Every finding on record at Village Care Center

Based on observation, interview, record review, and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 32 sampled residents (Resident (R) 2, R3, R41, and R84.Observation on 09/23/2025 during dinner service in the second-floor dining room revealed R3 did not receive his food at the same time as those that sat at his table did. Additionally, State Registered Nurse Aide (SRNA )7 was observed standing beside R2 feeding and coaxing her to eat, and SRNA5 was observed sitting between two residents, R41 and R84, feeding both simultaneously. The findings include:Review of the facility's policy, Resident Rights, reviewed 2022, revealed the facility would inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during their stay in the facility. Further review revealed the resident had a right to be treated with respect and dignity.1. Review of R3's Face Sheet revealed the facility admitted the resident on 04/12/2021 with diagnoses of type II diabetes mellitus with other circulatory complications, polyneuropathy, hyperglycemia, chronic peripheral insufficiency, heart failure, and hyperlipidemia.Review of R3's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/07/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15, indicating R3 was cognitively intact.Observation of dinner service in the second-floor dining room on 09/23/2025 at 6:12 PM revealed R3 did not receive his food at the same time those that sat at his table received food. R3 waited from 6:10 PM to 6:28 PM without food because dietary staff forgot to bring buns from the kitchen. When R3 received his burger, he was unhappy with the hamburger because it did not have cheese and vegetables on it. Staff removed the hamburger and R3 waited from 6:28 PM to 6:43 PM to receive a hamburger with cheese, vegetables, and condiments. All other residents seated at his table were finished eating by the time he received his food. In an immediate interview with R3 on 09/23/2025 at 6:28 PM, he stated he was angry, and they always messed up his food.In an interview with SRNA6 on 09/25/2025 at 10:03 AM, she stated dietary staff was notorious for not bringing up buns with the hamburgers and residents had to wait on their food when that happened.2. Review of R2's Face Sheet revealed the facility admitted the resident on 08/21/2025 with diagnoses of cerebral infarction, type II diabetes mellitus with other neurological and specified complications, delusional disorders, and cognitive communication deficit. Review of R2's Nursing Home Comprehensive (NC) Item Set MDS, dated 08/07/2025, revealed the facility assessed the resident to have a BIMS score of 3, indicating R2 was severely cognitively impaired.Review of R41's Face Sheet, revealed the facility admitted the resident on 05/26/2020 with diagnoses of late onset Alzheimer's disease, major depressive disorder, anxiety disorder, and hypertension.Review of R41's quarterly MDS, with an ARD of 09/13/2025, revealed the resident had not been assessed for a BIMS score. However, review of R41's previous quarterly MDS, with an ARD of 06/13/2025, revealed the facility assessed the resident to have a BIMS score of 3, indicating R41 was cognitively impaired.Review of R84's Face Sheet, revealed the facility admitted the resident on 12/08/2022 with diagnoses of epilepsy, repeated falls, major depressive disorder, and anxiety disorder.Review of R84's quarterly MDS, with an ARD of 09/07/2025, revealed the resident had not been assessed for a BIMS score. However, review of R84's previous quarterly MDS, with an ARD of 06/07/2025, revealed the facility assessed the resident to have a BIMS score of 3, indicating R84 was cognitively impaired.Observation of dinner service in the second-floor dining room on 09/23/2025 at 6:23 PM revealed SRNA7 was standing beside R2 feeding and coaxing her to eat, even though a chair was available to sit in on the other side of R2.In an immediate interview with SRNA7 on 09/23/2025 at 6:23 PM, she stated she should sit to feed residents or help them eat. She further stated standing to feed a resident could be seen as a dignity issue.Observation of dinner service in the second-floor dining room on 09/23/2025 at 6:43 PM revealed SRNA5 was sitting between two residents, R41 and R84, feeding both residents simultaneously. In an immediate interview with SRNA5 on 09/23/2025 at 6:43 PM, she stated it was common practice to feed two residents at once, but she should not be doing so. She further stated it could be seen as a dignity issue and an infection prevention issue. R2, R41, and R84 were not able to be interviewed due to their severe cognitive impairment.In an interview with the Unit Manager (UM) for the second floor on 09/25/2025 at 1:55 PM, she stated usually meals go smoothly and that the dinner observation on 09/23/2025 was a fluke. She stated residents did not have to wait while staff retrieved hamburger buns and condiments normally, and in the case of R3 having to watch all those around him eat their dinner while he waited nearly 30 minutes for staff to get the buns and condiments, it was not a dignity issue. She further stated, however, it was not how she would want residents to be treated.In further interview with the UM for the second floor, she stated standing over a resident while feeding them could be seen as a dignity issue but if there was not a chair available, she would rather that staff feed the resident while the food was hot rather than spend time looking for a chair. She stated staff should only feed one resident at a time due to the potential for cross-contamination and the possibility of accidently feeding a resident from the wrong plate. She further stated feeding two residents at once could be a dignity issue because the staff member was not giving the resident their full attention when feeding them. In an interview with the Director of Dining Services (DDS) on 09/25/2025 at 2:33 PM, she stated she was aware of the incident with R3, who did not get his meal in a timely manner due to kitchen staff forgetting portions of the meal in the kitchen. She stated typically buns were kept on each floor in the dining room stock areas, but they had to stop that practice because many of the buns were not getting used before expiring. She further stated to prevent similar incidents from occurring, dietary staff have been printing production sheets the previous day and going back over the production sheets prior to sending the boxes containing the food to the floor. The DDS stated she felt it was a dignity issue to watch others eat while you were waiting for your food to be served.In an interview with the Assistant Director of Nursing (ADON) on 09/26/2025 at 7:55 AM, she stated she did not feel R3 having to wait 30 minutes for his cheeseburger was a dignity issue. She stated it was a problem, and he should not have had to wait that long, but it was not an everyday occurrence. The ADON stated she did not consider SRNA7 standing to feed R2 as an issue. She further stated there was no chair available and she would rather staff feed a resident standing than to take time to find a chair to sit and feed. She stated feeding two residents at once was not an issue if there was not cross-contamination, and she did not feel it was a dignity issue. In an interview with the Director of Nursing (DON) on 09/26/2025 at 8:15 AM, she stated she was aware of R3 getting upset about having to wait for his cheeseburger due to dietary staff not having the appropriate food items to make his meal. She stated no one likes to wait for their food but R3 often changes his mind on what he wants when it comes time to eat, and she did not feel it was a dignity issue that he had to wait. In further interview with the DON, she stated there had been an influx of residents recently that needed assistance with eating or being fed. She stated they had been looking into a different set up for feeding and helping those residents. She further stated she did not think standing to feed someone was an issue if a chair was not readily available, and even if there was a chair, it was not a dignity issue to stand while feeding residents, and she would rather the resident be fed. The DON stated she expected staff to provide the best care they could for residents and if they could do so while feeding two residents, that was not a dignity issue either. She stated staff should take into consideration infection prevention, temperature, and if the resident felt they were not being treated with dignity. The DON stated ideally, she would like for a resident to have one to one feeding time where they were able to eat at their own pace and not be rushed. In an interview with the Administrator on 09/26/2025 at 8:37 AM, she stated a resident having to watch others eat was not what she would want for anyone. She stated it was not a dignity issue for R3 to have to wait on his food while other residents ate, it was a customer service issue instead. She stated R3 was prone to changing his mind about what he wanted to eat and while residents had the right to change their dinner choices, they might have to wait for those options to be served. She stated standing to feed was better than not feeding a resident while searching for a chair, allowing their food to get cold. The Administrator stated feeding two residents at once was acceptable, but staff needed to pay attention to what they were doing and not change hands. She further stated it would only be a dignity issue depending on the perception and preferences of the resident.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from verbal and physical abuse. This deficient practice resulted in actual harm for 1 out of 4 sampled residents, Resident (R) 13.On 09/14/2025, R13 stated State Registered Nurse Aide (SRNA) 12 was mean and hurtful during care. R13 reported SRNA12 lifted her legs in the air and then dropped them onto the bed, which hurt her back. She further stated SRNA12 handled her roughly during care, causing pain in her arm. The findings include:Review of the facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, dated 10/23/2024, revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Per the policy, abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being.Review of R13's admission Record revealed the facility admitted the resident on 09/03/2024 with diagnoses of pain in the right shoulder, adhesive capsulitis of right shoulder, contracture, right shoulder, anxiety disorder, other chronic pain, depression, polyneuropathy, muscle weakness, need for assistance with personal care, other abnormalities of gait and mobility, secondary osteoarthritis, right shoulder, and low back pain.Review of R13's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/24/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15, indicating R13 was cognitively intact.In an interview with R13 on 09/26/2025 at 9:12 AM, she stated SRNA12 hurt me every time she cared for me. R13 explained she did not initially report her concerns because she did not think anyone would believe her. R13 described an incident that occurred on 09/14/2025, when SRNA12 was rough during care, stating, She would lift my legs in the air and let them fall back in the bed, hurting my back. R13 said this occurred on more than one occasion and she feared SRNA12, describing her as having manhandled her during care. R13 stated she felt unsafe when SRNA12 cared for her. She further stated she felt safe after Registered Nurse (RN) 3 escorted SRNA12 from the facility following the resident's allegation and she had no further concerns regarding her care once SRNA12 left the facility.In an interview with Family Member (FM) 4 on 09/26/2025 at 2:00 PM, he stated R13 broke down and cried when telling him about her care. According to FM4, R13 stated SRNA12 was rough and had slammed her legs down on the bed. FM4 reported R13 told him she feared SRNA12. FM4 stated the Administrator later contacted him and informed him that SRNA12 would no longer care for his mother.Review of R40's admission Record revealed the facility admitted the resident on 08/22/2024 with type 2 diabetes mellitus, hypertension, muscle weakness, other abnormalities of gait and mobility, and anxiety disorder.Review of R40's comprehensive MDS, with an ARD of 07/19/2025, revealed the facility assessed the resident to have a BIMS score of 15, indicating R40 was cognitively intact.During an interview with R40 on 09/26/2025 at 9:00 AM, who was R13's roommate, she stated SRNA 12 had a terrible attitude and was nasty and short during care. R40 stated, It really upset me and made me cry. R40 reported she could hear SRNA12 pushing R13 over hard in the bed and heard SRNA 12 say, I'm not changing your bed. I'll change your diaper but not your bed. R40 stated after SRNA12 finished providing care, she heard R13 crying and went to her bedside to comfort her. R40 reported she informed Licensed Practical Nurse (LPN) 6 of SRNA 12's behavior, and afterward, RN3 escorted SRNA12 from the facility.The State Survey Agency (SSA) Surveyor attempted to reach LPN6 and RN3 by telephone on 09/25/2025 and 09/26/2025, however, they did not answer the call.The SSA Surveyor was unable to interview SRNA12 as she was an agency employee who was no longer permitted to work in the facility following the allegation. The facility did not have a current contact telephone number for SRNA12.In an interview with the Director of Nursing (DON) on 09/26/2025 at 2:30 PM, she stated R13 had never previously made false allegations and emphasized that staff were to handle residents with care and speak to them respectfully, without aggression or a harsh tone.In an interview with the Administrator on 09/26/2025 at 2:44 PM, she stated the allegation was unsubstantiated by the facility because, although R13's roommate overheard part of the conversation, it could not be confirmed the incident occurred as reported. The Administrator emphasized she expects staff to treat all residents with dignity and respect, as if they were caring for their own grandparents.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 3 resident refrigerators, the refrigerator located on the second floor.Observation on 09/24/2025 of the resident refrigerator located on the second floor revealed two unlabeled lunch boxes sitting next to resident food.The findings include:Review of the facility's policy titled, Use and Storage of Food Brought in by Family or Visitors, reviewed 11/2024, revealed it was the right of the residents of the facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. Further review revealed all food brought in already prepared by the family or visitor must be labeled with content and dated.Review of the facility's policy titled, Food and Supply Storage, revised 01/2025, revealed all food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Observation on 09/24/2025 at 2:45 PM of the resident refrigerator located on the second floor revealed two lunch boxes, not labeled, sitting on the third shelf of the refrigerator next to resident food.In an interview with State Registered Nurse Aide (SRNA) 3 on 09/25/2025 at 9:25 AM, she stated there was an office area in the basement of the facility that contained a refrigerator to place staff lunches in and that it was against facility rules for staff to place their lunches in the resident food refrigerators, located on the units.In an interview with SRNA5 on 09/25/2025 at 9:49 AM, she stated staff should not place personal lunches in the resident food refrigerators, but she could not give a reason why that was important. In an interview with SRNA6 on 09/25/2025 at 10:03 AM, she stated management gave approval for staff to place their personal lunches in the resident food refrigerators.In a concurrent interview with Licensed Practical Nurse (LPN) 4 and Kentucky Medication Aide (KMA) 2 on 09/25/2025 at 9:23 AM, both stated they did not have a break room to store their lunches in, however, it was not facility practice to store their lunches in the resident food refrigerators located on the units nor in the nourishment refrigerators in the dining rooms.In an interview with the Unit Manager (UM) for the second floor on 09/25/2025 at 1:55 PM, she stated staff should not store personal food in the resident food refrigerators or the nourishment refrigerators. She stated there was a potential for residents and staff of taking incorrect food, or if food was left there, it could become spoiled and outdated and potentially cause illness. She stated she was unaware of a refrigerator in the basement that staff could use to store their lunches. In an interview with the General Manager of Dining Services on 09/25/2025 at 8:35 AM, she stated dietary staff did not maintain the contents of the resident refrigerators on the units, they only maintained the refrigerators in the dining rooms. In an interview with the Assistant Director of Nursing (ADON) on 09/26/2025 at 7:55 AM, she stated the resident food refrigerators located behind the nursing station had a shelf that was for staff lunches only. She did not see any issues with staff storing their lunches in the refrigerator with residents' personal food if staff kept them on a shelf all to themselves. She further stated housekeeping staff were assigned to go through the refrigerators and throw away outdated or spoiled food. In an interview with the Director of Nursing (DON) on 09/26/2025 at 8:15 AM, she stated it was acceptable for staff to store personal lunches in the resident food refrigerator, she did not see any issues with that.In an interview with the Administrator on 09/26/2025 at 8:37 AM, she stated staff could put their personal lunches in the resident food refrigerators if food items were labeled and dated.

