resident #4 was unable to support herself and needed two staff members to provide incontinence care.A review of an emergency department report dated [DATE] revealed Resident #4 was transported for evaluation following a witnessed fall at the facility. Resident #4 was alert and oriented and complained about right knee pain. Extensive imaging studies were performed to evaluate Resident #4 for any fractures. All these imaging studies were negative. Resident #4 was transported back to the facility on [DATE] with no new orders.During an interview with NA#2 on [DATE] at 10:50am, she stated that she usually worked first shift (7:00am to 7:00pm) and cared for Resident #4 frequently. NA#2 stated that Resident #4 was unable to help herself turn due to her weakness on her left side. NA#2 reported she always had assistance when providing incontinence care for Resident #4.During an interview with Nurse #2 on [DATE] at 11:00am, she stated she usually worked first shift and was assigned to Resident #4's hall often. Nurse #2 stated Resident #4 required two staff members to turn her in bed and provide incontinent care.During an interview with the Director of Nursing on [DATE] at 2:10pm, she stated it was the nurse aide's responsibility to check and follow the care guides for each resident they are assigned to prior to providing care. The DON reported that if the care guide stated Resident #4 was dependent and required two staff members, then the nurse aide should have gotten assistance from another staff member.

Based on record review and Nurse Practitioner, Pharmacist and Medical Director interviews, the facility failed to act on a pharmacy medication regimen recommendation for a Resident taking aripiprazole; aripiprazole is an atypical antipsychotic medication that can be used to treat depression and for which possible side effects include tardive dyskinesia (uncontrollable abnormal movements of the face, tongue or other body parts and requires frequent assessment and monitoring). The deficient practice occurred in 1 of 5 residents reviewed for unnecessary medications (Resident #14).Findings included:Resident #14 was admitted to the facility on [DATE] with diagnoses including depression.Review of records revealed a 1/5/26 physician's order for aripiprazole 5 mg (milligrams) by mouth once a day for depression.Review of the Pharmacist's monthly Medication Regimen Review (MRR) dated 1/7/26 revealed an abnormal involuntary movement scale (AIMS) assessment which revealed no identified involuntary movements or medication issues and there were no new pharmacy recommendations. The Pharmacist's monthly MRR dated 2/2/26 included a recommendation to the provider to consider tapering Resident #14 off of aripiprazole and introducing a different medication to treat her depression if appropriate. The Medical Director's response on the recommendation was noted as in agreement with a handwritten note dated 2/24/26 that the Nurse Practitioner would follow up with regards to the medication taper or to initiate a psychiatric services consult for the recommended tapering of aripiprazole. An AIMS assessment dated [DATE] revealed a score of zero, which indicated no abnormal involuntary body movements.Review of Resident #14's medication administration records (MAR) for February 2026 and March 2026 revealed Resident #14 had continued to receive 5mg of aripiprazole daily per the 1/6/26 order with no taper attempts noted. Review of the April 2026 MAR revealed the aripiprazole was documented as administered on 4/1/26 and 4/2/26. Further review of Resident #14's medical record revealed no documentation by the provider regarding follow up of the pharmacist's recommendation on 2/2/26, no dose taper attempts or initiation of a psychiatry services referral. On 4/2/26 at 11:00 AM, an interview with the Primary Nurse Practitioner was conducted. The Primary Nurse Practitioner stated she was not the one responsible for performing follow-up on medication taper recommendations for antipsychotic medications as she only did Primary Care services. The Primary Nurse Practitioner indicated the Psychiatry Nurse Practitioner was the person to speak to for all psychiatric related questions. When asked if she was aware of the 2/2/26 pharmacy recommendation and the Medical Director's note of acknowledgement, the Primary Nurse Practitioner repeated that she was not the person to speak to about anything related to psychiatry or the medication taper. A telephone interview with the Psychiatric Nurse Practitioner was conducted on 4/2/26 11:20 AM. The Psychiatric Nurse Practitioner indicated she did not know Resident #14. The Psychiatric Nurse Practitioner stated she had never received a referral for Resident #14 and Resident #14 was not on her list of new residents to see or evaluate so she could not answer any questions. On 4/2/26 11:54 AM, a telephone interview with the Medical Director was conducted. The Medical Director stated she remembered the pharmacist's recommendation dated 2/2/26 but did not realize the follow up had not been completed. The Medical Director indicated she had delegated this task to the NP and did not know why the follow-up had not been completed but that it should have occurred sooner rather than later. The Medical Director said she had not been informed of any new issues with Resident #14's condition or her medications and wasn't sure where the breakdown had occurred. The Medical Director further stated that either herself or the Primary Nurse Practitioner could perform the recommended follow-up and then decide if a taper versus a psychiatric consult was appropriate. The Medical Director said she would ensure this would be done. An interview with the Director of Nursing (DON) was conducted on 4/2/26 at 12:00 PM. The DON stated anytime a pharmacist made a recommendation for the provider, the recommendations were emailed to the Assistant Director of Nursing (ADON) who then printed off the recommendations and gave them to the provider for review. The DON said there was no box or bin where these forms were placed for the providers to pick up but rather the forms were actually handed to the providers in person for their review, then the provider would carry out the recommendations as they deemed appropriate. On 4/2/26 at 12:10 PM, a follow up interview with the Primary Nurse Practitioner was conducted and included a review of Resident #14's medical record and the pharmacy recommendation dated 2/2/26 the Medical Director had documented on. The Primary Nurse Practitioner stated she had never seen the 2/2/26 pharmacy recommendation and did not know about it. The Primary Nurse Practitioner indicated she did not know there was a directive for her to follow up on the pharmacy recommendation for Resident #14 to ascertain if a medication taper versus a psychiatric referral was appropriate. The Primary Nurse Practitioner said that all referrals and/or pharmacy recommendations were given to either the Medical Director or herself, but she did not know about this particular recommendation. An interview was conducted with the ADON on 4/2/26 at 12:41 PM. The ADON said when the pharmacist made a medication regimen recommendation, the pharmacist emailed all their recommendations to her in a batch email. The ADON said she then reviewed every recommendation and printed them and hand delivered them to the providers, to either the Primary Nurse Practitioner or to the Medical Director, whoever was on site on the given day. The ADON said the provider then reviewed the recommendations and signed off on them and then returned them to her for scanning into the electronic medical record. The ADON said she monitored the recommendations to ensure the recommendations were actually acted upon. The ADON said she was aware of the recommendation dated 2/2/26 for Resident #14, had noticed no follow up had been conducted and re-delivered the recommendation in person to the Primary Nurse Practitioner for review and follow up. The ADON said she could not remember when she re-submitted the recommendation to the Primary Nurse Practitioner, but it was after she noticed that no apparent action had been taken. On 4/2/26 at 1:20 PM, a telephone interview with the Pharmacist was conducted. The Pharmacist stated that anytime she made a medication regimen recommendation, she would follow up on her recommendations to see if they were carried out. The Pharmacist indicated she was able to see all of her outstanding recommendations in their computer system as soon as she logged in. The Pharmacist noted follow ups were usually conducted by the providers within 30 to 45 days from the date of the recommendation but she sometimes allowed for a maximum of 60 days due to the schedules of the providers and not knowing the exact days the providers were onsite. The Pharmacist said if a recommendation was not acted upon within that timeframe, she would initiate a new recommendation to the provider. The Pharmacist further stated she would be coming to the facility next week for her next monthly visit and would follow up on the 2/2/26 recommendation for Resident #14 at that time. In an interview with the Administrator on 4/2/26 at 2:20 PM, the Administrator stated she did not know exactly where the breakdown had occurred with the pharmacy recommendation not yet being acted upon and her expectation was if a pharmacist made a medication regimen recommendation that the recommendation would be acted upon as soon as possible when the provider became aware of it to ensure the residents' medication needs were being addressed and met.

Based on observations and staff interviews, the facility failed to maintain sanitary conditions in the kitchen by not labeling and dating resealed food items; by failing to store food items off the floor; by failing to ensure kitchen equipment was clean and free from debris; by not correctly storing food service cleaning supplies; by not ensuring hair covering was worn by anyone entering the kitchen; and by not ensuring food items served at acceptable temperatures. Findings included: 1. During the initial tour on 3/27/22 at 10:32 a.m., 6-cases of food items were observed stacked in the middle of the floor in the dry storage room in the kitchen. There were multiple cases of food items stacked on the floor in the walk-in freezer. During an interview on 3/27/22 at 11:00 a.m., the Dietary Manager (Assistant DM) revealed food deliveries to the kitchen were on Wednesdays and Fridays. She indicated the items observed on the floors in the dry storage room and in the walk-in freezer were delivered on Friday (3/25/22). 2. On 3/27/22 at 10:50 a.m., during observations of the refrigeration units in the kitchen the following were observed: a dietary staff did not ensure the door to the walk-in cooler was completely closed (the door remained approximately six inches open for five minutes until this Surveyor entered the cooler); stored in the walk-in cooler was a stainless-steel container of a prepared food item, covered with cellophane wrap and dated 3/25 with no identifying label; stored in the reach-in refrigerator were 1-unopened (33 ounce) plastic bottle of water, 1-unopened (16.9 ounce) plastic bottle of water, and 1-unopened (16.9 ounce) plastic bottle of tea (all with the date of 3/27). The dietary cook revealed these 3-bottles belonged to the second shift cook. The dry storage room contained 1-resealed bag of croutons, 1-resealed bag of dry milk, and 1-resealed bag of batter stored on the storage racks but were not dated. 3a. On 3/27/22 at 11:05 a.m. during the kitchen observation, the 2-filters and vents of the ice machine were observed with thick, dark gray lint. The outside and outside of the food warmer was stained with dark brown substances and the stainless-steel trays inside the warmer contained food crumbs. The lid of the flour bin was stained, and the handle of the scoop stored in the bin was stained with a yellow-brown substance. The lid of the sugar bin was covered with sugar particles. The 6-brooms in the broom/mop closet were stored against the wall with the bristle heads on the floor of the closet. 3b. During a follow-up observation in the kitchen during meal preparation on 3/30/22 at 11:55 a.m., a food vendor deliveryman was observed transporting cases of food items through the kitchen to the storage areas. The deliveryman's hair was not covered. Also observed in the kitchen were dirty and wet pans were stacked on the storage rack: 1-(1/2 sized) steamtable pan stained with yellow particles, 1-(2 inch deep) steamtable pan, and 1-large muffin pan with yellow/white particles. There was 1-(2 inch deep) steamtable pan stacked wet on the storage rack. In the dry storage room, the lid of the sugar bin was covered with fine white particles. 3c. On 3/30/22 at 12:17 p.m., during the 500/600 hall satellite kitchen observation, the 2-filters and vents of the ice machine were observed with thick, dark gray lint. 4. During an observation of the meal tray line service in the 500/600 hall satellite kitchen on 3/30/22 at 12:25 p.m., a pan of tuna with cheese sandwiches (alternate entrée) was observed on the counter, next to the steamtable. The temperatures of the tuna with cheese sandwiches in the pan were 90 degrees Fahrenheit. The meal tray service consisting of one of the tuna sandwiches was stopped by this Surveyor before it was served to a resident. The Dietary Manager removed the sandwiches from the meal serving line and stated that she was unsure if the tuna sandwiches were to be served cold or hot but acknowledged the 90-degree Fahrenheit temperature was not acceptable for a food item to be served cold (41 degrees Fahrenheit or below) or a food item to be served hot (135 degrees Fahrenheit or above).

Based on record review, observations, staff and nurse practitioner interviews the facility failed to prevent a urinary catheter bag from encountering the floor to reduce the risk of infection or injury for 2 of 2 residents (Resident #10 and #29) reviewed for urinary catheter care. The findings included: A review of the facility policy, titled: Catheter care, Urinary from the manual, LSC Nursing Services, under the section, Urinary and Renal Conditions, was conducted. On page 1, under infection control, the policy read: The catheter tubing and drainage bag should be kept off the floor. 1. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had severe cognitive impairment, required assistance of one staff for activities of daily living (ADL) care and total assistance with dressing. The assessment revealed the Resident had a urinary catheter. A review of the care plan dated 10/19/2021 revealed a focused area that read: Resident #10 had a urinary catheter because she had chronic kidney disease with a goal that she would be free from a urinary tract infection. Interventions included to provide care to the catheter, monitor for signs and symptoms of infections, take care of the catheter equipment. A review of the physician orders revealed an order to provide catheter care every shift, dated 2/1/2022. An observation was conducted on 3/28/2022 at 3:47 PM of Resident #10 lying in bed with a urine catheter bag hanging on the bed frame at the foot of the bed with the lower half of the bag on the floor. The bed was in the lowest position. An interview was conducted on 3/28/2022 at 3:50 PM with Nursing Assistant (NA) #3 and he revealed when a resident had a catheter bag, the bag should not touch the ground because it was not sanitary. An interview was conducted on 3/28/2022 at 3:45 PM with NA #4 that was assigned to Resident #10 and #29 and she revealed when she has a resident with a urine catheter bag she hangs the bag on the side of the bed and likes to make sure the bag was emptied at the first of her shift and the end of her shift. She added that she had already made rounds and emptied the catheters for this shift. An observation was then conducted inside Resident #10's room with NA #4 and she stated she observed the urine catheter bag lying on the ground with the bed in the lowest position and the bag should not be touching the ground because this will cause the bag to leak urine. She raised the bed to take the bag off of the ground and stated the bed was to be in the lowest position but the bag touches. An interview was conducted with the Staff Development Coordinator (SDC) on 3/28/2022 at 4:03 PM and she revealed the facility expectation was for a urinary catheter bag to not touch the floor in order to prevent bacteria from entering the system through the tubing and causing the potential for infection. She stated she would follow up with NA #4 and provide education. She added that NA #4 was a new NA and had only been certified a brief time period. An observation was conducted on 3/29/2022 at 9:55 AM of Resident #10 lying in bed with half of the urine catheter bag lying on the floor. The bed was in the lowest position. An interview was conducted with Nurse #4 on 3/29/2022 at 10:01 AM in Resident #10's room and Nurse #4 revealed she observed the urinary collection bag lying on the floor with half of the bag on the floor. She stated it was her expectation that the bag be off the floor. She stated the bed was to be in the lowest position for the fall safety intervention for the Resident and something needs to be thought of to go between the floor and the collection bag for the Resident. She stated she was going to think of something and place it as a barrier. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed, in regard to a urine catheter collection bag touching the floor, the catheter bag was a direct line to the bladder and an increased risk for infection when it touches the floor. He added that Resident #10 was a high risk for infection from the amount of steroids she was ordered to take due to her disease process. He stated it was his expectation that the catheter bags be kept off of the floor. 2. Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change MDS, dated [DATE], revealed Resident #29 had severe cognitive impairment and required total assistance of one staff member with toilet use and personal hygiene. The assessment revealed the Resident had an indwelling urinary catheter. The care plan for Resident #29 revealed she had a focused area that read, she had a catheter because she had chronic kidney disease and was on [MEDICATION(S)] with a goal to be free from urinary tract infections with the catheter functioning properly with adequate fluid intake. The interventions included to have catheter care, ensure the catheter was not kinked, monitor for signs and symptoms of infections, and have the NAs provide care to the catheter equipment and skin. An observation was conducted on 3/28/2022 at 3:44 PM with Resident #29 lying in bed with the urinary catheter collection bag hanging on the bed frame at the foot of the bed with the bag sitting on the floor. An interview was conducted on 3/28/2022 at 3:50 PM with Nursing Assistant (NA) #3 and he revealed when a resident had a catheter bag, the bag should not touch the ground because it was not sanitary. An interview was conducted on 3/28/2022 at 3:45 PM with NA #4 that was assigned to Resident #10 and #29 and she revealed when she has a resident with a urine catheter bag, she hangs the bag on the side of the bed and likes to make sure the bag was emptied at the first of her shift and the end of her shift. She added that she had already made rounds and emptied the catheters for this shift. At 4:00 PM an observation was conducted with NA #4 of Resident #29's urine collection bag touching the floor and she stated she would raise the bed immediately. An interview was conducted with the Staff Development Coordinator (SDC) on 3/28/2022 at 4:03 PM and she revealed the facility expectation was for a urinary catheter bag to not touch the floor in order to prevent bacteria from entering the system through the tubing and causing the potential for infection. She stated she would follow up with NA #4 and provide education. She added that NA #4 was a new NA and had only been certified a brief time period. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed, in regard to a urine catheter collection bag touching the floor, the catheter bag was a direct line to the bladder and an increased risk for infection when it touches the floor.