Based on interviews, record reviews, and facility documents and policy review, it was determined the facility failed to protect residents' right to be free from physical abuse by a resident for eight (8) (Residents #94, #9, #3, #34, #235, #29, #335, and #87) of 19 residents reviewed for abuse. The findings included: Review of the facility's policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a review date of 11/07/2022, revealed, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of the policy revealed, Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy revealed, Physical abuse includes hitting, slapping, pinching, and kicking. Continued review revealed, It is the policy of [the facility] that each resident will be free from 'Abuse.' 1. A review of Resident #88's Admission Record revealed the facility admitted the resident on 10/12/2021, with diagnoses that included Alzheimer's disease and dementia with behavioral disturbance. The resident's diagnoses included cognitive communication deficit on 05/31/2022. Review of Resident #88's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/15/2022, revealed Resident #88 had a Staff Assessment for Mental Status (SAMS) conducted that indicated the resident had severe impairment in cognitive skills for daily decision making. The MDS revealed the resident had exhibited no behavioral symptoms during the assessment lookback period. Further review revealed the facility assessed the resident to require the extensive assistance with bed mobility, transfers, locomotion on the unit, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. The MDS revealed the resident did not receive antipsychotic medications during the seven-day lookback period. Review of Resident #88's Care Plan revealed a Focus area, initiated on 01/18/2022, that indicated the resident had the potential to demonstrate physical behaviors related to dementia or other cognitive impairment. Interventions directed staff to analyze and document key times, places, circumstances, and triggers for behavior, and what de-escalated the behaviors; assess for and address contributing sensory deficits; assess and anticipate the resident's needs; and provide physical and verbal cues to alleviate anxiety. Review of Resident #94's Admission Record revealed the facility admitted the resident on 02/09/2021. According to the Admission Record, the resident had a medical history that included diagnoses of dementia without behavioral disturbance, mood disorder, and major depressive disorder. Review of Resident #94's Quarterly MDS, with an ARD of 05/28/2022, revealed the facility assessed Resident #94 with a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had exhibited verbal behavioral symptoms directed toward others on one to three days during the assessment lookback period. Further review of the MDS revealed the resident required the extensive assistance with bed mobility, transfers, walking in the room, dressing, toilet use, and personal hygiene. Continued review of the MDS revealed the resident received no psychotropic medication during the seven-day lookback period. Review of Resident #94's Care Plan revealed a Focus area, initiated 02/24/2021, that indicated the resident had cognitive impairment. Interventions directed staff to keep communication simple and direct, reorient the resident as needed, and offer simple choices. Review of a Long Term Care Facility - Self-Reported Incident Form marked as an initial report and dated 05/31/2023, indicated physical abuse had taken place between Resident #88 and Resident #94. The form revealed there had been a resident conflict, no injuries were observed/noted, and an investigation was in progress. Review of a Long Term Care Facility - Self-Reported Incident Form, 5 Day Follow up/Final Report, dated 06/03/2023, revealed a typed summary of the incident and investigation that indicated Resident #88 had wandered into the room of Resident #94 and struck him/her. The summary revealed Resident #88 was immediately removed from the room and placed one-to-one with staff. Continued review revealed the facility assessed Resident #94 with no injuries. Resident interviews were completed on the floor on which Resident #88 and Resident #94 resided, with no concerns voiced by residents. Skin assessments were completed for residents who were not able to be interviewed, and no concerns were noted. Resident #94 was interviewed and stated Resident #88 struck him/her open-handed across the chest, while a witness stated Resident #94 was struck on their back. The summary revealed Resident #94's chest and back were assessed, with no areas noted. The physician gave no new orders. Staff interviews were completed, and an STNA [State Trained Nurse Aide] reported being outside the door and saw Resident #88 open-handed strike Resident #94 on the back as Resident #94 was looking out the window. The investigation revealed Resident #88's and Resident #94's family and physician were immediately notified. The summary revealed that Resident #88's physician ordered the resident to be sent to an emergency department (ED) for an evaluation. Continued review revealed Resident #88 was admitted to a behavioral health hospital for further evaluation. The summary revealed education was provided to staff to increase supervision of residents who were confused, to report any new or increased wandering behavior to their supervisor immediately, and to redirect residents who wandered from going into other residents' rooms. The facility's investigation revealed care plans for Resident #88 and Resident #94 were reviewed and updated. Resident #94 and their roommate initially agreed to have a stop sign across the door to detour Resident #88 from entering their room, but later, Resident #94 asked for the sign to be removed. Review of Resident #88's Progress Notes dated 05/31/2022 at 11:17 AM revealed the resident was in another resident's room, Resident #94. Resident #94 stated they were in the closet, and Resident #88 came up behind them. Resident #94 told Resident #88 to get out of the room, and Resident #88 struck Resident #94. The note revealed the resident had behaviors over the weekend that had subsided; however, that morning, the resident became physically aggressive with staff. The note revealed Resident #94 was immediately removed, placed on one-to-one staff supervision, and then transferred to the ED. During an interview on 10/16/2023 at 9:37 AM, Licensed Practical Nurse (LPN) #2 stated Resident #88 was in and out of a geriatric-psychiatric unit. LPN #2 stated Resident #88 was admitted to a behavioral unit the day of the incident. The LPN stated this incident was the only resident-to-resident incident she could recall for Resident #88. LPN #2 stated generally, the facility had residents evaluated so they would not hit any other residents. The LPN stated Resident #94 was assessed for injury and had none. During an interview on 11/17/2023 at 3:47 PM, the Director of Nursing (DON) stated Resident #88 mostly stayed by themselves because of a communication barrier. The DON stated Resident #94 also stayed to themselves and mostly stayed in their room and looked out the window. She stated Resident #94 was confused. The DON stated Resident #94 had told her that Resident #88 hit him/her on the chest. The DON stated that State Registered Nurse Aide (SRNA) #17 had witnessed the incident and had told her that Resident #88 had struck Resident #94 on the back. The DON stated that SRNA #17 removed Resident #88 from Resident #94's room immediately. She stated Registered Nurse (RN) #5 assessed Resident #94's back and chest and found no injury. The DON stated the documentation/investigation indicated that Resident #88 struck Resident #94 with an open hand. An interview with the Administrator on 11/17/2023 at 4:30 PM revealed she expected staff to be aware of any resident showing agitation or wandering, follow the resident's plan of care, and supervise residents who wandered. 2. A review of Resident #3's Admission Record revealed the facility initially admitted the resident on 02/09/2017 with diagnoses that included anxiety disorder and major depressive disorder. Further review of the Admission Record revealed the resident had diagnoses of Alzheimer's disease and dementia, with onset dates of 11/20/2021. Review of Resident #3's Quarterly MDS, with an ARD of 01/10/2023, revealed Resident #3 had a SAMS conducted that indicated the resident had severe impairment in cognitive skills for daily decision-making. The MDS revealed the resident received no psychotropic medication during the seven-day lookback period. According to the MDS, the resident required the extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and limited assistance from staff with locomotion on and off the unit and eating. The MDS revealed the resident had not received psychotropic medications during the seven-day lookback period. Review of Resident #3's Care Plan revealed a Focus area revised 01/11/2023 that indicated the resident had the potential to demonstrate physical behaviors related to kicking at others and hearing difficulty. Interventions directed staff to increase visual checks when the resident was in their wheelchair in the hall, provide one-to-one (1:1) staff supervision as needed, and intervene before the resident's agitation escalated by guiding the resident away from the source of distress and engaging the resident calmly in conversation. If the resident's response was aggressive, staff were instructed to walk away and reapproach later. The resident's Care Plan did not address wandering behavior with applicable interventions. A review of Resident #9's Admission Record revealed the facility admitted the resident on 04/12/2021 with diagnoses that included unspecified psychosis, bipolar disorder, major depressive disorder, persistent mood disorder, and generalized anxiety disorder. Review of Resident #9's Quarterly MDS, with an ARD of 12/15/2022, revealed Resident #9 had a BIMS' score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #9 had not exhibited behaviors during the seven days prior to the assessment date, including physical and verbal behavioral symptoms towards others, or other behavioral symptoms not directed toward others. The MDS revealed the resident required limited staff assistance with bed mobility, transfers, locomotion on and off their unit, dressing, toilet use, and personal hygiene. The MDS revealed the resident had received antipsychotic and antidepressant medication seven of seven days prior to the assessment date. A review of Resident #9's Care plan revealed a Focus area statement, initiated on 01/19/2023, that indicated the resident had the potential to demonstrate behaviors, such as manipulative behaviors and yelling at others. The care plan revealed interventions included instructions for staff to provide medications as ordered, ensure the resident had personal space, and leave and reapproach the resident later if they were agitated. A review of a Long Term Care Facility - Self-Reported Incident Form, dated 01/11/2023, revealed physical abuse had occurred between Resident #3 and Resident #9. The report indicated that Resident #3 wanted in Resident #9's room. The report revealed Resident #9 went to shut their door, and Resident #3 kicked Resident #9 in the leg. The report revealed the resident was assessed with no injury. Continued review revealed both residents quickly calmed with re-direction/separation. Review of a typed facility investigation summary dated 01/11/2023 revealed that on the night of 01/11/2023, Resident #9 had their door shut, and Resident #3 pushed the door open. The summary revealed Resident #3 wanted to enter the room, and Resident #9 tried to close the door. Further review revealed staff were on their way to the room to help Resident #9 when Resident #3 kicked their leg out, striking Resident #9 on their right leg. The summary revealed Resident #9 stated they were fine and not injured and that Resident #3 was confused and did not mean to hurt Resident #9. The summary revealed that a nurse assessed Resident #9 and did not find any injuries and indicated Resident #9 had no psychosocial concerns related to the incident. Continued review revealed social services staff visited with Resident #9 later in the day on 01/11/2023, with no concerns noted. The summary revealed Resident #3 was removed from the area, and staff stayed with Resident #3 until they were ready to go to bed. Review of the summary revealed Resident #3 was calm and easily redirected; the physician and families were notified. The summary revealed interviews were conducted with staff who worked the night of the incident. Per the summary, neither resident was upset or disgruntled prior to the incident. The summary revealed the Quality Assurance team met regarding the incident and, after investigating the event, could not substantiate abuse. During an interview on 11/13/2023 at 10:00 AM, Resident #9 stated they remembered Resident #3 came into Resident #9's room in January 2023. Resident #9 stated they were sitting in their wheelchair at the entry to their room and told Resident #3 to leave the room. Resident #9 stated Resident #3 kicked the door and hit them in the right leg. Resident #9 stated it hurt when the door hit their leg, but there was no bruising or injury. On 11/13/2023 at 10:46 AM, an attempt was made to interview Resident #3, but the resident was not able to be interviewed. During an interview on 11/16/2023 at 9:42 AM, LPN #2 stated she was not working at the time of the incident but did the follow-up as the unit manager. LPN #2 stated Resident #9's leg was not injured. LPN #2 stated Resident #3 was monitored as they wandered and was easily re-directable. LPN #2 stated that, to her knowledge, Resident #3 had not caused injury to any resident. LPN #2 stated Resident #9 confirmed the incident occurred, although no night shift staff had witnessed the incident. During an interview on 11/17/2023 at 3:47 PM, the DON said Resident #3 was trying to get into Resident #9's room, and Resident #9 was trying to stop Resident #3. The DON stated Resident #9 told the DON that Resident #3 was not trying to kick Resident #9. The DON stated Resident #3 tried to stop Resident #9 from closing the door and kicked Resident #9 in the right leg. The DON stated a stop sign was placed in Resident #9's doorway and was still there. The DON stated no other resident had tried to enter Resident #9's room. The DON stated the documentation/investigation of the incident indicated Resident #9 was struck in the right leg by Resident #3's leg. An interview with the Administrator on 11/17/2023 at 4:30 PM revealed she expected staff to be aware of any resident showing agitation or wandering, follow the resident's plan of care, and supervise residents who wandered. 3. A review of Resident #72's Admission Record revealed the facility admitted the resident on 03/08/2022 with diagnoses that included type two diabetes mellitus and cognitive communication deficit. A review of Resident #72's annual MDS, with an ARD of 12/20/2022, revealed Resident #72 had a BIMS' score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had no behavioral symptoms during the assessment period. The MDS revealed the resident did not receive psychotropic medication during the seven-day lookback period. According to the MDS, the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene and required limited assistance from staff with locomotion on and off the unit. A review of Resident #72's Care Plan revealed a Focus area, initiated 01/14/2023, that indicated the resident had the potential to demonstrate physical behaviors related to anger, hitting at others, and poor impulse control. Interventions directed staff to reduce noise, keep the resident's room door closed, and intervene before the resident's agitation escalated by guiding the resident away from the source of distress and engaging the resident calmly in conversation. If the resident's response was aggressive, staff were instructed to walk away and reapproach later. A review of Resident #3's Admission Record revealed the facility initially admitted the resident on 02/09/2017 with diagnoses that included anxiety disorder and major depressive disorder. Further review of the Admission Record revealed the resident had diagnoses of Alzheimer's disease and dementia, with onset dates of 11/20/2021. Review of Resident #3's Quarterly MDS, with an ARD of 01/10/2023, revealed Resident #3 had a SAMS conducted that indicated the resident had severe impairment in cognitive skills for daily decision-making. The MDS revealed the resident received no psychotropic medication during the seven-day lookback period. According to the MDS, the resident required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene, and limited assistance from staff with locomotion on and off the unit and eating. The MDS revealed the resident used a wheelchair for mobility. A review of Resident #3's Care Plan revealed a Focus area revised 01/11/2023 that indicated the resident had the potential to demonstrate physical behaviors related to kicking at others and hearing difficulty. Interventions directed staff to increase visual checks when the resident was in their wheelchair in the hall, provide one-to-one (1:1) staff supervision as needed, and intervene before the resident's agitation escalated by guiding the resident away from the source of distress and engaging the resident calmly in conversation. If the resident's response was aggressive, staff were instructed to walk away and reapproach later. The resident's Care Plan did not address wandering behavior with applicable interventions. A review of a Long Term Care Facility - Self-Reported Incident Form, marked by staff as the Initial Report and dated 01/14/2023, revealed Resident #3 wandered into Resident #72's room and Resident #72 struck Resident #3 on the arm. The residents were separated, and no injuries occurred. The form indicated an investigation was in progress. Review of Resident #72's Event Note, dated 01/14/2023 at 10:53 PM and written by Registered Nurse (RN) #6, revealed the RN overheard yelling in Resident #72's room. The note revealed the door was closed, and another resident (Resident #3) was just inside the door. RN #6 documented that upon entering the room, she observed Resident #72 strike the other resident with a grabber stick. The note indicated the other resident (Resident #3) was immediately removed from the room and checked for injury and Resident #72 was placed on 1:1 staff supervision. RN #6 documented that when asked if the other resident had struck him/her, Resident #72 stated, I never gave [the other resident] a chance. Review of Resident #3's Event Note, dated 01/14/2023 at 11:14 PM and written by RN #6, revealed Resident #3 entered another resident's room uninvited and then the other resident (Resident #72) struck Resident #3 with a grabber stick on their right upper arm. The note revealed Resident #3 was immediately removed from the room and assessed for injury; no injury was noted. Resident #3 had no complaints of pain. The note indicated a stop sign was placed on the other resident's door frame to deter uninvited entry. A review of a Long Term Care Facility - Self-Reported Incident Form, marked by staff as the 5-Day Follow up/Final Report and dated 01/19/2023, indicated that details of the investigation were attached. The attached Final Summary indicated that on 01/14/2023, Resident #3 went into Resident #72's room, and Resident #72 became upset, thinking Resident #3 was intruding in Resident 72's home. The summary revealed Resident #72 struck Resident #3 with a grabber tool, telling them to get out of Resident #72's room. The summary revealed the nursing team immediately intervened, removed Resident #3, and stayed with the resident until he/she went to bed. The summary revealed the facility assessed Resident #3, and no injuries were identified; the resident was in good spirits with no psychosocial concerns. The summary indicated that a nurse immediately interviewed Resident #72, who stated Resident #3 did nothing to them. The summary revealed the nurse encouraged Resident #72 to use the call light to ask for help rather than using the grabber tool or being aggressive. Further review of the summary revealed Resident #72 agreed to have a stop sign placed on their door to deter other residents from entering. The summary indicated that the RN Supervisor, Administrator, and DON discussed the incident's root cause and interventions to ensure the safety of residents. Continued review revealed Resident #3 remained on 1:1 supervision, and a stop sign was immediately placed on Resident #72's door. The summary revealed both residents' physicians and families were notified, and Resident #3's physician gave a new order for melatonin, as needed, for sleep. On 11/13/2023 at 10:46 AM, an attempt was made to interview Resident #3. Resident #3 did not respond appropriately to questions, and it was determined that the resident could not be interviewed. On 11/17/2023 at 8:39 AM, in a telephone interview, SRNA #19, who was working at the time of the incident, stated she did not recall the incident. The SRNA stated Resident #3 wandered the unit in a wheelchair. SRNA #19 stated Resident #3 looked into other residents' rooms, but she did not recall Resident #3 entering other residents' rooms. During an interview on 11/17/2023 at 9:22 AM, RN #6 stated she recalled the incident involving Resident #3 and Resident #72. RN #6 stated she was walking past Resident #72's room door and heard Resident #72 yelling at Resident #3 to get out. The RN stated she opened the door, but Resident #3's wheelchair blocked the door. RN #6 stated she saw Resident #72 hit Resident #3 with a grabber stick. The RN stated she examined Resident #3 and did not find any marks or signs of injury, and she did not think Resident #72 hit Resident #3 hard. The RN stated the residents were separated by removing Resident #3 from the room. RN #6 stated Resident #3 did not appear to be upset. She stated she had received abuse prohibition training at the facility. RN #6 stated the facility reviewed the abuse prohibition and reporting policy with staff following each incident of alleged abuse. During an interview on 11/17/2023 at 3:47 PM, the DON stated that RN #6 had witnessed the incident involving Resident #72 and Resident #3 and immediately intervened. The DON stated Resident #3 was assessed immediately, and no injury was identified. The DON stated Resident #3 was placed on 1:1 staff supervision, and a stop sign was placed on Resident #72's door. She stated the investigation indicated Resident #3 was struck with a grabber tool by Resident #72. An interview with the Administrator on 11/17/2023 at 4:30 PM revealed she expected staff to be aware of residents showing agitation or wandering, follow the resident's plan of care, and supervise residents who wandered. 4. A review of Resident #85's Admission Record revealed the facility admitted the resident on 08/22/2019 with diagnoses that included Alzheimer's disease, major depressive disorder, and anxiety disorder. Further review of the Admission Record revealed the resident had a diagnosis of vascular dementia with behavioral disturbance with an onset date of 10/01/2022. A review of Resident #85's annual MDS with ARD of 02/15/2023 revealed Resident #85 had a BIMS' score of three (3), which indicated the resident had severe cognitive impairment. The MDS revealed the resident exhibited physical and verbal behavioral symptoms directed toward others 1 to 3 days during the assessment lookback period. Further review of the MDS revealed the resident did not receive psychotropic medication during the seven-day lookback period. According to the MDS, the resident had no functional limitations in range of motion. A review of Resident #85's Care Plan revealed a Focus area initiated on 07/08/2021 that indicated the resident had the potential to demonstrate physical behaviors related to hitting others, poor impulse control, and throwing things at staff. Interventions directed staff to analyze key times, places, circumstances, triggers, and what de-escalates the resident's behavioral symptoms. Further review revealed interventions were initiated on 01/29/2023, directing staff to intervene before the resident's agitation escalated by guiding the resident away from the source of distress and engaging the resident calmly in conversation. If the resident's response was aggressive, staff were instructed to walk away and reapproach later. A review of a Long Term Care Facility - Self-Reported Incident Form, marked by staff as the Initial Report and dated 01/29/2023, revealed Resident #3 was sitting in the common area with Resident #85 when Resident #85 lightly swatted Resident #3 on their arm; no injury was noted. Further review of the form indicated the residents were historically friendly with each other. A review of Resident #85's Behavior Note, dated 01/29/2023 at 1:58 AM, revealed that staff reported Resident #85 was striking another resident (Resident #3). The note indicated the nurse went to intervene, and Resident #85 struck the nurse in the face multiple times. The note indicated that Resident #85 was sent to the hospital emergency department for an evaluation. A review of Resident #3's Physician Notification progress note, dated 01/29/2023 at 4:03 AM, revealed that another resident (Resident #85) was witnessed smacking Resident #3. The note indicated the residents were immediately separated, and Resident #3 had no apparent injuries. A review of a Long Term Care Facility - Self-Reported Incident Form, marked by staff as the 5 Day Follow up/Final Report and dated 02/03/2023, indicated the investigation summary was attached. The attached Final Summary revealed that on 01/29/2023 at 12:30 AM, Resident #85 showed agitation and frustration by smacking Resident #3 on their right arm. The summary revealed when staff intervened to separate the residents, Resident #85 became aggressive toward the nursing team and smacked the nurse in the chin several times. The summary indicated that the Administrator interviewed staff involved in the incident and learned that Resident #85 did not smack Resident #3 in a way to want to hurt Resident #3. The nurse stated Resident #85's face showed agitation, but the resident did not hit Resident #3 hard. The summary indicated Resident #3 was assessed, and no injuries were identified. The summary indicated Resident #3 was calm and did not react to Resident #85. The summary revealed Resident #85 was placed on 1:1 staff supervision, and their physician and family were notified. The summary revealed Resident #85's physician placed an order for the resident to be sent to the hospital for an evaluation. The summary indicated that Resident #85 returned from the hospital with no new orders. On 11/13/2023 at 10:46 AM, an attempt was made to interview Resident #3. Resident #3 did not respond appropriately to questions, and it was determined that the resident could not be interviewed. On 11/16/2023 at 2:10 PM, SRNA #21, who was working at the time of the incident involving Resident #85 and Resident #3, was interviewed by telephone. SRNA #21 stated Resident #3 was wandering in their wheelchair and got close to Resident #85; Resident #85 was easily agitated and swatted at Resident #3 when they got close. SRNA #21 stated Resident #85 had not struck out at any other resident after the incident on 01/29/2023. SRNA #21 stated she had received abuse prohibition training at the facility. SRNA #21 stated if she witnessed abuse, she would report abuse immediately to the charge nurse and then to the administrator if necessary. During an interview on 11/17/2023 at 3:47 PM, the DON stated she remembered receiving a phone call about the incident involving Resident #85 and Resident #3. The DON stated she was told Resident #85 smacked Resident #3 on the arm. The DON stated Resident #85 was placed on 1:1 staff supervision and was later sent to the hospital emergency department for an evaluation. The DON stated the resident returned to the facility with no new orders. An interview with the Administrator on 11/17/2023 at 4:30 PM revealed she expected staff to be aware of any resident showing agitation or wandering, follow the resident's plan of care, and supervise residents who wandered. 5. A review of Resident #54's Admission Record revealed the facility admitted the resident on 12/25/2021 with a diagnosis of age-related physical debility. On 01/07/2022, the facility diagnosed Resident #54 with cognitive communication deficit. A review of Resident #54's quarterly MDS, with an ARD of 02/08/2023, revealed Resident #54 had a SAMS conducted that indicated the resident had severe impairment in cognitive skills for daily decision making. The MDS revealed the resident had exhibited no behaviors during the assessment lookback period. The MDS revealed the resident required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and bathing. A review of Resident #54's Care Plan revealed a Focus area, initiated on 01/05/2022, that indicated the resident was cognitively impaired, as evidenced by a BIMS that indicated severe impairment, developmentally delayed, and impaired decision-making. Interventions directed staff to reorient the resident as needed. Further review revealed a Focus area initiated on 02/24/2023 that indicated the resident had the potential to demonstrate physical behaviors. Interventions directed staff to intervene before agitation escalates, guide the resident away from the source of distress and engage calmly in conversation. A review of Resident #34's Admission Record revealed the facility admitted the resident on 05/03/2022 with diagnoses that included cognitive communication deficit and mood disorder. The diagnosis of unspecified dementia was added on 08/24/2023. A review of Resident #34's annual MDS, with an ARD of 02/14/2023, revealed Resident #34 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had exhibited no behaviors during the assessment lookback period. The MDS revealed the resident required limited assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident #34's Care Plan revealed a Focus area initiated on 12/06/2022 that indicated the resident exhibited other behavioral symptoms such as going in and out of resident rooms and rummaging through other resident's stuff. Interventions directed staff to educate the resident on inappropriate behavior and allow the resident time to vent and express their feelings. Further review revealed a Focus area initiated on 02/28/2023 that indicated the resident had cognitive impairment. Interventions directed staff to observe for decline in the resident's cognitive function, notify the physician if noted, and keep routines and caregivers as consistent as possible. A review of a Long Term Care Facility - Self-Reported Incident Form, 5 Day Follow up/Final Report, dated 02/24/2023, revealed a typed summary of the incident and investigation that indicated Resident #54 and Resident #34 both enjoyed staying up later at night and on 02/21/2023, Resident #34 went into Resident #54's room to see Resident #54. The su [TRUNCATED]

Based on interviews, record review, facility document and policy review, it was determined the facility failed to ensure a resident was protected against misappropriation of property for one (Resident #95) of 1 sampled resident reviewed for misappropriation of property. The findings included: Review of the facility's policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Residents' Property, undated, revealed, It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of residents' property. The policy revealed, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belonging or money without the resident's consent. Review of the facility's policy titled Outside Medications Brought in for Residents, initiated on 02/10/2021 and reviewed by the facility on 11/07/2022, revealed, If the family is not present when medication is noted, explain to the resident that medication brought in from home can't be left at bedside and that nursing will contact family to pick them up. This medication will be taken to the DON [Director of Nursing] for secure storage until the family is available for [sic] pick them up. If the DON is not present, she is to be contacted to come in and secure medication. In the absence of the DON, the Administrator is to be contacted. Review of a typed facility investigation summary, signed and dated 02/15/2021 by the Director of Operations (DOO), revealed the family of Resident #95 dropped off a bag of clothing and other personal effects to be delivered to Resident #95. The summary revealed that the bag contained a community prescription bottle and an inhaler. The summary indicated the inhaler and prescription bottle were given to the charge nurse to be locked up until the family could pick up the items on their next visit. Continued review of the summary revealed the bottle of medication was noted to be missing from the drawer on 02/10/2021, and the facility initiated an investigation. The summary revealed a urine drug screen was conducted on staff who had access to the medication cart with no conclusive results. The facility's investigation concluded that the medication bottle could have been sent back to the pharmacy or otherwise discarded because the resident went to the hospital from 02/08/2021 to 02/12/2021. Resident #95 was interviewed upon return to the facility, and the resident stated they could not remember if anyone had sent the medication to the hospital with the resident and their belongings. Review of Resident #95's Admission Record revealed the facility admitted the resident on 01/27/2021 with diagnoses that included polyneuropathy and panlobular emphysema. Review of Resident #95's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/2022 revealed the facility assessed Resident #95 with a Brief Interview of Mental Status (BIMS) score of 15. This score indicated the resident was cognitively intact. Further review revealed the resident had received opioid medication daily during the seven-day lookback period. A review of Resident #95's Care Plan revealed a Focus area, initiated on 02/04/2021, that indicated Resident #95 was on a routine pain management program related to arthritis, neuropathy, osteoporosis, and spinal stenosis. Interventions directed staff to administer pain medications as ordered. A review of Resident #95's Inventory List, dated 02/12/2021, revealed the inventory sheet did not include a community prescription bottle or an inhaler. The resident did not have any further personal inventory sheets on file. During a telephone interview on 11/16/2023 at 8:28 PM, Central Supply Staff #4 stated she recalled a bottle of medication belonging to Resident #95 that was brought to the facility for the resident. She stated the medication was given to her by Medical Records Specialist (MRS) #25. Central Supply Staff #4 stated she took the bottle of medication to the Unit Manager at the time, and the Unit Manager told her to lock it in the narcotic box in the medication cart. Central Supply Staff #4 stated she did not see an inhaler, only a medication bottle. She stated the medication bottle was in the medication cart for approximately two weeks. She stated she was off work, and when she returned, the medication bottle was no longer in the cart. Central Supply Staff #4 stated she asked the Unit Manager where the medication went, and they could not find the medication, so she reported the missing medication to the DON. She stated MRS #24 no longer worked at the facility, and she could not remember the name of the Unit Manager. Central Supply Staff #4 stated the bottle was labeled as oxycodone (narcotic pain medication). During an interview on 11/16/2023 at 2:23 PM, Registered Nurse (RN) #3 stated she recalled seeing a pill bottle from a different pharmacy in the narcotic drawer that did not have a count sheet that belonged to Resident #95. RN #3 stated she did not remember what the medication was, but it was a pain medication. She stated there was not a sign-in sheet made for the medication, and there was no accountability to know who received the medication. During an interview on 11/17/2023 at 12:52 PM, the DOO stated she was currently the DOO, but was the Administrator when the incident occurred with Resident #95's missing medication. The DOO stated the resident was sent to the hospital, and they were unable to determine if the resident had the medication with them. The DOO stated the expectation was for medications to be secured by staff, and the family should be notified to pick them up for this type of situation. During an interview on 11/17/2023 at 4:40 PM, the DON stated the facility initiated a new policy after the incident occurred with Resident #95's medication. The DON stated if a family member brought in medications from home or the hospital, they asked the family to take them back. The DON stated, if necessary, they secured the medication until the family could get the medications. The DON stated she would come to the facility to secure the medications if necessary. The DON stated that Central Supply Staff #4 notified her of the missing bottle of medication that belonged to Resident #95. During an interview on 11/17/2023 at 5:53 PM, the Administrator stated her expectation was for staff to follow the policy related to family and residents bringing personal medications from home. The Administrator stated the new policy was for staff to notify the DON and give the medication to her to be secured and stored until the family could come and get the medication. She stated if it was after hours or the weekend and the DON was not in the building, staff should notify the Administrator. The Administrator confirmed that she did not know what happened to the missing medication.

Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure State Registered Nurse Aide (SRNA) #30 implemented care planned interventions to reduce the risk of accidents for 1 (Resident #93) of four (4) sampled residents reviewed for accidents. Specifically, on 06/01/2023 around 5:00 AM, SRNA #30 repositioned Resident #93 in the bed independently instead of utilizing a second staff member, as directed by the resident's care plan. The findings included: Review of the facility's policy titled Comprehensive Care Plans, reviewed 11/07/2022, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further indicated, 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. A review of Resident #93's Admission Record revealed the facility admitted Resident #93 on 01/10/2022 with diagnoses that included acquired absence of the left leg below the knee, acquired absence of the right leg above the knee, dependence on a wheelchair, unspecified dementia with behavioral disturbance, age-related cataracts, and an unspecified mood disorder. Review of Resident #93's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2023, revealed Resident #93 had a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated the resident had moderate cognitive impairment. According to the MDS, the resident required extensive assistance from two plus staff with bed mobility. A review of Resident #93's Care Plan revealed a Focus area, initiated on 01/21/2022, that indicated the resident had a self-care deficit as evidenced by debility, dementia, and non-ambulatory status. Interventions initiated on 01/21/2022 informed staff that the resident required extensive assistance from two staff members with bed mobility and had bilateral grab bars to increase independence with bed mobility. Review of Resident #93's Progress Notes revealed an Event Note, documented by the Director of Nursing (DON) and dated 06/01/2023 at 10:00 AM, that indicated the DON was at the resident's bedside after the resident reported to the charge nurse about being beat real good. The resident said the incident occurred at the bar but was unable to recall if anyone was with them and reported they drove there and two individuals of a specific gender and size roughed [him/her] up. Resident #93 was unable to state when the incident allegedly occurred and gave answers varying from the other night to three months ago. A review of a typed document summarizing the facility's abuse investigation, signed by the Director of Operations (DOO) on 06/06/2023, revealed the SRNA assigned to Resident #93, SRNA #30, fit the description provided by the resident. The summary included a narrative of a conversation between the DON and DOO with SRNA #30 conducted on 06/05/2023 at 11:00 AM. SRNA #30 reported that around 5:00 AM, he noted that Resident #93 was nearly sideways in the bed, so the SRNA turned the resident and situated the resident in bed. SRNA #30 confirmed this involved turning the resident, pushing the resident to roll, and pulling the resident up in bed by pulling under the resident's arms and with the use of a cloth bed pad. During a telephone interview on 11/15/2023 at 2:11 PM, SRNA #30 stated during the night shift on 06/01/2023, Resident #93 had been calling out for a family member, and when he checked on the resident, he found the resident sideways in bed and pulled them up using an outdated method of bed mobility. He stated he used a sheet. The SRNA stated the resident was confused and must have thought he beat them up because of how he pulled the resident to reposition them in bed. He stated he pulled the resident up by his/her armpits and that was his mistake, stating he should have gotten a second staff member to help with the resident's bed mobility. During a telephone interview on 11/16/2023 at 3:32 PM, SRNA #43 stated they no longer worked for the facility but recalled the incident with Resident #93 on 06/01/2023. She stated she was the other SRNA working with SRNA #30. SRNA #43 said she was sitting at the nurse's station, and SRNA #30 repositioned the resident himself and had not asked for her assistance. She stated the resident's room was right around the corner from the nurse's station. During an interview on 11/16/2023 at 4:27 PM, Registered Nurse (RN) #3 stated Resident #93 could assist with bed mobility, but they still required two-staff assistance. During an interview on 11/17/2023 at 2:51 PM, the DON stated as part of the investigation into Resident #93's allegation, she interviewed SRNA #30, who reported they had repositioned Resident #93 alone after finding the resident sideways in bed, but the resident required two people. During an interview on 11/17/2023 at 3:41 PM, the Administrator stated she expected staff to follow residents' plans of care.