Based on observations, record reviews, resident and staff interviews, the facility failed to accurately assess and code the minimum data set for 1 of 3 sampled residents (Resident #26) reviewed for range of motion/positioning; 1 of 6 sampled residents (Resident #40) reviewed for nutrition; and 1 of 2 sampled residents (Resident #11) reviewed for hospice services. Findings included: 1. Resident #26 was admitted to the facility on [DATE] readmitted : 9/27/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE] indicated Resident #26 was moderately, cognitively impaired; required extensive assistance with bed mobility and transfers; required supervision when eating; and had no impairments with range of motion of her upper and lower extremities. On 3/28/22 at 11:47 a.m., Resident #26 was observed in the dining room feeding herself. The resident was using her left hand to hold the fork. The resident revealed her right hand was her dominant hand but was unable to use it due to difficulty with straightening the fingers of her right hand. During an interview on 3/30/22 at 2:30 p.m., MDS Coordinator #1 acknowledged Resident #26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that section G0400 A and B of Resident #26's MDS were incorrectly coded as no impairment due to human error. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly minimum data set (MDS) dated [DATE] indicated Resident #40 was cognitively intact, eating occurred only 1-2 times with setup; had no weight loss; and received a mechanical altered diet. During an interview on 3/29/22 at 2:43 p.m., MDS Coordinator #2 indicated Resident #40 was independent with eating. She revealed she referred to and documented using the nursing assistants' tracking information for the period of 1/18/22 -1/24/22 when coding the MDS for eating function. She stated that a corrected MDS should have been re-submitted and the nursing assistant's error of the resident's eating assessment should have been documented in the nurse's note. 3. Resident #11 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record revealed Resident #11 was admitted to Hospice services on 1/1/22. The comprehensive MDS assessment dated [DATE] indicated the resident received Hospice services. Further review of the MDS assessment revealed a prognosis of less than six months was not checked. The Hospice agency's plan of care dated 1/1/22 was reviewed and indicated a prognosis of a life expectancy of six months or less. During an interview with MDS Nurse #1 on 3/29/22 at 11:21 AM, she explained she routinely checked Hospice care on the MDS when she completed the assessment for a resident who was admitted to Hospice services and checked yes on the assessment that the resident had a life expectancy of less than six months. MDS Nurse #1 verified she completed the MDS assessment dated [DATE] and stated the prognosis of less than six months should have been checked on the assessment. She thought it was an oversight that she missed the coding on the prognosis question. On 3/30/22 at 3:53 PM an interview was completed with the Administrator. She indicated the facility had corporate support who assisted with monitoring/auditing the accuracy of MDS assessments.

Based on observation, record review and staff interviews the facility failed to follow care planned interventions for 1 of 2 residents (Resident #10) reviewed for accidents. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had severe cognitive impairment, required extensive assistance of one staff for activities of daily living (ADL) care and total assistance with dressing. The assessment revealed the Resident had a fall with minor injury since the last assessment. The care plan had a focused area for falls that read, Resident #10 had the potential to fall down and hurt herself because she had decreased safety awareness and mobility with a goal to stay safe while she was moving about to avoid injury. An intervention was added on 10/29/2021 that read, bilateral fall mats and bolsters to the bed were added. The intervention was still active at the time of the investigation. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was conducted of Resident #10, on 3/27/2022 at 3:36 PM, lying in bed with a fall mat on the right side of the bed, between the wall and the bed, and not on the left side of the bed. An observation was conducted of Resident #10, on 3/28/2022 at 3:47 PM, lying in bed with a fall mat on the door side of the room and no fall mat on the window side of the bed. An observation was conducted of Resident #10, on 3/29/2022 at 11:52 AM, lying in bed with a fall mat between the bed and the wall with no fall mat on the window side of the bed. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nurse #4 on 3/29/2022 at 11:54 AM and she revealed that she had signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She then observed Resident #10 in bed and stated the Resident only had one fall mat on the wall side of the bed and she did not see a second fall mat anywhere in the room. She denied seeing a second fall mat prior to signing the MAR. She added she would try to acquire a second mat as soon as possible. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed when an order was written and care planned for a resident, such as the order for bilateral fall mats for Resident #10, it was his expectation that the order or care planned intervention be followed as written.