Based on interview, record review, and review of the facility's policies, it was determined 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 disease and infections to properly prevent and/or contain COVID-19. Observation, on 09/17/2020 at 8:50 AM, during medication administration, revealed Licensed Practical Nurse (LPN) #5 dropped a pill on the top of the medication cart, picked up the pill with an ungloved hand, put the pill in the medication cup, and then administered the medication to Resident #78. Observations, on 09/15/2020 and 09/16/2020, in the kitchen, revealed staff wearing face masks inappropriately and performing improper hand washing. The findings include: Review of the facility's policy titled, Medication Administration - General Guidelines, revision date 12/18/2012, revealed medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review revealed personnel authorized to administer medications did so only after they had familiarized themselves with the medication, and the facility would have sufficient staff to allow administering of medications without unnecessary interruptions. Review of the facility's policy titled, Use of Face Mask for Prevention, dated 07/13/2020, revealed a face mask should be worn at all times when in the facility unless the mask became visibly soiled. Review of the facility's policy titled, Dietary Employee Personal Hygiene, dated 2019, revealed dietary employees must follow guidelines for personal hygiene to prevent contamination of food by food service employees. 1. Observation of medication administration, on 09/17/2020 at 8:50 AM, revealed LPN #5 prepared Resident #78's morning medications for administration. Upon starting, LPN #5 sanitized her hands with hand sanitizer. LPN #5 opened a [MEDICATION NAME] one-hundred (100) milligram (mg) pill packet, and the pill fell on top of the medication cart. LPN #5 then picked up the pill with an ungloved hand and placed it into the medication cup. Continued observation revealed LPN #5 opened a Potassium Extended Release ten (10) milliEquivalent pill packet; again the pill dropped on top of the medication cart as she attempted to put it into the medication cup with an ungloved hand. However, the pill missed and fell on to the medication cart. This time LPN #5 stated, I guess I should get a new pill', which she proceeded to do. However she did not discard the 100 mg [MEDICATION NAME] pill she had previously picked up off the cart bare handed and placed in the cup. LPN #5 was observed administering medications that included the first dropped pill to Resident #78. Interview with LPN #5, on 09/17/2020 at 9:30 AM, revealed she did not think she picked up a pill off the medication cart. She stated she did drop one (1) pill on the cart, but stated she got a new pill. Per interview, LPN #5 stated if a pill dropped on the medication cart, it should be disposed of and a new pill obtained because giving the pill that dropped on the cart could be an infection control risk for the resident. Interview with the Director of Nursing (DON) and the Administrator, on 09/17/2020 at 5:58 PM, revealed they both expected safe medication practices to be followed, which included following infection control practices. Both stated LPN #5 should have thrown the pill away and gotten a new one, and at any time staff's hands became soiled while preparing medications for administration, they should be washed. The DON and the Administrator stated this was an infection control issue as the medication touched the cart and then was administered to the resident. 2. Observation, on 09/15/2020 at 10:01 AM, during the initial kitchen tour, revealed Cook #1 washed his hands, turned off the faucet with his bare hands, and then dried his hands. Further observation revealed Diet Aide #2, sat in the kitchen office, got up and walked into the kitchen not wearing a face mask, and continued to walk throughout the kitchen. Diet Aide #2 told Diet Aide #1, who entered the kitchen, to put on a hair net. Further observation revealed Diet Aide #1 and Diet Aide #2 did not wear face masks in the dish room while working with the dish machine. Continued observation, on 09/16/2020 at 1:15 PM, of the Dietary Manager in the kitchen revealed she wore a face mask which did not cover the nose correctly. Further observation in the kitchen revealed Diet Aide #1 and Diet Aide #2 wore face masks which did not cover their noses, and Diet Aide #3 wore a face mask below the nose with a face shield. Interview with Cook #1, on 09/16/2020 at 1:33 PM, revealed staff in the kitchen wore face masks in various ways because they got hot. He stated a face mask should be worn at all times in the kitchen to prevent the transfer and spread of the [MEDICAL CONDITION] to residents. Cook #1 stated he should have turned off the faucet with the paper towel after washing his hands because he recontaminated them by touching the faucet handle. Interview with Diet Aide #1, on 09/16/2020 at 1:51 PM, revealed the face masks she wore in the kitchen would slide down her face. However, she stated wearing face masks to cover the mouth and nose and proper hand washing by turning off faucets with paper towels protected residents from the spread of the [MEDICAL CONDITION] by preventing the spread of germs and the recontamination of hands. Interview with Diet Aide #2, on 09/16/2020 at 2:03 PM, revealed face masks should be worn in the kitchen and in hallways. Further interview revealed proper hand washing required turning off faucets with paper towels to prevent the spread of germs. Interview with Diet Aide #3, on 09/16/2020 at 2:22 PM, revealed she wore a face shield in the kitchen instead of a face mask; however, in resident areas she wore a face mask and face shield to prevent the spread of germs. Diet Aide #3 stated with hand washing, if the faucet handle was turned off with bare hands, they would be contaminated and would need to be washed again to prevent the spread of germs. Interview with the Dietary Manager, on 09/16/2020 at 2:40 PM, revealed face masks should be worn in the kitchen with social distancing to protect staff and residents from the spread of the [MEDICAL CONDITION] by airborne droplets. She stated correct hand washing included not touching the faucets with bare hands to prevent recontamination and the spread of germs. Interview with the DON, on 09/16/2020 at 4:30 PM, revealed she expected staff to wear masks and wash hands appropriately to prevent the spread of germs. Interview with the Administrator, on 09/16/2020 at 5:00 PM, revealed she expected staff to wear masks and wash hands properly to prevent the spread of germs and the [MEDICAL CONDITION].

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure all drugs and biological's were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys, for one (1) of twenty-two (22) sampled residents, Resident #36. In addition, the facility failed to ensure drugs and biological's were labeled, dated, and stored without food in accordance with currently accepted professional principles. Observation of Resident #36's room, on 09/15/2020, revealed a water basin, sitting on the shelf at the bedside contained treatment medications prescribed for Resident #36 . Record review revealed evidence the resident was assessed to safely self-administer medications. Observations, on 09/15/2020 and 09/16/2020, revealed five (5) of six (6) medications carts and one (1) of three (3) medication refrigerators contained opened medications without open dates; two (2) of six (6) medication carts with medications not labeled with a resident's name; and four (4) of six (6) medication carts with food stored with medications. The findings include: Review of the facility policy titled, Storage of Medications, undated, revealed medications and biological's were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Per policy, the medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Continued review of the policy revealed medication rooms, carts, and medication supplies were locked when not attended by persons with authorized access. 1. Review of Resident #36's medical record revealed the facility admitted the resident, on 02/26/2015, and readmitted the resident, on 07/29/2020, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/29/2020, revealed the facility assessed Resident #36 as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating the resident was moderately cognitively impaired. Observation during the initial tour, which began on 09/15/2020 at 10:30 AM, revealed two (2) bottles of Remedy Antimicrobial Liquid, one (1) tube of [MEDICATION NAME], one (1) bottle of [MEDICATION NAME] Menthol Lotion, and one (1) bottle of Sarna [MEDICATION NAME] Lotion prescribed for Resident #36, in a plastic water basin, on the resident's bedside shelf next to the resident's bed. Review of Resident #36's Physician's Orders revealed orders for [MEDICATION NAME] Cream 0.05%, apply to blistered areas topically every evening shift, with a start date of 09/08/20; [MEDICATION NAME]-Menthol Lotion 0.05%, apply to upper/lower extremities topically every eight (8) hour, with a start date of 07/29/20; [MEDICATION NAME] Propionate Cream 0.05%, apply to abdomen/buttock/breast topically as needed for intact blister, with a start date of 08/26/2020; and Remedy Antimicrobial Cleanser Liquid, apply to perineal area topically every shift, with a start date of 07/29/2020. Further review of Resident #36's medical record revealed no evidence the resident had been assessed to self-administer medications, and review of the Comprehensive Care Plan (CCP) revealed no evidence of a care plan related to self-administration of medications. Interview with the Administrator, on 09/15/2020 at 10:35 AM during the initial tour, revealed the medications should not be in Resident #36's room. Further interview revealed Resident #36's case was complicated related to infection control, and the facility decided to leave treatment medications at the bedside. Furthermore, the Administrator agreed medications should not be by the bedside, and leaving them there did not follow the facility's policy. Interview with Licensed Practical Nurse (LPN) #3, on 09/16/2020 at 4:01 PM, revealed she had worked at the facility for seven (7) years and was assigned to Unit One where Resident #36 resided. She stated residents were not allowed to have medications or prescriptions in their rooms. She stated it was not the facility's common practice. Per interview, LPN #3 stated leaving medications at the bedside could be harmful to residents and others. Interview with Unit Manager/LPN #4, on 09/17/2020 at 9:26 AM, revealed she had worked at the facility for five (5) years. She stated she did not expect medications to be stored at the bedside. Per interview, residents were not allowed to have any forms of medications in their rooms; however, staff could leave gauze in the residents' rooms. The Unit Manager stated the risk for leaving medications at the bedside could be that another resident or the actual resident could get the medications and harm themselves. Furthermore, she stated medications should be locked at all times, and this occurrence was not common practice for the facility. Interview with the Assistant Director of Nursing (ADON), on 09/17/20 at 10:53 AM, revealed she had worked at the facility for fifteen (15) years. She stated it was not the facility's common practice to leave medications at the bedside. Further interview revealed all medications should be locked in the medication cart. Interview with the Director of Nursing (DON), on 09/17/20 at 4:37 PM, revealed medications should be locked in the Medication/Treatment carts. Further, she stated medications should not be left in residents' rooms. The DON stated it was for the safety of all residents that medications be locked. She further stated the facility discouraged this practice and educated against it. Continued interview revealed she expected all medications to be locked in the Medication/Treatment carts. Subsequent interview with the Administrator, on 09/17/2020 at 5:28 PM, revealed she had worked at the facility for thirteen (13) years. She stated all medications were to be stored under lock and key per the facility policy. Per interview the facility did not follow their policy related to medication storage. 2. Observation of the First Floor East Medication Cart, on 09/15/2020 at 3:40 PM, revealed the following items located in stock and available for resident use: one (1) bottle of Dorzolamide [MEDICATION NAME] eye drops, with no open date and one (1) [MEDICATION NAME] eye drop, with no open date. Additional observation revealed six (6) pudding snacks, three and one-half (3.5) ounce (oz), and one (1) apple sauce, four (4) oz, stored in a side drawer with medications. Interview with LPN #1 (assigned to the First Floor East Medication Cart), on 09/15/2020 at 3:40 PM, revealed all multi-dose medications should be dated with an open and/or an expiration date by the nurse who opened the medication. Per interview, dating a multi-dose medication ensured all nurses knew when a medication was expired and when not to use the medication. Additionally, it was important to administer medications safely to residents because medications should have a therapeutic effect. LPN #1 stated the Unit Manager and staff from the Pharmacy audited the medication carts periodically to ensure medications were stored appropriately. Further, she stated when the medication cart was assigned to her, she was responsible to ensure medications were labeled with open and expiration dates before administering the medication. Observation of the First Floor West Medication Cart, on 09/16/2020 at 10:57 AM, revealed the following items located in stock and available for resident use: two (2) bottles of [MEDICATION NAME] nasal spray with no open date or expiration date and one (1) bottle of Calcitonin Salmon nasal spray with no open date or expiration date. Additional observation revealed six (6) pudding snacks, three and one-half (3.5) oz, stored in a side drawer with medications. Interview with Unit Manager/LPN #4 (Unit Manager for First Floor), on 9/16/2020 at 10:57 AM, revealed all nasal spray should be dated with an open to ensure the resident received unexpired medication. Additionally, the assigned nurse was responsible to ensure all multi-dose medications were dated with open and/or expiration dates. Further, she stated expired medications would not have the most therapeutic effect. Observation of the Second Floor East Medication Cart, 09/15/20 at 3:58 PM, revealed the following items located in stock and available for resident use: one (1) bottle of [MEDICATION NAME] with no open date or expiration date. Additional observation revealed three (3) pudding snacks, three and one-half (3.5) oz, and two (2) applesauce, four (4) oz, stored in a side drawer with medications. Interview with Kentucky Medication Aide (KMA) #1 (assigned to Second Floor East Medication Cart), on 09/15/2020 at 3:58 PM, revealed he/she was responsible to ensure multi-dose medications were labeled with open dates when assigned to the medication cart. Continued interview revealed nursing leadership routinely audited medication carts for proper medication storage and labeling. Per interview, it was important that medications were administered to residents safely and unexpired to decrease the risk for adverse reactions. Observation of the Second Floor West Medication Cart, on 09/15/20 at 4:15 PM, revealed the following items located in stock and available for resident use: one (1) bottle of Levetiracetam with no open or expiration date. Additional observation revealed three (3) pudding snacks, three and one-half (3.5) oz, and two (2) applesauce, four (4) oz, stored in a side drawer with medications. Observation of the Third Floor Medication Room refrigerator, on 09/15/20 at 4:24 PM, revealed the following items located in stock and available for resident use: one (1) bottle of [MEDICATION NAME] with no open expiration date. Observation of the Third Floor East Medication Cart, on 09/15/20 at 4:24 PM, revealed the following items located in stock and available for resident use: one (1) bottle of Kepra with no open or expiration date. Additionally, one (1) bottle of Miconazorb AF powder with no resident name was observed. Observation of the Third Floor West Medication Cart, on 09/15/20 at 4:24 PM, revealed the following items located in stock and available for resident use: one (1) tube of Aspercream with no resident name and one (1) tube of [MEDICATION NAME] with no resident name. Interview with LPN #2, (assigned to Third Floor East Medication Cart), on 09/15/ at 4:24 PM, revealed medications should be stored per the facility policy and standards of practice. Additionally, all multi-dose mediations should be dated when opened by the assigned nurse. Per interview, he completed medication storage audits when assigned to medications and did not identify that the medication in the refrigerator did not have an open date. Further, all medications, including topical medications, should have a resident's name noted on the container to ensure the correct medication was administered to residents, and for infection control. Interview with the Pharmacy Consultant, on 09/16/2020 at 9:20 AM, revealed she had not identified there was a need for correction related to date opening on multi-dose medications or food stored with medication. Further interview revealed it was important for medications to be dated with open dates to ensure sterility of the medications and to keep the product close to manufacturing standards. Interview with the DON, on 09/17/2020 at 5:00 PM, revealed multi-dose medications were dated when put on medication carts with an open date or expiration date, per standards of practice. Per interview, night shift nurses and the contracted Pharmacy completed audits of medication carts for proper storage and labeling. Additional interview revealed all medications should be labeled appropriately and have a resident's name on the container, and no food should be stored with medication to ensure standards of practice were maintained for medication administration. Further, the DON stated proper labeling of medications would decrease the risk for administration of expired medications. She stated expired medications would not have the most beneficial effect for residents. Per interview, the DON stated she expected all multi-dose medications on medication carts to be labeled with open and expiration dates. Interview with the Administrator, on 09/17/2020 at 6:00 PM, revealed medications should be stored, labeled, and dated per standards of practice and regulation. Per interview, multi-dose medications should have open dates and/or expiration dates on them once they are in the medication carts. Additionally, the Administrator stated nursing staff should maintain standards of practice; each medication should have an open date and expiration date. Further, it was important for residents to receive medications that were not expired to ensure they had the most therapeutic effect from their medications.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store and prepare food under sanitary conditions. A staff member entered the kitchen without wearing a hair net; unopened, unlabeled opened food was found on a kitchen shelf; and three (3) varieties of expired soup were sitting on cupboard shelves in three (3) unit kitchenette pantries. The findings include: Review of the facility's policy titled, Food Safety Requirements, dated 2019, revealed labeling, dating, and monitoring food, including, but not limited to leftovers must be done, so food would be used by its use-by or expiration date. Observations, on [DATE] at 10:00 AM, during the initial kitchen tour, revealed Diet Aide #1 not wearing a hair net in the kitchen. In addition, above the cooks table, wrapped cookies were not labeled or dated, two (2) packages of almost empty brown sugar were not labeled or dated, and the flour ingredient bin had no visible label or date. Continued observations, on [DATE] beginning at 10:35 AM, of the unit kitchenette pantry cabinets revealed, in the first floor cabinet, there were three (3) varieties of individual low sodium soup cans (Vegetable, Chicken Noodle and Tomato) that were expired with expiration dates between ,[DATE] and ,[DATE]. Interview with Cook #1, on [DATE] at 1:33 PM, revealed food expired three (3) days after it had been opened, so it must be labeled and dated to know when to dispose of it. In addition, he stated food not labeled or dated must be thrown out because the length of time on the shelf was not known, and it could have bacteria growth. Per interview, Cook #1 stated it was a resident safety issue if residents received spoiled or contaminated food. He stated hair nets were worn to prevent contamination and keep hair dander out of food. Interview with Diet Aide #1, on [DATE] at 1:51 PM, revealed it was important to label and date all opened foods with use by date three (3) days after opening; food was thrown out if not labeled and dated or it reached the date of expiration. She stated if food was not handled this way, bacteria could grow and cause cross-contamination. In addition, Diet Aide #1 stated she forgot to wear her hairnet; however, it was important to wear a hairnet to prevent cross-contamination of food. Interview with Diet Aide #2, on [DATE] at 02:03 PM, revealed the cooks mainly labeled and dated food. In addition, the dry storage was rotated, with the soup cans rotated twice weekly. She stated foods not labeled or dated were thrown away, as was food that had been opened for three (3) days. Further, she stated it was important to do this because expired or unlabeled/undated food could spoil and bacteria could grow, causing illness. Diet Aide #2 stated a hairnet worn in the kitchen was done to prevent hair getting into food. Interview with Diet Aide #3, on [DATE] at 2:22 PM, revealed all opened food must be labeled, dated, and disposed of after three (3) days. She stated food outdated or not labeled or dated had to be thrown out because it could contain bacteria and make residents' sick. Diet Aide #3 stated a hairnet must be worn in the food preparation area and while serving food to prevent cross-contamination of food. Interview with the Dietary Manager, on [DATE] at 2:40 PM, revealed all food was labeled and dated after opening and thrown away after three (3) days. She stated expired food and unlabeled and undated opened food had to be thrown away because food could spoil and contain bacteria. The Dietary Manager stated canned soups on the units were rotated by the first in/first out (FIFO) method. Per interview, staff should wear hairnets at all times, to prevent cross-contamination of food. Interview with the Director of Nursing (DON), on [DATE] at 4:30 PM, revealed food was labeled, dated, and rotated to prevent food spoilage and growth of bacteria. The DON stated she expected staff to wear hairnets at all times in the kitchen to prevent cross-contamination. Interview with the Administrator, on [DATE] at 5:00 PM, revealed she expected food to be labeled, dated, and rotated to prevent spoilage. She stated hairnets were worn to prevent cross- contamination of food.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure there was proper notification of the resident's representative and Physician for a significant change in the resident's weight for one (1) of twenty-two (22) sampled residents (Resident #21). The findings include: Review of the facility's policy titled, Weight Change: Loss/Gain, revision date 02/07/2020, revealed the policy was to ensure that each resident's body weight was maintained within measurable parameters, unless the resident's clinical condition demonstrated it was not possible. Continued review revealed if there was a five (5) pound or more difference from the previous weight, another weight must be taken and recorded within twenty-four (24) hours. In addition, the interdisciplinary team (IDT) would notify the Physician, resident, and/or the resident's representative of any weight changes as noted. Review of Resident #21's medical record revealed the facility admitted the resident, on 10/13/2017, with [DIAGNOSES REDACTED]. Review of Resident #21's Comprehensive Care Plan revealed a focus, initiated on 10/25/2017, of the resident was at risk for alteration to nutritional status related to [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Vitamin D Deficiency, Dementia, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], Tremors, and reported allergy to Ensure. The goal, target date 10/04/2020, stated Resident #21 would be free of changes to nutritional status as evidenced by remaining free of significant weight change, complaints of hunger, or signs and symptoms of dehydration. Further review revealed an intervention, initiated on 10/25/17, was to notify the Physician and responsible party of any significant weight change. Review of Resident #21's weights revealed, on 07/08/2020, the resident was weighed to be 109.8 pounds. On 08/07/2020, the resident was weighed to be 99.8 pounds. This was a loss of 10.0 pounds and a 9.11 percent weight loss in one (1) month. Review of Resident #21's medical record revealed no documented evidence the resident's Power of Attorney (POA) or Physician were notified of the resident's weight loss. Interview with the Unit Manager for Unit Two, on 09/17/2020 at 3:40 PM, revealed she expected staff to follow the facility's policy and notify the resident's Power of Attorney (POA) and Physician regarding any changes in weight. She stated the family was well aware of Resident #21's weight loss. However, staff did not follow the facility's policy and notify the POA of the resident's weight loss. Interview with the Director of Nursing (DON), on 09/17/2020 at 4:39 PM, revealed she expected staff to follow policy. She stated she was unaware the family of Resident #21 was not notified regarding the weight loss discovered on 08/07/2020. She stated the family was made aware, but the notification was not timely as it was almost a month later. Interview with the Administrator, on 09/17/2020 at 5:23 PM, revealed she expected staff to follow policy regarding a weight loss or gain and notify the appropriate parties. She stated Resident #21's family and POA should have been notified sooner than a month later regarding his/her weight loss.

Based on observation, interview, record review, review of the facility's policies, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a Person-Centered Comprehensive Care Plan (CCP) for each resident to meet a resident's medical and nursing needs identified in the comprehensive assessment for four (4) of twenty-two (22) sampled residents (Residents #34, #36, #42, and #21). Resident #34 had an active order for oral [MEDICATION NAME] (a medication given to decrease anxiety) as needed (PRN) every eight (8) hours with a start date of 07/16/2020 and an end date of 01/12/2021. Per the CCP, a rationale for the continuation of the [MEDICAL CONDITION] (drugs that affect a person's mental state and given to treat a variety of mental health issues) PRN medication was required but was not documented in the medical record. Resident #36, on 05/08/2020, was turned in bed by State Registered Nurse Aide (SRNA) #7 who placed a Hoyer (mechanical lift) pad under the resident to get him/her ready for a shower. Per the facility's policy and Resident #36's CCP, a two (2) person assist was required for bed mobility and Hoyer transfers. Resident #42 had an active order for oral [MEDICATION NAME] Sprinkles (medication given as a mood stabilizer) PRN every eight (8) hours with a start date of 08/31/2020. Per the CPC, this [MEDICAL CONDITION] PRN medication had a required review date by the Physician within fourteen (14) days of the start date that was not done. Resident #21 had a weight loss of ten (10) pounds in one (1) month, and the facility failed to follow the CCP to re-weigh the resident. The findings include: Review of the facility's policy, Comprehensive Care Plans, dated 10/31/2019, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. Additional review revealed the CCP was prepared by an interdisciplinary team of health care professionals and would be developed to identify which discipline(s) would be responsible to carry out approaches and interventions for residents. Review of the facility's policy, Nursing Assistant Care Plan, dated 10/31/2019, revealed each resident would have a Kardex which would consist of specific information required to meet their individual needs. The Kardex was an essential tool to be used for communicating information from the Nursing Care Plan to the Nursing Assistants and other staff. Further review revealed information from the Kardex was used to set up the task in the Point of Care (POC) which was where staff would document care given to each resident as soon as it was provided. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the CCP must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written CCP. Continued review revealed the CCP was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a CCP based on a thorough assessment and effective clinical decision making was compatible with current standards of clinical practice, which provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Further review revealed a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized CCP as appropriate and necessary. 1. Review of Resident #34's medical record revealed the facility admitted the resident, on 08/21/2017, with [DIAGNOSES REDACTED]. Review of Resident #34's CCP revealed a focus of the resident used anti-anxiety medications related to an Anxiety Disorder and was also taking an antidepressant with a revision date of 11/13/2017. The goal stated the resident would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date of 11/18/2020. Interventions, initiated 08/31/2017, included to attempt non-pharmacological interventions such as redirection, reassurance, distraction, music, offer toileting, offer snacks, etc., prior to giving PRN medications; consult the Physician for possible gradual dose reduction (GDR) PRN; and educate resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of anti-anxiety drugs being given. Further review of the CCP revealed interventions, initiated on 09/06/2019, which were to follow-up with Psychiatry and Psychology as ordered/needed; give anti-anxiety medications ordered by the Physician; Monitor/document side effects and effectiveness of the anti-anxiety medications, such as drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, and blurred or double vision. Continued review revealed paradoxical side effects (opposite to the effect of the medication that would normally be expected) to monitor included mania, hostility and rage, aggressive or impulsive behavior, and hallucinations. Further review of Resident #34's medical record revealed he/she had an active order for [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 milligrams (mg) by mouth every eight (8) hours as needed (PRN) for anxiety, with a start date of 07/16/2020 and an end date of 01/12/2021. There was no documented evidence of a rationale for the continued use of the [MEDICATION NAME]. Review of Resident #34's Consultation Report, dated 06/28/2020 to 06/30/2020, revealed the Consulting Pharmacist documented the resident used this medication sporadically and to consider an extended stop date of one hundred eighty (180) days. 2. Review of Resident #36's medical record revealed the facility admitted the resident, on 02/26/2015, and readmitted the resident, on 07/29/2020, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/29/2020, revealed the facility assessed Resident #36 as having a Brief Interview for Mental Status (BIMS) score of three (03) out of fifteen (15), indicating the resident was cognitively impaired. In addition, the MDS assessment revealed the facility assessed Resident #36 as requiring a two (2) person assist for bed mobility and transfers. Review of Resident #36's CCP, revised 05/12/2020, revealed a focus of the resident was at risk for falls related to unsteadiness on feet and muscle weakness and required the use of a Hoyer lift for transfers. The goal of the CCP stated the resident would remain free from significant injury should falls occur through the review date. The CCP interventions included anticipate needs; Dycem (nonslip material) to wheelchair when up; ensure resident had proper non-skid footwear on prior to rising; and Hoyer lift to be used with the assistance of two (2) staff, which included putting a Hoyer pad under the resident and removing the Hoyer pad while in bed. Review of the facility's Incident Report, dated 05/08/2020, revealed SRNA #7 was rolling Resident #36 in bed to change him/her when the resident's left leg started to go over the right leg; SRNA #7 tried to grab the resident but the lower half of his/her body had already started to roll off of the bed with the leg. Per report, the SRNA ran around to the left side of the bed to attempt to intervene and stop the resident from falling by lowering his/her upper torso to the floor. Further review revealed the resident was lying on his/her side and rolled onto the stomach. Further review revealed SRNA #7 called the Nurse for help, and the resident was immediately assessed. The findings of the assessment were neurological checks were normal; there were no signs or symptoms of pain with movement; vital signs were stable; and a red area was noted to the right side of the resident's forehead. Review of the Comprehensive Resident Assessment Progress Note, dated 05/12/2020 at 4:35 PM, completed by Licensed Practical Nurse (LPN) #4, revealed while SRNA #7 was getting Resident #36 ready with the Hoyer pad by turning the resident onto his/her right side, the resident's left leg slid off the edge of the bed causing the resident's weight to shift to his/her right side of the bed. Further review revealed SRNA #7 was able to intercept the fall by lowering the resident onto the floor; she then called for the Nurse. Per the note, Resident #36 was assessed for injury, and the resident was noted to have a small reddened area to the right side of the forehead where he/she had been lying on the floor. Further review revealed Resident #36 was then assisted by three (3) staff and the use of the Hoyer life to get him/her onto the shower chair, so SRNA #7 could give him/her a shower. Resident #36's Physician was made aware of the incident. Review of the Verbal Warning, dated 05/08/2020, initiated by LPN #4, Unit Manager, revealed the violation was, on 05/08/2020, while SRNA #7 was getting the Hoyer pad under Resident #36, he/she rolled out of bed with no injuries noted. In addition, the KARDEX stated two (2) people were required with all bed mobility. Telephone interview with SRNA #7, on 09/17/2020 at 2:43 PM, revealed she was assigned to Resident #36 on 05/08/2020. She stated she was doing bed mobility and placing the resident under the Hoyer pad. Per interview, she had never been trained to use two (2) people with bed mobility. She further stated she now understood she should have use two (2) people and followed the resident's care plan. Interview with the Unit Manager, on 09/17/2020 at 09:26 AM, revealed she was the manager on Resident #36's unit. She stated staff should look at the resident's Kardex or care plan to ensure proper transfers. She further stated a resident's care could change frequently, therefore it was very important to know what kind of care needs were to be provided. She stated there should be two (2) people at all times for Hoyer transfers. Furthermore, the Unit Manager stated Resident #36 was care planned for two (2) person bed mobility and transfers, and she expected staff to follow the care plan. Interview with the Assistant Director of Nursing (ADON), on 09/17/2020 at 11:21 AM, revealed she expected staff to implement interventions for residents per their care plans. Per interview, she stated following the care plans was important and allowed for the best care possible for each resident. Interview with the Director of Nursing (DON), on 09/17/2020 at 5:00 PM, revealed she expected care plans to be implemented and followed for the best possible care to be provided for each resident. Interview with the Administrator, on 09/17/2020 at 6:00 PM, revealed she expected care plans to be implemented. Per interview, she stated it took two (2) people for all Hoyer transfers. She stated the SRNA should have followed the care plan for bed mobility as well as two (2) persons used for Hoyer transfers. 3. Review of Resident #42's medical record revealed the facility admitted the resident, on 06/30/2019, with [DIAGNOSES REDACTED]. Continued review revealed a physician's orders [REDACTED].\agitation. Continued review of Resident #42's medical record revealed a Comprehensive Resident Assessment Note, dated 09/17/2020 at 1:15 PM, by LPN #6 that stated she spoke with the Physician about reviewing the order for [MEDICATION NAME] sprinkles. The note revealed the Physician continued the [MEDICATION NAME] PRN order without changes and stated it would be reviewed again in fourteen (14) days. The call, on 09/17/2020, to the Physician from LPN #6 was made three (3) days past the fourteen (14) day stop date, of 09/14/2020, for review of the PRN [MEDICATION NAME]. Continued review of Resident #42's medical record revealed Health Status Progress Notes documented, from 08/31/2020 through 09/17/2020, the PRN medication [MEDICATION NAME] sprinkles doses were given to Resident #42 for behaviors of paranoia and agitation. Review of the Electronic Medication Administration Record [REDACTED]. Review of the CCP, dated 07/12/2019, revealed a focus of risk for adverse reactions related to polypharmacy. The CCP goal was the resident would be free of adverse drug reactions through the review date, with a target date of 09/27/2020. Additional review of CCP interventions were to review the resident's medications with the Physician/Consulting Pharmacist for duplicate medications or prescription; for proper dosing, timing and frequency of administration; for adverse reactions; and for a supporting diagnosis. The CCP stated the Physician was to review PRN medications every fourteen (14) days. Interview with LPN #6, on 09/17/2020 at 3:45 PM, revealed Resident #42 was receiving PRN [MEDICATION NAME] sprinkles for behaviors. She stated PRN medications were reviewed within fourteen (14) days, and if the Physician had not prescribed the date for review, the nurse would notify the Physician of the required fourteen (14) day review. Per interview, the [MEDICATION NAME] sprinkles were ordered on [DATE] and did not specify fourteen (14) days for review. LPN #6 stated, on 09/17/2020, she notified the Physician the [MEDICATION NAME] sprinkles needed review for Resident #42. LPN #6 stated she did not follow the care plan fourteen (14) day requirement to notify the Physician to review the PRN medication. Interview with the DON, on 09/17/2020 at 4:30 PM, revealed PRN medications have a fourteen day (14) review date. She stated the [MEDICATION NAME] sprinkles did not have a specified review date; however, the Nurse should notify the Physician when PRN medications needed to be reviewed, within the fourteen (14) days. The DON stated she expected staff to follow the care plan and to notify the Physician of PRN medications needing to be reviewed. Interview with the Administrator, on 09/17/2020 at 5:00 PM, revealed PRN medications were required to be reviewed every fourteen (14) days. She stated if the Physician did not order the stop date for fourteen (14) days, the nurse could contact him/her to review the PRN medication within the required fourteen (14) days. The Administrator stated she expected staff to follow the care plan pertaining to notification of the Physician concerning PRN medications. 4. Review of Resident #21's medical record revealed the facility admitted the resident, on 10/13/2017, with [DIAGNOSES REDACTED]. Review of Resident #21's Comprehensive Care Plan revealed a focus, initiated on 10/25/2017, of the resident was at risk for alteration to nutritional status related to [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Vitamin D Deficiency, Dementia, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], Tremors, and reported allergy to Ensure. The goal, target date 10/04/2020, stated Resident #21 would be free of changes to nutritional status as evidenced by remaining free of significant weight change, complaints of hunger, or signs and symptoms of dehydration. Interventions, all initiated on 10/25/2017, included a No Added Salt (NAS) diet, medications administered as ordered and monitored/documented for side effects and effectiveness; resident monitored for signs and symptoms of dehydration; obtain and honor food preferences; obtain and monitor lab/diagnostic work as ordered; provide and serve diet as ordered; monitor intake and record every meal; Registered Dietician to evaluate and make recommendations as needed; weigh monthly and as needed at the same time of the day and record; notify Physician and responsible party of any significant weight changes; avoid foods which could cause gastrointestinal upset and monitor for signs and symptoms of upset; evaluation by Occupational Therapy for adaptive equipment for feeding as needed; and provide assistance with meals as needed and allowed by resident. Review of Resident #21's weights revealed, on 07/08/2020, the resident weighed 109.8 pounds. On 08/07/2020, the resident was weighed to be 99.8 pounds. This weight reflected a loss of 10.0 pounds and a 9.11 percent weight loss in one (1) month. Review of Resident #21's medical record revealed no documented evidence the resident was immediately re-weighed per policy, nor was the resident's Power of Attorney (POA) or the Physician notified of the resident's weight loss. Interview with the Unit Manager for Unit Two, on 09/17/2020 at 3:40 PM, revealed she expected staff to follow the facility's care plan because it was the basis for resident interventions. She stated a focus of Resident #21's care plan was nutritional status, and his/her weight was to be taken monthly and as needed with proper notifications if there was a significant change. She stated staff did not follow the care plan when the resident had a ten (10) pound weight loss in one (1) month. Interview with the Director of Nursing (DON), on 09/17/2020 at 4:39 PM, revealed she expected staff to follow the resident's care plan and policy. She stated Resident #21 should have been re-weighed with the significant weight loss, and when he/she was not, staff was not following the resident's care plan. Interview with the Administrator, on 09/17/2020 at 5:23 PM, revealed she expected staff to follow the resident's care plan because it was important to guide staff in providing quality care to residents. She stated the resident should have been re-weighed, per the care plan, with the significant weight loss and closely monitored.