Based on observation, record review, staff and Nurse Practitioner interviews the facility failed to provide the interventions for fall prevention for 1 of 2 residents (Resident #10) reviewed for falls. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], an [CONDITION(S)] disease, diabetes mellitus II, chronic kidney disease, pressure ulcers of the right and left heels with a history of falls. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had severe cognitive impairment, required extensive assistance of one staff for activities of daily living (ADL) care and total assistance with dressing. The assessment revealed the Resident had a fall with minor injury since the last assessment. A review of the fall incident reports revealed Resident #10 had an incident on 9/16/2021 that documented the Resident was observed on the floor with a fall from the bed. A review of the fall incident reports revealed Resident #10 had an incident on 9/17/2021 that documented the Resident was observed on the floor in the Resident's room with a fall from the bed. A review of the fall incident reports revealed Resident #10 had an incident on 10/11/2021 that documented the Resident was observed on the floor in the Resident's room. A review of the physician orders revealed an order, dated 10/27/2021, that read, floor mats to both sides when in bed for safety due to multiple falls with continuous use. A review of the fall incident reports revealed Resident #10 had an incident on 10/29/2021 observed in the floor next to the bed on a floor mat. The care plan had a focused area for falls that read, Resident #10 had the potential to fall down and hurt herself because she had decreased safety awareness and mobility with a goal to stay safe while she was moving about to avoid injury. An intervention was added on 10/29/2021 that read, bilateral fall mats and bolsters to the bed were added. The intervention was still active at the time of the investigation. An observation was conducted of Resident #10, on 3/27/2022 at 3:36 PM, lying in bed with a fall mat between the bed and the wall and there was no fall mat on the window side of the bed. An observation was conducted of Resident #10, on 3/28/2022 at 3:47 PM, lying in bed with a fall mat on the door side of the room and no fall mat on the window side of the bed. An observation was conducted of Resident #10, on 3/29/2022 at 11:52 AM, lying in bed with a fall mat between the bed and the wall with no fall mat on the window side of the bed. A review of the Medication Administration Record (MAR) for the date of 3/29/2022 revealed the order for the bilateral floor mats had been signed as complete and in place by Nurse #4. An interview was conducted with Nurse #4 on 3/29/2022 at 11:54 AM and she revealed that she had signed the MAR today that Resident #10 had bilateral fall mats in place. She then observed Resident #10 in bed and stated the Resident only had one fall mat on the wall side of the bed and she did not see a second fall mat anywhere in the room. She denied seeing a second fall mat prior to signing the MAR. She added she would try to acquire a second mat as soon as possible. An interview was conducted with the Nurse Practitioner on 3/29/2022 at 2:15 PM, and he revealed when an order was written and care planned for a resident, such as the order for bilateral fall mats for Resident #10, it was his expectation that the order or care planned intervention be followed as written.

Based on 2 of 2 dining observations, record reviews, and staff interviews, the facility failed to ensure staff were seated while assisting Resident #38 during dining. Findings included: 1a. Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set, dated dated dated [DATE] indicated Resident #38 was severely, cognitively impaired; was total dependent on staff for eating; and had a swallowing disorder of holding food in her mouth/cheeks. The care plan revealed Resident #38 received a mechanically altered and therapeutic diet and was at high risk for weight loss. Interventions included: the resident was to be fed by staff. On 3/28/22 at 1:01 p.m., Resident #38 was in bed with the head of the bed raised to approximately 85 degrees. Nursing assistant (NA#1) was standing next to the resident's bed as he fed the resident a pureed meal with regular liquids. During an interview on 3/30/22 at 10:04 a.m., nursing assistant (NA#1) acknowledged his standing while feeding Resident #38. He revealed he had been educated on the correct way to feed residents; he should have been sitting in a chair when feeding the resident. NA#1 stated he stood while feeding Resident #38 because there was no chair in the room, and he did not want to disrespect the resident by sitting in her wheelchair. 1b. An observation was conducted on 3/29/2022 at 9:34 AM of Resident #38 lying in bed, turned to her right side, sitting with the head of the bed elevated, being fed her meal by Nursing Assistant, NA, #2. The NA was standing beside the bed while feeding assistance was provided from 9:34 AM until 9:45 AM. An interview was conducted on 3/29/2022 at 9:30 AM with NA #2 and the NA revealed that Resident #38 was the only Resident she had to provide total feeding assistance to during the breakfast meal on this day because other staff helped with the other residents. She added that she preferred to stand when she fed residents but does not always stand, it depended on how the day goes and the Resident she was working with. She stated she stood while feeding Resident #38 often. She denied being told to not stand while feeding. During the interview Nurse #3 was present and did not add any further information. An interview was conducted with Nurse #3 on 3/29/2022 at 9:46 AM upon exiting Resident #38's room. When asked what the facility policy for feeding a resident while standing was, she identified it was the facility policy to not stand while feeding a resident. She then went back into Resident #38's room and requested NA #2 to not stand while feeding the Resident.

Based on observation, staff interview and facility policy and procedure review it was determined that 1 of 1 nursing assistants (#1) taking vital signs failed to wash/sanitize her hands and the equipment she was using while taking vital signs during a COVID -19 pandemic. Findings included: 1. Review of facility document titled Handwashing and Hand Hygiene dated 12/21/09 stated, (Facility) considers hand hygiene the primary means to prevent the spread of infections. All staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. Staff are expected to follow handwashing/hand hygiene procedures to help prevent the spread to other staff members, residents, and visitors. Procedures listed as a part of the document included, Use an alcohol -based hand rub containing at least 62% alcohol; or alternatively soap and water for all the following situations: Before and after coming on duty, before and after direct contact with residents, after contact with the resident's intact skin, after contact with inanimate objects (e.g. medical equipment) in the immediate vicinity of the resident. Observation of nursing assistant (NA) #1 on 8/27/2020 at 3:28 PM revealed her entering room [ROOM NUMBER] with the vital sign equipment. NA#1 was observed taking the temperature of the resident, picking the clipboard up from the table, writing something down and exiting room [ROOM NUMBER]. She did not wash her hands, sanitize her hands or clean the equipment. NA #1 was observed entering room [ROOM NUMBER] at 3:31 PM. She was observed taking the resident's temperature, the resident's blood pressure and documenting on the clipboard. She did not wash her hands, use sanitizer or wipe down the equipment as she proceeded into room [ROOM NUMBER] at 3:34 PM. NA #1 was overheard telling the resident that she was going to take blood pressure and temperature. She was observed touching the end of the bed in 104 then exiting the room with the vital sign equipment. She did not clean or sanitize the equipment. She sanitized her hands and entered room [ROOM NUMBER]. The NA was heard washing her hands and observed using sanitizer as she exited room [ROOM NUMBER] and proceeded to room [ROOM NUMBER] at 3:43 PM. NA#1 was observed exiting 109 and proceeding to room [ROOM NUMBER] without washing her hands, using sanitizer or cleaning the equipment at 3:46 PM. She was observed taking temperature and blood pressure before documenting on her clipboard. During interview with NA #1 at 3:44 PM on 8/28/2020, she stated that she had a lot on her mind. She revealed that she had previous training on hand washing. She stated that prior to entering the room she was to sanitize, wash her hands and wipe down equipment before going to the next room. Interview with the Director of Nurses on 8/28/2020 at 3:49 PM revealed that staff were supposed to carry disinfectant wipes to clean equipment between use with each resident. She stated that there would normally be a small container in the basket or that staff could use the sanitizer on the wall to clean the equipment.