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team (IDT) composed of individuals who had knowledge of the resident and his/her needs for one (1) of twenty-two (22) residents, (Resident #9). Review of Resident #9's Comprehensive Care Plan revealed no documented evidence of revision to reflect Resident #9's fall event on 09/01/2020 or interventions status [REDACTED]. The findings include: Review of the facility's policy, Comprehensive Care Plans, dated 10/31/2019, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. Additional review revealed the CCP was prepared by an interdisciplinary team of health care professionals and would be developed to identify which discipline(s) would be responsible to carry out approaches and interventions for residents. Review of the facility's policy, Nursing Assistant Care Plan, dated 10/31/2019, revealed each resident would have a Kardex which would consist of specific information required to meet their individual needs. The Kardex was an essential tool to be used for communicating information from the Nursing Care Plan to the Nursing Assistants and other staff. Further review revealed information from the Kardex was used to set up the task in the Point of Care (POC) which was where staff would document care given to each resident as soon as it was provided. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the CCP must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written CCP. Continued review revealed the CCP was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a CCP based on a thorough assessment and effective clinical decision making was compatible with current standards of clinical practice, which provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Further review revealed, a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized CCP as appropriate and necessary. Review of Resident #9's medical record revealed the resident was admitted to the facility, on 07/27/2018, with [DIAGNOSES REDACTED]. Review of Resident #9's Fall Risk Assessment, dated 04/17/2020, revealed the resident scored a twenty (20), indicating the resident was at high risk for falls. Review of Resident #9's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have short and long-term memory problems related to severe cognitive impairment. Per assessment, the resident required extensive assistance of two (2) staff with bed mobility and total assistance of two (2) staff with transfers between surfaces. Additional assessment revealed the resident had no history of falls since the prior assessment. Continued review revealed the resident was seventy-two (72) inches tall and weighed two hundred thirty-eight (238) pounds. Further, the resident received Occupational Therapy, which ended on 05/04/2020. Review of Resident #9's Fall Incident Report, dated 09/01/2020, revealed two (2) aides were transferring the resident from his/her wheelchair to the bed, in the resident's room, when the mechanical lift equipment malfunctioned causing the resident to rest on the floor on his/her back across the mechanical lift's legs. Per report, Resident #9 obtained a small skin tear to his/her right outer arm and red blanchable areas to his/her back. Continued review revealed the Medical Director and the resident's family were notified. Further, the report stated the CCP was reviewed and was appropriate at that time. Additional review of Resident #9's Fall Incident Report, dated 09/01/2020, revealed while SRNA #8 and SRNA #9 were transferring the resident from his/her chair to the bed, the lift pad strap ripped, and the resident fell to the floor. Further review of Resident #9's Fall Incident Report, dated 09/01/2020, revealed immediate action taken was a new lift pad was obtained and placed under the resident after assessment, and the resident was transferred, per five (5) staff members back to bed with a mechanical lift. Review of physician's orders [REDACTED]. In addition the order stated to replace the pad and forward the old pad to the DON, with a start date of 09/01/2020. However, the CCP was not revised status [REDACTED]. Review of Resident #9's CCP, revealed the resident was at risk for falls related to cognitive impairment from dementia, impaired safety awareness, and use of [MEDICAL CONDITION] medications. The goal was for the resident to remain free of falls. The CCP interventions included to anticipate needs; encourage the resident to be in the common area when up; and use the Hoyer lift with the assistance of two (2) persons. However, there was no documented evidence the CCP was revised to include the fall event, on 09/01/2020, or interventions from the Fall Incident Report to prevent falls of the same nature from re-occurring. Interview with SRNA #4, on 09/17/2020 at 2:25 PM, revealed she had worked at the facility for two (2) years and usually worked on the first floor. Additionally, she used the CCP and the Kardex to know how to care for each resident. Further, she stated it was important to have an accurate care plan that was revised to meet the resident's needs and safety requirements. Interview with Licensed Practical Nurse (LPN) #4, Unit Manager for the first floor, on 09/17/2020 at 9:30 AM, revealed she had worked at the facility for five (5) years. Additionally, she stated direct care nurses were responsible to revise the care plan with immediate interventions status [REDACTED]. Further, Resident #9's care plan should have been revised to include interventions after the fall on 09/01/2020. Interview with the Assistant Director of Nursing (ADON), on 09/17/2020 at 11:21 AM, revealed she had worked at the facility for thirteen (13) years. Per interview, the CCP should be revised appropriately as needed with any incident because the CCP was how information was communicated to staff to care for the residents. Additional interview revealed the SRNAs used the Kardex, which was populated from the CCP as a guide on how to provide care to meet the resident's needs. Continued interview revealed the CCP was expected to be revised with fall events, which would allow staff to know the history of the resident and what interventions had previously worked. She stated this would provide the best care to the resident. Further, the DON stated the CCP should be revised status [REDACTED]. Interview with the Director of Nursing (DON), on 09/17/2020 at 5:00 PM, revealed she had worked at the facility since six (6) months. Additionally, she expected the CCP to be revised with intervention(s) for every fall event. Further, all nurses were responsible to ensure the care plan was revised after a fall to ensure appropriate interventions were communicated to all staff to provide the best care to the residents. Interview with the Administrator, on 09/17/2020 at 6:00 PM, revealed she had worked at the facility for thirteen (13) years. Per interview, she expected the CCP to be revised immediately after a fall event to decrease the risk for re-occurrence of an additional fall. Further, the Administrator stated it was important to revise the CCP to ensure safe care for residents with optimal outcomes achieved.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for three (3) of twenty-two (22) sampled residents (Resident #9, Resident #28, and Resident #36). Resident #9 was being transferred from the wheelchair to the bed with a mechanical lift, on 09/01/2020, when it malfunctioned, causing the resident to to rest on the floor across the lift's legs. Resident #9 sustained a small skin tear to his/her right outer arm. Resident #28 was being transferred from the bed to the wheelchair with a mechanical lift, on 09/13/2020. Resident #28 lifted himself/herself forward in the lift and sustained a laceration to his/her right eyebrow, on 09/13/2020. Resident #36 was being rolled in bed, on 05/08/2020, when he/she rolled onto the floor suffering a red area to the forehead. In addition, Resident #36 sustained an abrasion to the right knee, on 10/13/2019, because of improper use of the mechanical lift used for transfers. The findings include: Review of the facility's Policy titled, Falls Advisory Opinion and Process, revised 11/1/2019, revealed all residents were to receive adequate supervision, assistance, and assistive devices to prevent injury. 1. Review of Resident #36's medical record revealed the facility admitted the resident, on 02/26/2015, and readmitted the resident, on 07/29/2020, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/29/2020, revealed the facility assessed Resident #36 as requiring a two (2) person assist for bed mobility and transfers. Review of the Incident/Condition Report, dated 05/08/2020, revealed State Registered Nurse Aide (SRNA) #7 was rolling Resident #36 in bed to position a Hoyer lift pad, and the resident's left leg started to go over the right side of bed. Further review revealed SRNA #7 went to the resident and was able to lower him/her to the floor. As the resident was lying on his/her side, a reddened area was noted to the forehead. Review of the Incident/Condition Report, dated 10/13/2019, revealed the Wound Nurse went in to perform Resident 36's treatment to the right hip and observed an abrasion on the resident's right knee. The report stated the abrasion was caused from the handle on the Hoyer (mechanical lift) lift. The lift was checked for jagged or sharp edges; none were noted. Further review revealed staff were educated on positioning of the handle on the lift to prevent the resident from scraping it when using the lift. Interview with Licensed Practical Nurse Unit Manager (LPN #4), on 09/17/2020 at 9:26 AM, revealed she was assigned to Resident #36. She stated when SRNA #7 was providing bed mobility and preparing the resident for a Hoyer lift transfer for a shower, the SRNA should have had two (2) staff for turning and lifting. She stated it was the facility's policy, and it was her expectation. She stated had the SRNA followed the policy the fall could have been avoided. Per interview, the staff had training for use of the Hoyer lift upon hire, and if there was a specific incident, they would receive additional training. Furthermore, she stated the incident that happened, on 10/13/2019, could also have been avoided had staff used the Hoyer lift appropriately. Telephone interview with SRNA #7, on 09/27/2020 at 2:43 PM, revealed she had worked at the facility for six (6) years and was assigned to Resident #36 on any shift she worked. She stated she was unaware at the time that she was supposed to have two (2) people for bed mobility and placing the Hoyer pad under the resident. However, she was now' aware and received a verbal warning from her Unit Manager. SRNA #7 stated the fall, on 05/08/2020, could have been avoided had she followed policy. Per interview, she stated she received Hoyer lift training upon hire and annually. Interview with the Assistant Director of Nursing (ADON), on 09/17/2020 at 11:21 AM, revealed she had worked at the facility for fifteen (15) years. She stated she expected staff to follow the policies related to Hoyer placement and the assist of two (2) staff for all Hoyer transfers. She further stated anytime there was an incident re-education was provided. Interview with the Director of Nursing (DON), on 09/17/2020 at 5:00 PM, revealed improper placement of the Hoyer lift handle was responsible for the incident on 10/13/2019; for the incident on 05/08/2020, the aide should have had two (2) people assisting with care for Resident #36. The DON stated she expected staff to follow policies, and by following policies, those incidents would probably have been avoided. Interview with the Administrator, on 09/17/2020 at 6:00 PM, revealed she had worked at the facility for thirteen (13) years. She stated she expected staff to follow policies related to falls and injuries. She stated the facility took formal disciplinary action for staff who did not follow policies. Furthermore, she stated proper placement of the Hoyer lift with a two-person assist was a requirement, and re-education had been provided since those incidents occurred. 2. Review of Mechanical Lift Competency Check Off, revealed during a transfer from bed to wheelchair there were to be two (2) staff present, one (1) staff will operate the lift while the other guides the resident's legs. Review of Resident #28's medical record revealed the facility admitted the resident on 10/19/2017, with [DIAGNOSES REDACTED]. Review of Resident #28's Comprehensive Care Plan revealed a focus of resident had a self-care deficit as evidenced by Dementia, required extensive assistance with majority of all activities of daily living, with an initiation date of 10/24/2017. The goal stated the resident will continue to participate in activities of daily living as able through the review date of 10/04/2020. Interventions include: administer medications as ordered; allow resident time to complete tasks; bed against wall per preference; bilateral side rails in use to increase independence with bed mobility; encourage participation in activities of daily living; encourage resident to cross arms prior to lifting in Hoyer; extensive assistance of one (1) staff with dressing; extensive assistance of 2 staff with toileting; extensive assistance of two (2) with bed mobility; observe for decline in ADL function or range of motion and notify medical doctor if noted; and totally dependent of two (2) staff with Hoyer for all transfers- use large Hoyer pad and one (1) staff member to have hands on resident at all times during transfer, initiated 9/14/2020. Review of Resident #28's Progress Notes revealed, on 09/13/2020 at 7:15 AM, SRNA's were getting the resident up for breakfast. There were two (2) SRNA's in the resident's room to use the mechanical lift to get the resident in his/her wheelchair. While the resident was in the mechanical lift with the two (2) SRNA's present, the resident moved forward hitting the area above his/her right eye, causing a very small abrasion. Resident #28 stated ouch, that was my head, and the Nurse assessed the resident for any injuries. Per note, there was a very small abrasion above his/her right eye with no swelling, and the area was cleansed with wound wash. Further review revealed neurological checks and vital signs were stable. Review of the facility's Comprehensive Resident Assessment Note, on 09/14/2020 at 8:15 AM, revealed the Nurse on duty reported when the SRNA's were getting the resident up in his/her wheelchair for breakfast and lowering the Hoyer, he/she leaned forward hitting his/her right brow on the Hoyer, causing a small abrasion below the brow. Per note, the Nurse on duty assessed the resident and the vital signs were stable at the time and neurological checks were initiated. Neurological checks were stable also, area was cleansed and left open to air. The care plan was updated for one SRNA to have hands on the resident at all times when transferring with the Hoyer. Wound nurse was notified of area. Continued review of the progress notes revealed a note on 09/16/2020 at 7:14 PM which stated resident had an abrasion on right side of head below brow. Upon assessment resident had a 0.2 cm (centimeter) x 0.2 cm x less than 0.1 cm abrasion on his/her head below the brow. No signs or symptoms of infection. Resident had no pain related to abrasion during assessment. Interview with the Administrator, on 09/17/2020 at 5:19 PM, revealed in their morning meeting they felt Resident #28's skin tear was a result of him/her lifting himself/herself up in the Hoyer pad. She stated that now one staff would have their hands on the resident while the other operated the Hoyer, this way to prevent the resident from hitting his/her head again. She stated this was their normal process; however, the resident still hit his/her head on the lift and caused a skin tear. 3. Review of Resident #9's medical record revealed the resident was admitted to the facility, on 07/27/2018, with [DIAGNOSES REDACTED]. Review of Resident #9's Fall Risk Assessment, dated 04/17/2020, revealed the resident scored a twenty (20), indicating the resident was at high risk for falls. Review of Resident #9's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have short and long-term memory problems related to severe cognitive impairment. Per assessment, the resident required extensive assistance of two (2) staff with bed mobility and total assistance of two (2) staff with transfers between surfaces. Additional assessment revealed the resident had no history of falls since the prior assessment. Continued review revealed the resident was seventy-two (72) inches tall and weighed two hundred thirty-eight (238) pounds. Further, the resident received Occupational Therapy which ended on 05/04/2020. Review of Resident #9's Fall Incident Report, dated 09/01/2020, revealed two (2) aides were transferring the resident from his/her wheelchair to bed, in the resident's room when the mechanical lift equipment malfunctioned causing the resident to rest on the floor on his/her back across the mechanical lift's legs. Per report, Resident #9 obtained a small skin tear to his/her right outer arm and red blanchable areas to his/her back. Continued review revealed the Medical Director and the resident's family was notified. Further, the Plan of Care was reviewed and was appropriate at that time. Additional review of Resident #9's Fall Incident Report, dated 09/01/2020, revealed while SRNA #8 and SRNA #9 were transferring the resident from his/her chair to bed, the lift pad strap ripped, and the resident fell to the floor. Further review of Resident #9's Fall Incident Report, dated 09/01/2020, revealed immediate action was taken and a new lift pad was obtained and placed under the resident after assessment, and the resident was transferred, per five (5) staff members, back to bed with a mechanical lift. Review of physician's orders [REDACTED]. Further, there was an order to inspect Hoyer pads each shift to ensure appropriate function and integrity of the pad for holes, tears, or any concerns noted; replace pad and forward old pad to the DON, with a start date of 09/01/2020. However, the Comprehensive Care Plan was not revised status [REDACTED]. (See F657) Review of Resident #9's Progress Note, dated 09/01/2020 at 6:34 PM, written by the ADON, revealed aides were transferring the resident from chair to bed and when raised in the air, the mechanical lift equipment malfunctioned causing the resident to rest on the floor. The note stated the resident obtained a skin tear to his/her right outer arm, which required first aid and an ordered treatment. Per note, the resident was transferred to bed with five (5) staff and a Hoyer lift. Further, the Plan of Care was reviewed and was appropriate at this time. Review of Resident #9's Progress Note, dated 09/04/2020 at 12:50 PM, written by the DON, revealed while two (2) SRNA's were transferring the resident from his/her wheelchair, the lift equipment malfunctioned. Per note, the resident rested on the floor, on his/her back across the mechanical lift legs causing a small skin tear to the right outer arm and red blanchable areas to the back. Further review revealed a new Hoyer pad was obtained and placed under the resident after assessment, and the resident was transferred by five (5) staff to bed with the Hoyer lift. Review of the Hoyer Lift Maintenance Schedule, revealed the Hoyer lift was checked, on 08/26/2020, with no discrepancies noted. Additional review revealed the Hoyer lift was not checked again until 09/09/2020, eight (8) days after the noted mechanical lift malfunction. Continued review revealed the lift inspection did not include assessing the Hoyer lift pads. Further, there was no documented evidence all lift pads in the facility were assessed, on or after 09/01/2020, to ensure adequate integrity and safety. Interview with LPN #4, Unit Manager for first floor, on 09/17/2020 at 9:30 AM, revealed she had worked at the facility for five (5) years. Per interview, direct care nurses were responsible to determine the root cause of fall events at the time of the fall. Additionally, it was important to do a thorough post-fall assessment including the environment, any equipment or device in use, and the overall health status of the resident to establish the root cause for each fall. Further, she stated the root cause was important because it was used to determine what interventions should be implemented to reduce the risk for falls of the same nature again and injury. Further, she stated any equipment used during a fall should be assessed to ensure proper functioning. Interview with the ADON, on 09/17/2020 at 11:21 AM, revealed she had worked at the facility for thirteen (13) years. Per interview, after Resident #9's fall, on 09/01/2020, the interdisciplinary team (IDT) including the Administrator, DON, Unit Manager, Quality Assurance Nurse, Minimum Data Set Nurse, and Social Worker, reviewed the fall event and determined the Hoyer lift pad was the malfunction of the lift equipment; however, she was not aware of what specific malfunction occurred with the pad. Per interview, there should have been documentation in the Progress Notes, after the IDT meeting, stating the specific malfunction/root cause of the fall event and actions moving forward to reduce the risk for further falls of the same nature. Further interview revealed the pad was replaced immediately at the time of the malfunction, and an order was developed after IDT review, for all residents using Hoyer lift pads. She stated the order required nursing staff to assess the pads each shift and prior to use; however, she was not aware if the facility assessed all Hoyer lifts, on or after 09/01/2020. Interview with the DON, on 09/17/2020 at 5:00 PM, revealed she had worked at the facility for six (6) months. Per interview, she expected the root cause for every fall to be determined to prevent another fall of the same nature from re-occurring. Additionally, she expected the direct care nurse to attempt to determine the root cause for each fall. Continued interview revealed the IDT met daily and reviewed fall events and the root cause for each fall to ensure a thorough assessment was completed and intervention was implemented to keep residents safe. Further, she stated the specific lift pad malfunction for Resident #9 should have been documented in the Progress Notes and the Fall Incident Report, and all lift pads should have been assessed for proper functioning. Interview with the Administrator, on 09/17/2020 at 6:00 PM, revealed she had worked at the facility for thirteen (13) years. Per interview, she expected the root cause to be determined for all fall events, specific to the fall event and individual resident. Additionally, she stated establishing the root cause was important to prevent future occurrences and keep the residents safe. Continued interview revealed Resident #9's Hoyer pad ripped on 09/01/2020 causing the resident's fall. Further, she stated staff should have been educated after 09/01/2020 related to checking the integrity of pads before use.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident's nutritional status was maintained for one (1) of twenty-two (22) sampled residents (Resident #21). Resident #21 experienced a ten (10) pound weigh loss from 07/08/2020 to 08/07/2020; however, there was no documented evidence the resident was immediately re-weighed per policy. The findings include: Review of the facility's policy titled, Weight Change: Loss/Gain, revision date 02/07/2020, revealed the policy was to ensure that each resident's body weight was maintained within measurable parameters, unless the resident's clinical condition demonstrated it was not possible. Continued review revealed if there was a five (5) pound or more difference from the previous weight, another weight must be taken and recorded within twenty-four (24) hours. Review of Resident #21's medical record revealed the facility admitted the resident, on 10/13/2017, with [DIAGNOSES REDACTED]. Review of Resident #21's Comprehensive Care Plan revealed a focus, initiated on 10/25/2017, of the resident was at risk for alteration to nutritional status related to [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Vitamin D Deficiency, Dementia, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], Tremors, and reported allergy to Ensure. The goal, target date 10/04/2020, stated Resident #21 would be free of changes to nutritional status as evidenced by remaining free of significant weight change, complaints of hunger, or signs and symptoms of dehydration. Interventions, all initiated on 10/25/2017, included a No Added Salt (NAS) diet, medications administered as ordered and monitored/documented for side effects and effectiveness; resident monitored for signs and symptoms of dehydration; obtain and honor food preferences; obtain and monitor lab/diagnostic work as ordered; provide and serve diet as ordered; monitor intake and record every meal; Registered Dietician to evaluate and make recommendations as needed; weigh monthly and as needed at the same time of the day and record; notify Physician and responsible party of any significant weight changes; avoid foods which could cause gastrointestinal upset and monitor for signs and symptoms of upset; evaluation by Occupational Therapy for adaptive equipment for feeding as needed; and provide assistance with meals as needed and allowed by resident. Review of Resident #21's weights revealed, on 07/08/2020, the resident was weighed to be 109.8 pounds. On 08/07/2020, the resident was weighed to be 99.8 pounds. This was a loss of 10.0 pounds and a 9.11 percent weight loss in one (1) month. Review of Resident #21's medical record revealed no documented evidence the resident was immediately re-weighed per policy. Interview with the Unit Manager for Unit Two, on 09/17/2020 at 3:40 PM, revealed she expected staff to follow the facility's policy regarding any changes in weight. However, she agreed staff did not follow policy with re-weighing the resident. Interview with the Director of Nursing (DON), on 09/17/2020 at 4:39 PM, revealed she expected staff to follow policy, and the resident should have been re-weighed with close monitoring of his/her weights. Interview with the Administrator, on 09/17/2020 at 5:23 PM, revealed she expected staff to follow policy regarding a weight loss or gain and should have re-weighed the resident and done monitoring as required to maintain Resident #21's body weight and nutritional status.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure irregularities reported to the facility by the Pharmacy Consultant were acted upon. The Attending Physician failed to document in the resident's medical record that the identified irregularities has been reviewed and what, if any, action had been taken to address it for one (1) of eighteen (22) sampled residents (Residents #34). The findings include: Review of the facility's policy titled, Medication Monitoring and Management, revised 11/17/2017, revealed the policy set forth procedures relating to [MEDICAL CONDITION] medication use. Continued review revealed the facility should comply with the Psycholopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS) and the State Operations Manual. As needed (PRN) [MEDICAL CONDITION] medications (drugs that affect a person's mental state and given to treat a variety of mental health issues) should be ordered for no more than fourteen (14) days. Further review revealed each resident who was taking a PRN [MEDICAL CONDITION] drug would have his/her prescription reviewed by the Physician or prescribing practitioner every fourteen (14) days. Review of Resident # 34's medical record revealed the facility admitted the resident on 08/21/2017, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], review of Section E - Behaviors, revealed the resident did not exhibit any behaviors during the look back period. Review of the Comprehensive Care Plan revealed a focus of the resident used anti-anxiety medications related to Anxiety Disorder and was also taking an antidepressant with a revision date of 11/13/2017. The goal stated the resident would be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date of 11/18/2020. Interventions include: Attempt non-pharmacological interventions such as redirection, reassurance, distraction, music, offer toileting, offer snacks, etc., prior to giving PRN medications, initiated 08/31/2017; consult medical doctor for possible gradual dose reduction as needed, initiated 08/31/2017; educate resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-anxiety medication drugs being given, initiated 08/31/2017; follow up with Psychiatry and Psychology as ordered/needed, initiated 09/06/2019; give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations initiated 09/06/2016; and resident is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety, initiated 08/31/2017. Record review revealed Resident #34 had an active order for [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 mg (milligrams) by mouth every eight (8) hours as needed for anxiety with a start date of 07/16/2020 and an end date of 01/12/2021 There was no documented evidence of a rationale for the continued use of the as needed [MEDICAL CONDITION] medication. Review of Resident #34's Consultation Report dated for 06/28/2020 to 06/30/2020 revealed the Consulting Pharmacist documented the resident used this medication sporadically and to reconsider an extended stop date of one hundred eighty (180) days. Interview with the Pharmacy Consultant on 09/17/2020 at 9:02 AM revealed as the facility's consultant she reviewed resident's records monthly for any irregularities. With any irregularities noted, she would report them to the Director of Nursing. Interview with the Director of Nursing on 09/17/2020 at 4:34 PM, revealed the Pharmacy Consultant gave her the recommendations and then she distributed them to the units and contacted the physician regarding the recommendations or faxed them to the physician. She stated then the physician contacted the Unit Managers to relay any changes they wanted to make. She stated the [MEDICATION NAME] was not a new medications and therefore did not need to be re-evaluated for continuation as an as needed medication, as the physician extended the medication for fourteen days. However she stated there should be a rational for the continuation in the resident's medical record. Interview with the Administrator on 09/17/2020 revealed the facility should be following the regulations and policy regarding as needed [MEDICAL CONDITION] medications. She stated the physician's orders [REDACTED]. Additionally, she stated there should be a rational as to why the medication is extended for one hundred eighty (180) days and it should be documented in his/her medication record.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure PRN (as needed) orders for [MEDICAL CONDITION] drugs were limited to fourteen (14) days, except when extended by the physician or prescribing practitioner beyond fourteen (14) days with documented rationale in the resident's medical record for one (1) out of twenty-two (22) sampled residents (Resident #34). Resident #34 had an active order for [MEDICATION NAME] 0.5mg by mouth every eight (8) hours as needed with a start date of 07/16/2020 and an end date of 01/12/2021 with no rational provided regarding the extension of one hundred eighty (180) days. The findings include: Review of the facility's policy titled Medication Monitoring and Management, revised 11/17/2017, revealed the policy sets forth procedures related to [MEDICAL CONDITION] medication use. Continued review revealed the facility should comply with the Psycholopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services and the State Operations Manual (SOM). Per the SOM, PRN (as needed) orders for [MEDICAL CONDITION] medications are limited to fourteen (14) days. If the Physician believes it is appropriate for the PRN order to extend beyond fourteen (14) days, he or she should document the rational in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to fourteen (14) days and cannot be renewed unless the Physician evaluates the resident for appropriateness of that medication. Review of Resident #34's medical record revealed the facility admitted the resident on 08/21/2017 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE], review of Section E - Behaviors revealed, the resident did not exhibit any behaviors during the look back period. Review of the Comprehensive Care Plan revealed a focus of the resident uses anti-anxiety medications related to Anxiety Disorder and was also taking an antidepressant with a revision date of 11/13/2017. The goal stated resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date of 11/18/2020. Interventions include: Attempt non-pharmacological interventions such as redirection, reassurance, distraction, music, offer toileting, offer snacks, etc. prior to giving PRN medications, initiated 08/31/2017; consult Physician for possible GDR (gradual dose reduction) PRN, initiated 08/31/2017; educate resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-anxiety medication drugs being given, initiated 08/31/2017; follow up with Psychiatry and Psychology as ordered/needed, initiated 09/06/2019; give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. PARADOXICAL SIDE EFFECTS: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations initiated 09/06/2016; and resident is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor for safety, initiated 08/31/2017. Record review revealed Resident #34 had an active order for [MEDICATION NAME] ([MEDICATION NAME]) tablet 0.5 milligrams (mg) by mouth every eight (8) hours as needed for anxiety with a start date of 07/16/2020 and an end date of 01/12/2021. There was no documented evidence of a rational for the continued use of the as needed [MEDICAL CONDITION] medication. Review of Resident #34's Electronic Medication Administration Record [REDACTED]. In September 2020 the resident received [MEDICATION NAME] three (3) times. However, review of Resident #34's medical record revealed no documented evidence the Physician provided a rational for the continuation of use for the as needed [MEDICATION NAME] for one hundred eighty (180) days. Interview with the Pharmacy Consultant on 09/17/2020 at 9:02 AM, revealed she reviewed the residents' records monthly for any irregularities. With any irregularities noted, she reported them to the Director of Nursing. She stated with [MEDICAL CONDITION] medications there needed to always be an indication for use by the Physican. With PRN [MEDICAL CONDITION] medications, there was to be a limit of fourteen (14) days; and, therefore they needed a stop date so the Physician could re-evaluate the need. Once they re-evaluated and determine the continued need, then they can extend the PRN for one hundred eighty (180) days, but they must provide a rationale as why the [MEDICAL CONDITION] PRN medication was needed to be extended for use. Interview on 09/17/2020 at 4:30 PM with Director of Nursing (DON), revealed PRN medications have a fourteen (14) day review date. Interview on 09/17/2020 at 5:00 PM with Administrator, revealed the PRN medications should be reviewed every fourteen (14) days. If the Physician did not order the stop date for fourteen (14) days, the nurse should contact the Physician to review the PRN medication within fourteen (14) days. 3. Review of Resident #42's medical record revealed the facility admitted the resident, on 06/30/2019, with [DIAGNOSES REDACTED]. Continued review revealed a physician's orders [REDACTED].\agitation. Continued review of Resident #42's medical record revealed a Comprehensive Resident Assessment Note, dated 09/17/2020 at 1:15 PM, by LPN #6 that stated she spoke with the Physician about reviewing the order for [MEDICATION NAME] sprinkles. The note revealed the Physician continued the [MEDICATION NAME] PRN order without changes and stated it would be reviewed again in fourteen (14) days. The call, on 09/17/2020, to the Physician from LPN #6 was made three (3) days past the fourteen (14) day stop date, of 09/14/2020, for review of the PRN [MEDICATION NAME]. Continued review of Resident #42's medical record revealed Health Status Progress Notes documented, from 08/31/2020 through 09/17/2020, the PRN medication [MEDICATION NAME] sprinkles doses were given to Resident #42 for behaviors of paranoia and agitation. Review of the Electronic Medication Administration Record [REDACTED]. Review of the CCP, dated 07/12/2019, revealed a focus of risk for adverse reactions related to polypharmacy. The CCP goal was the resident would be free of adverse drug reactions through the review date, with a target date of 09/27/2020. Additional review of CCP interventions were to review the resident's medications with the Physician/Consulting pharmacist for duplicate medications or prescription; for proper dosing, timing and frequency of administration; for adverse reactions; and for a supporting diagnosis. The CCP stated the Physician to review PRN medications every fourteen (14) days. Interview with LPN #6, on 09/17/2020 at 3:45 PM, revealed Resident #42 was receiving PRN [MEDICATION NAME] sprinkles for behaviors. She stated PRN medications were reviewed within fourteen (14) days, and if the Physician had not prescribed the date for review, the nurse would notify the Physician of the required fourteen (14) day review. Per interview, the [MEDICATION NAME] sprinkles were ordered on [DATE] and did not specify fourteen (14) days for review. LPN #6 stated, on 09/17/2020, she notified the Physician the [MEDICATION NAME] sprinkles needed review for Resident #42. Therefore, she stated she did not follow the care plan fourteen (14) day requirement to notify the Physician to review the PRN medication. Interview with the DON, on 09/17/2020 at 4:30 PM, revealed PRN medications have a fourteen (14) review date. She stated the [MEDICATION NAME] sprinkles did not have a specified review date; however, the Nurse should notify the Physician when PRN medications need review, within fourteen (14) days. The DON stated she expected staff to follow the care plan and to notify the Physician of PRN medications needing to be reviewed. Interview with the Administrator, on 09/17/2020 at 5:00 PM, revealed PRN medications were required to be reviewed every fourteen (14) days. She stated if the Physician did not order the stop date for fourteen (14) days, the nurse could contact him/her to review the PRN medication within the required fourteen (14) days. The Administrator stated she expected staff to follow the care plan pertaining to notification of the Physician concerning PRN medications.