Based on record review, family interview, and staff interviews, the facility failed to protect 1 of 3 sample residents (Resident #1) from physical abuse inflicted by a staff member that resulted in Resident #1 being struck in the face. The Findings Included: Resident #1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired, had behavioral symptoms that significantly interfered with care and social interactions. The MDS also revealed Resident #1 required extensive assistance with 1-person assistance for activities of daily living (ADL's). Review of Resident #1's care plan dated 12/5/2019 revealed focus areas included for resident to be comfortable living in facility, remain safe and avoid injury while moving throughout the facility, and to effectively communicate her needs. Resident #1 was also care planned for confusion, behaviors, and mood disorientation. Review of the 24-hour Report dated 7/31/2020 revealed an allegation of physical abuse of Resident #1 by NA (Nurse Aid) #1 that occurred on 7/31/2020 at 6:30 PM. The 24-hour report was signed by the Staff Development Coordinator on 7/31/2020. Review of the 5-Working Day Report dated 8/4/2020 revealed the allegation of abuse to Resident #1 was investigated and substantiated. The report stated on 7/31/2020 at approximately 6:30 PM NA #2 witnessed NA #1 slap resident on face while resident was sitting in a wheelchair. Resident #1 had gotten out of her wheelchair and was walking alone in the hallway. NA #1 assisted resident back into wheelchair. As NA #2 was walking towards NA #1 and Resident #1, NA #1 slapped resident across right cheek. NA #1 was suspended on 7/31/2020 with a termination on 8/6/2020. Notification was made to law enforcement and the state agency. Review of written statement by NA #1 dated 8/6/2020, revealed on 7/31/2020 she noticed Resident #1 holding onto the side rails in the hallway. NA #1 walked over to Resident # 1 and sat her down into a wheelchair. Resident #1 spoke to NA #1, NA #1 then tapped Resident #1 on the chin. An observation on 8/18/2020 at 12:20 PM of camera footage, recorded by the facility, dated 7/31/2020 at 5:33 PM, revealed Resident # 1 walking in the hallway. NA #1 approached Resident #1 and assisted Resident into her wheelchair. NA # 1 was observed using her left hand to contact Resident #1's face. An interview with Director of Nursing (DON) on 8/18/2020 at 11:52 AM revealed she received a phone call on 7/31/2020, stating NA #1 had hit Resident #1 in the face. The DON was not at the facility at the time of the call about the incident, but stated she called the Staff Development Coordinator, who was present in the facility, and instructed her start the investigation. An interview with Staff Development Coordinator (SDC) on 8/18/2020 at 12:32 PM revealed on 7/31/2020 she received a phone call from the DON. The DON informed SDC of the reported incident and asked her to investigate. The SDC stated upon her immediate arrival to unit, she relieved NA#1 of her duties and asked to leave the building. NA #1 was asked to provide a written statement detailing the incident. NA #1 declined to leave a written statement prior to exiting the facility on 7/31/2020. SDC stated she completed the 24-hour report. An interview with NA #2 (who witnessed the incident) on 8/18/2020 at 12:46 PM, revealed on 7/31/2020, upon exiting another resident's room, NA #2 looked down the hallway and observed NA #1 placing Resident #1 into her wheelchair. He stated that Resident #1 appeared to be agitated and lashed out towards NA#1. He stated he then observed NA #1 slap Resident #1 on the face. NA #2 stated he removed Resident #1 from the situation and reported the incident to Nurse #1. An interview was attempted on 8/18/2020 at 1:03 PM with NA #1 via telephone. There was no answer and no returned call. An interview with Nurse #1 on 8/18/2020 at 1:03 PM revealed during her shift on 7/31/2020, NA # 2 reported to her that NA #1 hit Resident #1 in the face. Nurse # 1 contacted the Director of Nursing and performed a physical assessment of Resident #1. An interview with Resident #1's family member on 8/18/2020 at 2:45 PM, revealed family member received a telephone call from facility staff stating Resident #1 had been struck in the face by a Nurse Aid. Family member stated she was advised the police had been notified and were investigating. She further stated the police contacted her the following day regarding the investigation. An interview was conducted with the Administrator on 8/19/2020 at 4:40 PM. During this interview, she stated NA#1 should have asked for a change in assignment if she was feeling burn out from working with Resident #1. On 8/19/20 at 4:18PM, the facility shared the following plan to address the incident: Plan of Correction for QAPI Incident date 7-31-20 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was immediately removed from contact with this nursing assistant (C.N.A.#1) and the observing CNA (C.N.A. #2) reported to his nurse (RN) on unit. Staff Development Coordinator was in building on another unit. She immediately told CNA #1 to leave facility and that she could not return until she had been contacted by DON. Resident #1 was immediately assessed by RN on unit. There was no redness nor bruising noted. Physician Services and family have been notified by DON. Completed 7-31-20 2. How will you identify other residents having the potential to be affected? All residents had skin assessments completed as well as individual interviews. There were no issues identified with these audits. Completed 7-31-20 to 8-4-20. 3. What measures will be put into place or systemic changes made to ensure it will not happen again? Staff education completed for all employees on Abuse. Completed all working by 8-3-20 to 8-5-20, then completed mailing to any that were not working 8-5-20. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Quality Improvement Coordinator will monitor four employees 3X weekly for 4 weeks observing interactions with residents and outcomes. These audits will be presented at our Quality Assurance Performance Improvement (QAPI) meeting for review. Began week of 8-3-20, will complete week of [DATE]. Will review results in QAPI meeting on 9-11-20. 5. Completion date 8-5-20 As part of the validation process on 8/18/20 and 8/19/20, the plan of correction was reviewed and included the in-services related to abuse, resident rights, staff burnout and dementia care for all staff members, documentation that revealed 100% of all residents alert and oriented were interviewed regarding concerns about safety/abuse, in- house residents had a skin assessment conducted, employee files were reviewed to verify background checks and abuse training was completed upon hire, the grievance logs were reviewed to verify no complaints related to abuse were reported, and the QAPI plan to include monitoring to be completed. Date of correction action completion. Final Compliance date 8/5/20.

Based on observations and family and staff interviews, the facility failed to maintain clean wheelchairs for a sampled resident (Resident #57) and failed to maintain wheelchairs in good repair for 2 sampled residents (Resident #'s 57 and 70). The findings included: An observation on 12/19/19 at 12:01 PM revealed Resident #57 was in his wheelchair in the dining room of the 300 hall locked unit waiting to eat lunch. His wheelchair was observed to be soiled with dried debris on the seat in front of the cushion and along the inner sides. The wheelchair was also observed to have several cracks in the vinyl of the left armrest pad. An interview was conducted on 12/2/19 at 2:48 PM with Resident #70's family member during the initial pool process. An observation conducted in conjunction with the interview revealed Resident #70's wheelchair had several tears in the vinyl on the armrest pad. Resident #70's family member stated the wheelchair armrest pads did not look good. An observation on 12/5/19 at 3:15 PM revealed Resident #57's wheelchair remained soiled with dried food debris and the armrest pads remained torn. Resident #70's wheelchair armrest pads remained torn. An interview was conducted on 12/5/19 at 3:22 PM with the Housekeeping Director. She revealed she tried to do wheelchair cleaning monthly when she had the staff to do it, but she didn't always have the staff available. She stated when any staff members see a soiled wheelchair, it should be cleaned at that time. An interview was conducted on 12/5/19 at 3:37 PM with the Maintenance Director. He stated he did monthly and quarterly inspections and items such as wheelchairs are included in the inspection. He stated housekeeping cleans the wheelchairs monthly and should be notifying maintenance at that time if a wheelchair needs repairing. He also stated any nursing staff member can let maintenance know if a wheelchairs armrest pads need to be replaced.

Based on record review and staff interview the facility failed to accurately code the minimum data set (MDS) assessment for the resident discharge to an assisted living facility for 1 of 1 sampled resident reviewed for MDS accuracy (Resident #103). Findings included: 1. Resident # 103 was admitted to the facility on [DATE] with a history of Type 2 diabetes, [MEDICAL CONDITIONS], and dementia. The discharge minimum data set ((MDS) dated [DATE] identified resident was discharged to an acute care hospital. Review of Nurses note dated 9/4/19 revealed the resident was discharged to an assisted living facility on 9/4/19 at 2:40 PM. An interview was conducted with MDS Nurse #1 on 12/05/19 at 9:57 am and she stated Resident #103 was discharged back to an assisted living facility and not the hospital as indicated on the MDS assessment. She stated it was an honest mistake and she will do a modification to the assessment.

Based on record review and staff interviews, the facility failed to develop a comprehensive individualized and person-centered care plan in the area of antipsychotics for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #70). The findings included: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #70's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #70 had severe cognitive impairment. Resident #70 had exhibited physical behaviors toward others daily and verbal behaviors directed toward others 1-3 days during the assessment period. The assessment revealed Resident #70's behaviors put her at significant risk for illness or injury and interfered with her care. Resident #70's behaviors had also put others at significant risk for physical injury and intruded on the privacy or activity of others. The assessment revealed she had received an antipsychotic medication during the assessment period. A review of the Resident #70's care plan did not include use of an antipsychotic medication. A record review revealed a physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. An interview was conducted with NA #1 on 12/5/19 at 9:49 AM. She revealed Resident #70 was combative with care at times, wandered around the unit frequently and was difficult to redirect. An interview was conducted with MDS #1 on 12/5/19 at 2:00 PM. She revealed Resident #70 did have antidepressant and antianxiety medication care planned. She also stated Resident #70 was not on the antipsychotic medication when she was admitted .

Based on observations, record reviews and staff interviews, the facility failed to accurately document on the Medication/Treatment Administration Records (MAR/TAR) that an order to monitor [DEVICE] was discontinued for 1 of 3 residents reviewed for skin conditions (Resident#2). Nursing staff continued to document that they were monitoring the [DEVICE] even when the resident no longer had the [DEVICE]. Findings included: Resident #2 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent minimum (MDS) data set [DATE] indicated Resident #2 severely, cognitively impaired; had lower left extremity impairment; and had a surgical wound. The care plan dated 11/26/19 revealed Resident #2 had the potential for skin injury due to the left hip surgical wound and had a [DEVICE] in place. The Approaches to the care plan included: provide wound care if needed; check skin weekly; inform the physician of any changes; and report any fever or odor to the hip surgical site to nursing. The care plan was updated on 11/29/19 indicating the [DEVICE] was discontinued. A review of the NP (Nurse Practitioner's) written order dated 11/26/19 included: 1) discontinue treatment to the left thigh wound. 2) Clean surgical wound with puracyn (wound cleansing solution) spray; apply (pack) with algicell ag strip gauze (Antimicrobial silver dressing) to base of wound; cover with foam dressing; and change daily in the morning. 3) X-ray left hip and femur due to decreased healing wound. The review of the (MONTH) 2019's MAR/TAR for Resident #2 revealed the NP's order to discontinue the treatment using the [DEVICE] was not transferred to the MAR/TAR. The nursing staff documented the [DEVICE] portable device was monitored during first, second and third shifts on 11/27/19, 11/28/19, 11/29/19 and 11/30/19. The [DEVICE] was not discontinued on the MAR/TAR until 12/4/19. During an observation on 12/02/19 at 4:19 p.m., Resident #2 was reclining in her bed with the bedlinen to her waist, watching television. There was no [DEVICE] observed in the room. During an interview on 12/03/19 at 2:28 p.m., the DON (Director of Nursing) revealed Resident #2 was admitted to the facility on [DATE] with a deep surgical wound to her left hip and a [DEVICE] which was discontinued a week prior to this interview. The DON stated that the resident was hosptalized on [DATE] through 4/3/19 due to [MEDICAL CONDITION] and the treatment continued upon her readmission. She stated that in (MONTH) 2019, the resident developed [MEDICAL CONDITION] in the wound and was sent to infectious disease consult. During an interview on 12/4/19 at 3:21 p.m., and after reviewing Resident #2's MAR/TAR, the DON acknowledged the nursing staff continued signing the MAR/TAR on (MONTH) 27 through (MONTH) 30, 2019 indicating the [DEVICE] was monitored after the [DEVICE] was discontinued. She stated the order should have been removed from the MAR/TAR by the person who transferred the order onto the MAR/TAR on the day the [DEVICE] was discontinued. The DON stated indicated only part of the NP's order was transferred to the MAR/TAR; the monitoring of the [DEVICE] was mistakenly left on the MAR/TAR. During an interview on 12/4/19 at 3:35 p.m., Nursing Supervisor #1 revealed she removed the [DEVICE] and started the new wound treatment on Resident #2 on (MONTH) 26, 2019. During an interview on 12/4/19 at 4:13 p.m., Staff Nurse #1 stated the NP wrote the order which included discontinuing the [DEVICE] treatment. The Nurse Supervisor signed the order and transferred the order to the MAR/TAR. Staff Nurse #1 stated that she re-checked the order to ensure it was transferred to the MAR/TAR but failed to notice that the monitoring of the [DEVICE] was still on the MAR/TAR. She revealed she mistakenly signed the MAR/TAR on 11/27/19 during second shift indicating she monitored the [DEVICE]. During an interview on 12/4/10 at 4:30 p.m., Med Aide #1 (Medication Aide) revealed she was aware the wound treatment with the [DEVICE] was discontinued for Resident #2. She stated that she mistakenly signed the MAR/TAR for the monitoring of the [DEVICE] on 11/27/19 and 11/29/19.

Based on record review and staff interviews the facility failed to provide dignity for a resident with dementia when a staff member changed the last name on her office door plaque from her last name to the resident's last name as a joke for 1 of 1 residents (Resident #1) reviewed for abuse. Findings included: Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed he had severely impaired cognition, he required one-person limited assistance for eating, and one-person extensive to total assistance with all other activities of daily living. Review of the facility reported incident and subsequent investigation from 10/9/19 revealed that staff had shared concerns with administration of inappropriate behavior from the Activity Director (AD) towards Resident #1. The report stated that Resident #1 was cognitively impaired and was observed and reported by staff to have spent more and more time in the AD's office. Staff reported that the AD had put a sign outside of her office door with her first name and Resident #1's last name. It also stated that due to the resident's cognitive impairment he would not necessarily understand if the relationship was real or if it would progress. During an interview with Nurse Assistant (NA) #1 on 10/29/19 at 12:27 PM she stated that the Activity Director had changed her name on her door plaque outside her office to her first name and Resident #1's last name but was not sure of the date it happened. NA #1 had thought this was strange and did not understand why she would do that. During an interview with the Staff Development Coordinator (SDC) on 10/29/19 at 12:56 PM she stated that her office was right beside the Activity Director's office. She reported that Resident #1 would stay in the Activity Director's office from approximately 8:00-830 AM all day until the Activity Director left for the day. On one occasion when the SDC had attempted to get Resident #1 to leave the AD's office while she was not present, Resident #1 had stated to the SDC, you aren't going to tell me what to do in my woman's office. The SDC also reported that the AD had put a sign on her door with the AD's first name and Resident #1's last name for about a week. The SDC stated that she felt it was inappropriate. During an interview with the MDS Coordinator on 10/29/19 at 2:53 PM she stated that the AD had told her that Resident #1 had told her he wanted to shut the door and have his way with her, and the AD had laughed about it. She reported that the AD had a sign outside her door with the AD's first name and Resident #1's last name. The MDS Coordinator had not seen any touching but felt it was strange and inappropriate behavior. During an interview on 10/29/19 at 3:28 PM with the Activity Assistant/Social Work Assistant (AA) she stated that the AD had changed her name on her door to the Resident #1's last name and that she would tell her not to do things like that, but the AD would just laugh it off. The AA stated that Resident #1 went straight to the AD's office every day looking for her and seemed sad when he could not find her. During an interview with the Administrator on 10/29/19 at 3:38 PM she stated that after staff reported incidents to her, an investigation was started, and the state agency was notified per policy. Based on her investigation and its findings, she had terminated the AD for inappropriate behavior towards Resident #1. When asked if she had witnessed the sign outside the AD's door with her first name and Resident #1's last name, she stated she had and had immediately questioned the AD about it. The AD had told her that Resident #1 had started coming to her office all the time and that had she wanted to make it easier for him to find her office. During the investigation, the Administrator stated that each particular incident reported by the staff would not have necessarily been abuse, and that she could see why it had not been directly reported to her. She stated that as a whole and after all of the separate incidents were reported to her, the AD's actions had been unnerving and inappropriate. All staff were educated to report any and all behavior that seemed inappropriate to administration, whether it constituted as abuse or not, so that this situation would not happen again. During a telephone interview with the previous AD on 10/29/19 at 4:21 PM she stated that she had worked one-on-one with Resident #1 for approximately the last two weeks of employment. She stated that Resident #1 would come to her office each day, and several times a day. The AD reported that she had gathered information about Resident #1 for facial/location stimulation of where he used to live and the church that he used to go to for dementia therapy. She stated that the pictures used during their one-on-one sessions was affecting him in a positive way, and that Resident #1 was moving more and socializing with her as well as other residents. When asked about the sign on her door with her first name and Resident #1's last name on it, she stated that it had been a joke because Resident #1 had proposed to her during an activity session and she thought it was funny. She stated that she felt that she had made a positive impact on Resident #1, that she had never abused him mentally, physically, or sexually and she did not understand why she was terminated from her job.