Based on observation, interview, and record review, it was determined the facility failed to have an effective system to ensure medical records were complete and accurate for one (1) of twenty-two (22) sampled residents (Resident #8). The findings include: Interview with the facility's Administrator, on 09/17/2020 at 5:35 PM, revealed accuracy of medical records was a standard of practice, but the facility did not have a policy related to accuracy of medical records for staff to follow. Review of Resident #8's clinical record revealed the facility admitted the resident, on 04/22/2020, with [DIAGNOSES REDACTED]. Review of Resident #8's Progress Notes, dated 09/02/2020 at 3:17 PM, revealed the Physician was made aware of the resident's weight loss, poor appetite, increased confusion, and hazy urine. Further review revealed new orders were received for a urinalysis with culture if indicated. Review of Resident #8's Completed Orders, revealed an order with a start date of 09/02/2020, for a urinalysis with a stop date of 09/03/2020. Review of the laboratory report, with a date of specimen collected on 09/03/2020 and a reported date of 09/05/2020, documented Resident #8's urine was cloudy in clarity, positive for blood, positive for protein, positive for [MEDICATION NAME], and positive for leukocytes, indicating the need for a urine culture. Continued review revealed the results of the urine culture were positive for [MEDICAL CONDITIONS] (a bacterium that causes infections in different parts of the body). Review of Resident #8's Completed Orders, revealed an order with a start date of 09/06/2020 for Bactrim (an antibiotic) Tablet 400-80 milligrams (mg), give one tablet by mouth two (2) times a day for Urinary Tract Infection for seven (7) days, with an end date, of 09/13/2020. Review of Resident #8's Comprehensive Care Plan, revealed a focus, which stated resident had a Urinary Tract Infection [MEDICAL CONDITION], with an initiation date of 06/04/2020, and a revision date of 09/08/2020. The goal stated the resident's UTI would resolve without complications by the review date, with a target date of 10/04/2020. An intervention, initiated on 06/04/2020, was to maintain universal precautions when providing resident care. Observation of Resident #8's room, on 09/16/2020 at 10:49 AM, revealed a sign on the outside of the resident's door stating see nurse before entering, contact precautions, as well as a bin outside the door housing personal protective equipment (PPE). Interview with Licensed Practical Nurse (LPN) #7, on 09/16/2020 at 8:15 AM, revealed Resident #8 was placed in precautions related to an infection in his/her urine (MRSA). However, review of Resident #8's Physician orders [REDACTED]. Interview with the Director of Nursing (DON), on 09/17/2020 at 5:01 PM, revealed she expected medical records to be accurate. She stated Resident #8 was on contact precautions and should have an order for [REDACTED]. Interview with the facility's Administrator, on 09/17/2020 at 5:59 PM, revealed she expected resident records to be complete and accurate. She stated she knew Resident #8 was on contact precautions as he/she had signage and a PPE bin located outside the door for staff, indicating the contact precautions. She stated per policy, if a resident was on contact precautions, there should be a physician's orders [REDACTED]. She stated the importance was to ensure all staff was aware of the resident's care.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were able to examine the results of the most recent surveys of the facility by Federal or State surveyors, by posting in a place readily accessible to residents. Observation, during tour in the facility on 09/15/2020 through 09/17/2020, revealed the Annual Survey results binder was not easily accessible to residents. The findings include: Review of the facility's policy titled, Resident Rights, revised 11/01/2019, revealed the facility would inform the residents of his or her rights during the stay in the facility. Additionally, the residents had the right to information and communication. Per policy, the resident had the right to be informed of his or her rights and of rules and regulations governing resident conduct and responsibilities during his or her stay in the facility. Further, the resident had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any Plan of Correction (POC) in effect with respect to the facility. Observation, of the lobby during initial tour, on 09/15/2020, revealed no signage related to the location of the Annual Survey results binder, which was not readily accessible to residents. Additional observation revealed the Annual Survey results binder was located in the right wing of the lobby, behind a table and desk, on the top shelf of a bookcase. Further observations, on 09/16/2020 and 09/17/2020, revealed the Annual Survey results binder remained on the top shelf of the bookcase. Interview with Licensed Practical Nurse (LPN) #4, Unit Manager for the first floor, on 09/17/2020 at 9:30 AM, revealed she had worked at the facility for five (5) years. Additionally, she stated she expected all residents to be afforded their rights as a resident at all times. Per interview, residents had the right to be informed of survey results. Further, she stated the survey results should be readily accessible to residents, to ensure they were informed of what was going on in the facility. Interview with the Assistant Director of Nursing (ADON), on 09/17/2020 at 11:21 AM, revealed she had worked at the facility for thirteen (13) years. Per interview, it was a resident's right to know the survey results and have results readily available to them. The ADON stated the Annual Survey results binder was usually located on a table in the front lobby; however, the table was moved to be used for COVID-19 screenings, and the binder was moved to the bookcase behind the desk. Further, she stated she felt the binder's location on the top shelf of the bookcase was readily accessible to residents because staff would assist them with getting the binder at their request. Interview with the Director of Nursing (DON), on 09/17/2020 at 5:00 PM, revealed she had worked at the facility for six (6) months. She stated she expected survey results to be readily available to all residents at all times. Further, it was the facility's responsibility to honor Resident Rights, and residents should be able to easily access the survey results binder independently at anytime. Interview with the Administrator, on 09/17/2020 at 6:00 PM, revealed she had worked at the facility for thirteen (13) years. Per interview, she expected the Annual Survey results binder to be readily available at all times to all residents. Additional interview revealed residents in wheelchairs would not be able to reach the survey binder independently without staff assistance. The Administrator stated it was an important right for the residents to be informed of survey results and the facility's POC.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure food safety was maintained. Record review revealed no documented evidence temperatures were obtained and recorded on the Temperature Logs for the nourishment room refrigerator/freezer and the resident room refrigerators on 01/16/19 and 01/17/19. The findings include: Review of the facility's policy titled Refrigerators, dated (YEAR), revealed the facility was to ensure safe and sanitary use of refrigerators. Continued review revealed staff shall record refrigerator temperatures nightly on a temperature log. Further review of the policy revealed if temperatures are out of range, nursing staff shall notify the maintenance department, discard any foods that require refrigeration, and take measures to remedy the problem. Review of Unit #2's nourishment room refrigerator Temperature Log sheet revealed there was no documented evidence temperatures were recorded for 01/16/19 and 01/17/19. Review of the Temperature Log sheet for resident rooms revealed temperatures were not recorded for the resident refrigerators for rooms 212-2, 216-1 and 220 on 01/16/19 and 01/17/19. Interview with Registered Nurse (RN) #1/Unit 2 Manager, on 01/23/19 at 10:56 AM, revealed the night shift nurses were responsible for obtaining nourishment room refrigerator/freezer temperatures and resident room refrigerator temperatures, and documenting the temperatures on the Temperature Log. Interview with the Director of Nursing (DON), on 01/23/19 at 3:11 PM, revealed the night shift nurses were responsible to record the nourishment room refrigerators/freezers and resident refrigerators nightly. Per interview, if the refrigerator and freezer temperatures were not checked there could be spoilage of food, and possible food poisoning. Continued interview revealed it was her expectation that staff would obtain the temperatures nightly and document the temperature on the temperature log per the facility's policy. Interview with the Administrator, at 01/23/19 at 3:28 PM, revealed the night shift nursing team was to check refrigerators/freezers in the nourishment room and in resident rooms and document the temperatures nightly. Per interview, it was important to check the temperatures on a consistent basis to ensure food safety. Continued interview revealed it was his expectation that staff follow the facility's policy to obtain and document the refrigerator temperatures nightly.

Based on observation, interview, record review and review of the facility's Policies, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two (2) of twenty-five (25) sampled residents (Resident #19 and #287). Observation of pericare and Foley catheter (FC) on 01/22/19, for Resident #287, revealed staff used poor infection control technique related to pericare/FC care, handwashing and glove usage prior to, during, and after care provided. In addition, observation of medication pass on 01/22/19, revealed the nurse touched Resident #19's medications with her bare hands and then administered the medication to the resident. The findings include: 1. Review of the facility's Policy, titled, Hand Washing, dated 01/16/14, revised 11/13/18, revealed the facility considered hand washing the single most important procedure for preventing nosocomial infections. Review of the facility's Policy, titled, Foley Catheter Care, dated 05/23/07, revised 11/13/18, revealed residents would be provided Foley catheter (FC) care as needed and as soiling occurred. FC care would include a thorough cleansing of the perineal and catheter-meatal areas using soap and water or a product designed for perineal cleansing. Continued review of the Policy, revealed the catheter-meatal junction is a significant portal of entry for bacteria into the urinary tract, potentially causing urinary tract infections; therefore, it is most important that the perineum, catheter-meatal junction and tubing be kept clean and free of fecal contamination. Additional review of the Policy revealed staff would wash hands and apply gloves prior to procedure. Review of the facility's Policy, titled, Perineal Care, revised 11/13/18, revealed the facility would provide residents with routine perineal care with morning and bedtime care and with each incontinent episode. Further review of revealed the resident's perineal care would include cleansing with soap and water for each incontinent episode to prevent odor, infection, skin breakdown and to promote comfort. Review of Resident #287's clinical record revealed the facility admitted the resident on 1/21/19 with [DIAGNOSES REDACTED]. Observation of Resident #287's Foley catheter (FC) and perineal care performed by State Registered Nurse Aide (SRNA) #5 and SRNA #6 on 01/22/19 at 10:15 AM, revealed both SRNAs washed hands and applied clean gloves prior to providing care. SRNA #5 was observed using warm, soapy water from the basin and several wash clothes to wash the resident's perineal area. Further observation revealed SRNA #5 used the same washcloth used to provide perineal care to provide Foley catheter care. SRNA #5 washed the catheter-meatal junction, using a downward motion to cleanse the Foley catheter tubing, approximately six (6) inches down the tubing. SRNA #5 then poured the soapy water down the sink, rinsed out the basin, and ran clean water into the basin. SRNA #5 then returned to Resident #287's s bedside and with the same soiled gloves used to provide perineal care, and used to handle the sink faucet to obtain rinse water, rinsed the resident's peri-area and Foley catheter tubing. Continued observation revealed SRNA #5 and SRNA #6 removed their soiled gloves, but failed to wash their hands before applying clean gloves. The SRNAs then placed a lift pad underneath the resident, and hooked the lift pad to the Hoyer Lift (mechanical lift). SRNA #5 hand-cranked the lift to obtain the resident's weight. SRNA #5 and SRNA #6 then lowered the lift back down to place the resident back in to a lying position (supine). SRNA #5 picked up the bed remote to reposition the bed, and repositioned the resident's gown, bed linens and oxygen tubing. SRNA #5 was observed to pick up the two (2) bags containing soiled linen from the foot of the resident's bed and place the bags on the floor, and then place both bags in the resident's wheelchair. SRNA #5 exited the resident's room while wearing soiled gloves, returned to the room, removed her gloves, washed her hands and again exited the resident's room. SRNA #6 then removed her gloves and washed her hands prior to exiting the resident's room. Interview on 01/23/19 at 1:58 PM with SRNA #5 revealed after she performed perineal care, she should have obtained a clean wash cloth prior to cleaning the FC for Resident #287. Further interview revealed after she obtained clean rinse water, she should have washed her hands and donned new gloves before rinsing the resident's peri-area and Foley catheter tubing. Further interview revealed after providing pericare and FC care, she should have removed her soiled gloves, washed her hands, and then donned new gloves before handling the Hoyer Lift to weigh the resident, and touching items in the room such as the resident's bed linens, bed remote, and assisting the resident with the oxygen tubing. Further interview revealed it was an infection control violation to place dirty linens in a resident's wheelchair. Additional interview with SRNA #5, revealed she needed to wash her hands at appropriate times while providing care and prior to exiting a resident's room as handwashing was the single most effective way to prevent cross contamination. Interview on 01/23/19 2:17 PM with SRNA #6, revealed hand washing was the most important procedure used to protect against preventing the spread of infections, and germs to residents and staff. SRNA #6 revealed she should have removed her soiled gloves, washed hands and applied clean gloves after assisting SRNA #5 with FC care and perineal care, and prior to assisting with weighing Resident #287. Interview on 01/23/19 2:38 PM, with Registered Nurse #2, revealed she was assigned to provide care for Resident #287 on 01/22/19. Further interview revealed SRNA #5 and SRNA #6 were both familiar with facility policies on infection control and prevention, hand washing, perineal care and Foley catheter care and were strong SRNAs. RN #2 revealed SRNA #5 and SRNA #6 should have removed gloves, washed hands, and applied clean gloves after providing pericare/Foley care and prior to weighing Resident #287 with the Hoyer Lift, and touching items in the room such as the resident's bed linens, and bed remote. Additional interview revealed soiled linens on the resident's wheelchair was an infection control violation and soiled linens were to be placed in the soiled linen closet. RN#2 stated hand washing was the single most effective way to prevent the potential spread of infections to the facility residents, staff and visitors. Interview on 01/23/19 3:32 PM, with the Unit Manager for the Transitional Care Unit where Resident #287 resided, revealed it was her expectation staff follow the infection control, hand washing, perineal care and Foley catheter care policies. Interview on 01/23/19 4:12 PM, with the Director of Quality and Reporting and Infection Control, revealed staff should have removed soiled gloves, washed hands and applied clean gloves at appropriate times during peri-care/FC care and between tasks during care. Per interview, the SRNAs should use clean wash cloths as necessary while providing peri-care/FC care. Further interview revealed the SRNAs should have washed hands and applied clean gloves after performing FC Care and before weighing Resident #287, repositioning the resident's bed linens, and touching other items in the resident's room. Further interview revealed Hand washing was the single most effective way to prevent the spread of infection to staff resident and visitors. Interview with Assistant Director of Nursing (ADON) on 01/23/19 at 5:00 PM, revealed she was not responsible for teaching the staff hand washing, and infection control skills, but did review the material with staff during the facility's Annual Skills fest in August. Further interview revealed it was the ADON's expectation that staff wash hands and change gloves at appropriate times before, and during peri-care/FC care as necessary and between tasks during care, especially when going from dirty to clean. Continued interview revealed the ADON expected all staff to provide proper FC care and use proper hand washing during the procedure. Continued interview revealed, I would expect my staff to properly remove the soiled linen from the resident's room and place it in the soiled linen room, not on a resident's wheelchair. This is a violation of infection control. Interview on 01/23/19 at 5:14 PM, with the Director of Nursing (DON, revealed it was her expectation staff use proper infection control techniques related to perineal care/FC care, and hand washing and glove usage while providing perineal and FC Care. Further interview revealed the SRNAs should have washed hands and donned new gloves after providing FC and incontinence care and prior to obtaining Resident #287's weight; readjusting the resident's bed linen; and handling the bed remote. Further interview revealed staff should always wash hands after providing care and prior to exiting a resident's room. Interview with the Administrator, on 01/23/19 5:33 PM, revealed it was her expectation staff provide excellent customer service and adhere to the facility infection control policies. 2. Review of the facility Policy titled Preparation and General Guidelines HA2: Medication Administration-General Guidelines, revised 12/18/12, revealed, If breaking a tablet is necessary to administer the proper dose, Hands are washed with soap and water or alcohol gel prior to handling tablets. Observation during medication pass, on 01/22/19 at 11:00 AM, revealed Licensed Practical Nurse (LPN) #1 touched the medication cart surfaces, the keys used to open the controlled medication/narcotic storage drawer, computer screen on top of the medication cart, and pen and documents in the controlled drug/narcotic drug log when signing out [MEDICATION NAME] and [MEDICATION NAME]-[MEDICATION NAME] controlled narcotic medications. The nurse then removed one (1) [MEDICATION NAME] 600 mg (milligrams) tablet from the labeled medication card, and one (1) [MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg tablet from the labeled medication card. The LPN was observed to touch both of these medications with her bare hands and then administer the medications to Resident #19. Interview with LPN #1 immediately after the medication pass observation, revealed she popped the second [MEDICATION NAME]-[MEDICATION NAME] right into her hand. During subsequent interview with LPN #1, on 01/23/19 at 02:09 PM, the nurse stated she should have wasted the medication which she had handled with her bare hands instead of administering the medication to the resident. Further interview revealed, per policy she should not have touched the resident's medication with her bare hands due to cross-contamination. She reviewed the policy titled Preparation and General Guidelines HA2: Medication Administration-General Guidelines and the policy titled Hand washing. Interview on 01/23/19, at 2:31 PM, with the Unit Manager on the 300 unit, revealed it was never acceptable to use the bare hand to place medication tablets into the medication cup for administration to a resident. The Unit Manager further stated medication tablets should not be handled with bare hands and this was an infection control issue. Continued interview with the Unit Manager, revealed the nurse should have wasted the narcotic medication which she touched with her bare hands. Interview with the Assistant Director of Nursing, (ADON), on 01/23/19 at 3:21 PM, revealed it was not acceptable to touch resident medication with hands and then administer the medication to the resident as this was an infection control concern. The ADON further revealed if the nurse inadvertently touched the pills with her bare hands she should have wasted the medication which would require two (2) nurses to dispose of the narcotic medication. Interview on 01/23/19 at 4:04 PM, with the facility Director of Nursing (DON), revealed it was not acceptable for staff to touch a pill with bare hands and then administer the medication to the resident as there was the potential for cross contamination. The DON further stated it was not safe for staff to touch any medication with their bare hands as some medications could be absorbed through the skin and could be harmful. Continued interview with the DON, revealed when the nurse touched the resident's pills, the nurse should have wasted the controlled medications which would require a second nurse to witness. The DON was provided the facility Policies titled, Preparation and General Guidelines HA2: Medication Administration-General Guidelines and Hand washing, and reviewed the policies, and stated the policies did not address what to do if a resident's oral medication (pills) were touched or contaminated. The DON stated she was not sure if the tablets would need to be wasted if the pills touched the cart, but stated it was not acceptable for staff to touch resident medication with bare hands and then administer the medication to the resident. Interview with the Administrator, on 01/23/19 at 4:43 PM, revealed when the question was posed as to whether staff should administer a resident's medication tablet after touching the medication, she stated absolutely not. The Administrator stated a resident's oral medication (pills) should not be administered if it touched staff's bare hands or the medication cart. She further stated it was her expectation staff would waste the medication if this occurred due to the potential for cross contamination. Further interview revealed she reviewed the facility policies and they did not specifically address the need to dispose of or waste medication that had touched staff's bare hands or the medication cart.