Based on observations and staff interviews the facility failed to allow dishware to air dry and failed to maintain dishware free of food debris in the main kitchen and 3 of 4 service kitchens. The facility failed to maintain clean ice machine filters in 3 of 4 service kitchens. Findings Included: 1. An observation of the main kitchen with the Dietary Manager (DM) was conducted on 10/30/17 at 3:15 pm and revealed: A) 11 steam table pans were stacked together wet on a shelf for storage of clean dishware B) 1 steam table pan with dried food particles was on a shelf for storage of clean dishware 2. An observation of service kitchen #1 with the DM was conducted on 10/30/17 at 3:30 pm and revealed: A) 2 - 8 ounce (oz.) bowls were wet and stored inverted on a solid tray ready for service B) 2 - 8 oz. bowls contained food particles and were stored on a solid tray ready for service C) The ice machine filter had a build-up of dust 3) An observation of service kitchen #2 with the DM was conducted on 10/30/17 at 3:45 pm revealed the ice machine filter had a build-up of dust. 4) An observation of service kitchen #3 with the DM was conducted on 10/30/17 at 3:50 pm and revealed: A) 13 - 8 oz. coffee mugs were wet and stored inverted on a solid tray ready for service B) 2 - 8 oz. coffee mugs contained food particles and were stored on a solid tray ready for service C) The ice machine filter had a build-up of dust 5) An observation of service kitchen #4 with the DM was conducted on 10/30/17 at 4:00 pm and revealed: A) 5 - 8 oz. bowls were wet and stored inverted on a solid tray ready for service B) 2 - 8 oz. bowls contained food particles and were stored on a solid tray ready for service 6) An observation of service kitchen #4 with the DM was conducted on 11/1/17 at 12:10 pm and revealed 24 - 8 oz. glasses were wet and stacked together on a solid tray ready for service. An interview with the DM on 11/2/17 at 11:45 am revealed it was her expectation that all dishware were clean and allowed to air-dry before being placed into service for the next meal. She stated she expected the ice machine filters to be clean and free from dust. An interview with the Administrator on 11/2/17 at 4:31 pm revealed she expected dishware to be clean and dry before being used. The Administrator stated she expected the ice machine filters to be clean.

Based on record review and staff interviews the facility failed to develop a comprehensive interdisciplinary care plan that addressed Resident #86 behaviors in 1 of 3 residents reviewed with behavioral issues. Findings included: Resident #86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the behavior sheets from 5/9/17 through 8/1/17 revealed 55 (fifty-five) episodes in which Resident #86 was either screaming, grabbing, hitting, throwing, smearing food/waste, or refusing care. Review of the admission 5/12/17 and quarterly 8/4/17 the Minimum Data Set (MDS) revealed impaired cognition with behavioral issues of rejection of care and other behaviors such as hitting, scratching and screaming. Record review reviewed on 6/15/17 a mental health consultation was performed due to slapping another resident on the cheek. Review of the care plan dated 10/19/17 revealed a problem with the tendency of being combative during care related to dementia and anxiety manifested by hostile actions of striking out and refusing care. There were no interventions for what the staff should do to address these behaviors except for 1:1visits by the social worker, allow resident to vent (referring to expressing feeling) and referral for a psychiatric consultation. Interview on 11/02/2017 at 11:31AM with Nurse #1 revealed Resident #86 had outburst during care and resisted care. Nurse #1 stated the staff need to tell her what you are doing or have another person to talk with Resident #86 while care was given. Continued interview with Nurse #1 revealed staff are supportive to the resident every day. Interview on 11/02/2017 at 1:27 PM with MDS #1 (responsible for updating care plans) revealed she did not realize that the care plan had not been updated with individualized resident centered interventions. Interview on 11/02/2017 at 6:27 PM with the administrator and Director of Nurses was held. The administrator stated her expectations for staff were to follow the regulations when care plans need to be updated and reflect the interdisciplinary team.

Based on record review, observation and staff interview the facility failed to promote dignity during Resident #71 incontinence care. Full visual privacy was not provided when Resident #71 was not fully clothed. This was evident in 1 of 5 residents reviewed for activities of daily living. Findings included: Resident #71 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and totally dependent on 2 staff for bathing and extensive assistance for personal hygiene Observation on 11/02/2017 at 10:46 AM of incontinence care performed by Nursing Assistant (NA) # 5 and NA #4 was conducted. Resident #71 experienced a bowel and urine episode of incontinence. The privacy curtain was pulled between A and B bed, but was not pulled completely around the bed exposing the Resident #71's unclothed body during incontinence care. Interview on 11/02/2017 at 10:58 AM with NA #5 who stated, I pulled the curtain between her roommate. An interview on 11/2/17 at 5:00 pm with the Assistant Director of Nurses revealed her expectation that privacy would be private during incontinence care.

Based on observation, record review and staff interview the facility failed to appropriately and thoroughly provide incontinence care for Resident #127 and Resident #71 in 2 of 5 residents reviewed for activities of daily living. Findings included: 1, Resident #127 was initially admitted to the facility on - 3/13/15 and readmitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #127 was severely cognitively impaired, required total dependence of one person for dressing and bathing and extensive assistance of one person for toilet use and personal hygiene. The MDS coded the resident as always incontinent of bowel and bladder. Review of the care plan dated 4/5/17 included: -I have self-care deficit related to [MEDICAL CONDITION]. Goal: I will have my ADL needs identified and met with staff assistance and intervention while maintaining highest level of independent function possible. - I have functional incontinence related to [MEDICAL CONDITION]. Goal: I will maintain fluid balance. Interventions: Wear incontinence briefs, change PRN, Cleanse peri-area and apply barrier cream to skin after incontinent episodes and whenever necessary. An observation on 11/1/2017 at 4:00 PM was conducted during incontinent care performed by Nursing Assistant (NA) #2 and NA #3 for Resident #127 who was observed to be incontinent of both urine and stool. NA #3 obtained soap, wash cloths and a basin of water. Then NA #3 removed the stool using a washcloth and placed the soiled washcloth in a plastic bag. Additional stool was removed with another soapy washcloth. NA #3 then proceeded to rinse the soiled washcloth in the basin of water. Using the same soiled washcloth, NA #3 washed the perineal area. During the washing of Resident #127's perineal area NA #3 was first noted to use a circular motion to cleanse the perineal area and then vertically from back to front then front to back. NA #2 assisted NA #3 to turned Resident #127 on her side and was noted with urine that continued to dribble. NA #3 did not attempt to clean the urine that had dribbled out before an application of a barrier cream. An interview with NA #3 on 11/1/2017 immediately after the observation of the incontinence care revealed that this was how she always performed incontinence care. An interview on 11/2/2017 at 5:00 PM with the Assistant Director of Nurses revealed her expectation was that incontinence care would be provided utilizing clean wash cloths and cleansing the perineal area from a front to back motion. Interview on 11/02/2017 at 6:07 PM with the Administrator and Director of Nurses (DON) was held. The DON stated her expectations for staff during perineal care was to follow the basic procedure of washing the perineal area with soapy water in a front to back motion and obtain clean water to rinse the skin. 2. Resident #71 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and totally dependent on 2 staff for bathing and extensive assistance for personal hygiene. The MDS coded the resident as incontinent of bowel and bladder. Review of the care plan dated 8/16/17 revealed the problem of functional incontinence was not updated. Observation on 11/02/2017 at 10:46 AM of incontinence care performed by Nursing Assistant (NA) # 5 and NA #4 was conducted. Resident #71 experienced a bowel and urine episode of incontinence. NA #5 wet 2 washcloths at the bathroom sink and brought them into the resident's room along with a dry towel. NA #5 placed soap on one of the wet wash cloths. Then NA #5 used the wet wash cloth without the soap to remove stool and cleanse Resident #71's perineal area using a back and forth motion front to back then back to front. Resident #71 was repositioned on her left side with the assistance of NA #4. Resident # 71's 's buttocks was cleansed with the same wet wash cloth previously used to remove the stool. Then used the wet washcloth with soap to rinse the skin. While using the soaped wash cloth NA #-5 stated to NA #4 I used the soaped wash cloth to rinse the _____ (referring to the buttocks). NA #5 then dampened the end of the towel at the bathroom sink to remove the soap off the skin then proceeded to applied barrier cream on the buttocks. Interview on 11/02/2017 at 10:58 AM with NA #5 who stated this was her usual routine because that is the way everyone (referring to other NA) does. An interview on 11/2/2017 at 5:00 PM with the Assistant Director of Nurses revealed her expectation was that incontinence care would be provided utilizing clean wash cloths and cleansing the perineal area from a front to back motion. Interview on 11/02/2017 at 6:07 PM with the Administrator and Director of Nurses (DON) was held. The DON stated her expectations for staff during perineal care was to follow the basic procedure of washing the perineal area with soapy water in a front to back motion and obtain clean water to rinse the skin.

Based on record review, observation and staff interview the facility failed to reassess and update the effectiveness of the care plan interventions associated with the use of an antipsychotic and antidepressant medication for Resident #1. The facility failed to reassess and update the effectiveness of the care plan interventions associated with the use of an antidepressant, antianxiety, a diuretic and anticoagulant medication for Resident #10. The facility failed to update the care plan for falls risk for Resident #10. This was evident in 2 of 5 residents reviewed for unnecessary medications. The facility failed to update the effectiveness of the interventions associated with functional incontinence for Resident #127 in 1 of 5 reviewed for activities of daily living. Findings included: 1.Resident #1 was originally admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the medical record revealed physician orders [REDACTED]. [MEDICATION NAME] is used to treat the symptoms of [MEDICAL CONDITION] and major [MEDICAL CONDITION]. [MEDICATION NAME] XR is an extended release. antidepressant. Review of the care plan dated 6/21/17 revealed a problem of potential for adverse medication side effects related to depression and [MEDICAL CONDITION] treated with the antipsychotic use of [MEDICATION NAME] and antidepressant use of [MEDICATION NAME] XR. The interventions included to monitor for side effects and request dose reduction bi-annually. The goal to reassess the problem was 3 months. Further review of the care plan revealed no update or reassessment since 6/21/17 related to the use of the antipsychotic and antidepressant medications. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had impaired cognition, dependent on staff for care and had no behavioral problems identified during this assessment. Observation of Resident #1 on11/1/17 at 2:10 PM revealed Resident #1 was ambulating in a wheelchair and would not speak or respond nonverbal. Interview on 11/02/2017 at 11:29 AM with Nurse #1 who stated Resident #1 was pleasant, may start laughing when not obvious to anyone else what the laughter was about and cooperative. Interview on 11/02/2017 at 1:27 PM with MDS #1 (responsible for updating care plans) stated she had not realized the care plans had not been updated. Interview on 11/02/2017 at 6:27 PM with the administrator and Director of Nurses was held. The administrator stated her expectations for staff were to follow the regulations when care plans need to be updated. 2.Resident #10 was initially admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed in the last seven days Resident # 10 received antianxiety, antidepressant and diuretic therapy. Review of the care plan dated 7/3/2017 revealed the resident had a potential for side effects related to the use of an antidepressant and antianxiety medication. The interventions included monitoring of side effects and report unusual behaviors. Additionally, the care plan addressed the use of anticoagulant therapy (Aspirin) and falls risk. The goal time to be reassessed was 3 months. These care plans were not updated. Review of the October 2017 physician orders [REDACTED].> [MEDICATION NAME] 7.5 milligrams (mg) once a day by mouth (po) since 5/3/17. [MEDICATION NAME] is a drug used to treat generalized anxiety disorder. [MEDICATION NAME] 2 mg po since 7/1/17 due to chronic systolic [MEDICAL CONDITION]. [MEDICATION NAME] 20 mg delayed capsules po since 6/27/16. [MEDICATION NAME] is used to treat major [MEDICAL CONDITION], general anxiety disorder and nerve pain. Aspirin 81 mg po once a day to prevent blood clots. Interview on 11/02/2017 at 1:27 PM with MDS #1 (responsible for updating care plans) stated she had not realized the care plans had not been updated. Interview on 11/02/2017 at 6:27 PM with the administrator and Director of Nurses was held. The administrator stated her expectations for staff were to follow the regulations when care plans need to be updated. 3. Resident #127 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on 2 staff for bathing and extensive assistance for personal hygiene. The MDS coded the resident as incontinent of bowel and bladder. Reviewed the care plan dated 8/16/17 revealed the problem of functional incontinence was not updated since 6/27/17. Interview on 11/02/2017 at 1:27 PM with MDS #1 (responsible for updating care plans) stated she had not realized the care plans had not been updated. Interview on 11/02/2017 at 6:27 PM with the administrator and Director of Nurses was held. The administrator stated her expectations for staff were to follow the regulations when care plans need to be updated.