Every finding on record at Windsor House

Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #s 1, 2, and 4 were free from abuse. 1) On [DATE], Employee Identifier (EI) #4, a CNA (Certified Nursing Assistant) and EI #5, a CNA were providing care for RI #2. During the care RI #2 had gotten feces on his/her hands and was trying to touch EI #4. EI #5 witnessed EI #4 telling RI #2 not to touch her, and that RI #2 was nasty. EI #5 said, EI #4 held RI #2's hands down pinning RI #2's arms down by his/her head and said, don't fucking touch me. The witness (EI #5) said RI #2 stated ok I'm sorry but you're hurting me. According to the facility's investigation and interviews, EI #5 did not initially identify the incident as abuse or report this incident of abuse until [DATE]. EI #5 stated she was unsure it was abuse. EI #4 continued to work in the facility on [DATE] and five more days where she had continued access to RI #2 before being discharged home, and other vulnerable residents. 2) On [DATE], a second incident was witnessed by EI #11, volunteer. EI #11 stated upon entering the room RI #1 was yelling out which was not abnormal. EI #11 said, EI #4 grabbed RI #1's head with both hands and told RI #1 to shut the fuck up and then put a washcloth in RI #1's mouth. The incident was not reported to the administrator until [DATE]. EI #4 continued to provide patient care after the second incident including full access to RI #1 and other residents on the hallway she was working. EI #4 worked the remainder of the shift on [DATE], and for three additional days after the second incident. 3) On [DATE], RI #4, stated EI #6, CNA assisted him/her to the bed. RI #4 stated after getting in bed he/she wanted some water, so RI #4 pressed the call light. RI #4 said, EI #6 stormed back into the room saying, homie don't play that. RI #4 stated, EI #6 jerked the call light and they wrestled with the call light. RI #4 said EI #6 pried RI #4's fingers open and again said homie don't play that. RI #4 said, EI #6 left the room. Again, RI #4 pressed the call light because he/she assumed another CNA would answer the light. RI #4 said, EI #6 came back into the room. RI #4 stated he/she was holding the call light as tight as he/she could when EI #6 pulled on it. RI #4 said EI #6 proceeded to remove the call light from his/her hands and wrapped it around his/her neck several times, then EI #6 went behind the bed and pulled RI #4 up in bed with the call light cord. RI #4 stated he/she was trying to say something but could not breathe. RI #4 stated he/she was fearful and thought it was the end of his/her life. These deficient practices affected RI #s 1, 2, and 4, three of eight sampled residents reviewed for abuse. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of J. On [DATE] at 10:33 PM, the Administrator, EI #1, the Director of Nursing Services, EI #2, and the Director of Clinical Operations, EI #3 were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy; substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 600- Free from Abuse and Neglect. The IJ began on [DATE] and continued until [DATE] when survey team verified onsite that corrective actions had been implemented. On [DATE] the immediate jeopardy was removed, F600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings include: The facility's policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of ,d+[DATE], revealed: . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 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 . Mental Abuse: is the use of verbal or nonverbal conduct which cause or has the potential to cause the resident to experience humiliation, fear shame, agitation, or degradation . Physical Abuse: Includes, but is not limited to, hitting, slapping, punching, biting, and kicking . Verbal abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability . 1) RI #2 was admitted to the facility on [DATE] for Hospice Respite with diagnosis to include Alzheimer's Disease, Dementia, and Palliative Care. RI #2 Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], listed RI #2's Brief Interview Mental Status (BIMS) as 03, which indicated the resident was cognitively impaired. The Alabama Department of Public Health Online Incident Reporting System form, dated [DATE], documented, . Narrative summary of incident: (name of EI # 2, DNS [Director of Nursing Services]) informed Admin (name of EI #5, CNA) told her about a previous incident (date unknown) where (name of EI #4, CNA) held patient (name of RI #2)'s arms down when providing care . An undated typed statement from EI #1, Administrator, documented, . (RI #2) . admitted to (name of facility) on [DATE] for a 5-day hospice respite stay. [DATE]: DNS interviewed (EI #5) who reported about a week ago she witnessed (EI #4) hold patient (RI #2)'s arms down when providing care. (EI #5) said patient (RI #2) had feces on (his/her) hands and (EI #4) yelled at (RI #2) to not touch her. (EI #5) said she witnessed (EI #4) hold (RI #2) arms down and (RI #2) was telling (EI #4) to stop your hurting me. (EI #5) said she then told (EI #4) she will take care of (RI #2) and (EI #4) exited the room. DNS asked (EI #5) why she did not report the incident immediately and (EI #5) did not know. (EI #5) reported (EI #4) had been acting differently lately. Allegation of abuse-physical is substantiated. (EI #5) witnessed (EI #4) hold (RI #2) down when providing patient care. Admin is unable to get a statement from victim as (local hospice agency) informed Admin (RI #2) expired on [DATE]. A telephone interview was conducted with EI #5 on [DATE] at 3:20 PM. EI #5, stated on [DATE], RI #2 had feces on his/her hands. EI #5 said, EI #4 and herself went in to clean up the resident. EI #5 stated RI #2 kept trying to touch EI #4. In response, EI #4 told RI #2 not to touch her and that he/she was nasty. EI #5 stated, EI #4 held RI #2 hands down forcefully and said, don't fucking touch me. EI #5 stated RI #2 said ok, I'm sorry, but you are hurting me. EI #5 stated she told EI #4 she would hold RI #2's hands while EI #4 cleaned RI #2. EI #5 stated she told EI #9, Licensed Practical Nurse (LPN) about the incident, but admitted it was days later. EI #5 stated she considered the incident abuse. EI #5 stated the concern of not reporting abuse timely was EI #4 could have continued to hurt the resident or another resident. Review of EI #4's timecard documented that EI #4 continued to work in the facility after the [DATE] incident involving RI #2. EI #4 worked [DATE], [DATE], [DATE], [DATE] and [DATE], before the incident was reported to EI #1, Administrator on [DATE]. A telephone interview was conducted with EI #9, LPN on [DATE] at 4:39 PM. EI #9 stated she became aware of RI #2's abuse allegation on [DATE], when EI #5 came to her and said EI #4 was being rough with residents. EI #9 stated EI #5 told her it had something to do with RI #2's arms. EI #9 stated she sent EI #5 straight to EI #2, DNS to report the allegation. An interview was conducted with EI #2, DNS on [DATE] at 6:29 PM. EI #2 stated she became aware of the allegation of abuse involving RI #2, on [DATE]. EI #2 stated EI #5 informed her of the incident. EI #2 stated the incident had happened the week prior. RI #2 was discharged from the facility on [DATE]. An interview was conducted with EI #1, Administrator on [DATE] at 5:21 PM. EI #1 stated she became aware of the allegation of physical abuse on [DATE]. EI #1 stated the allegation of physical abuse was substantiated because the incident was witnessed by EI #5. 2) RI #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Aphasia, Cognitive Communication Deficit, Altered Mental Status, Vascular Dementia, Anxiety Disorder and Parkinson's Disease. RI #1's Admission MDS assessment, with an ARD of [DATE], revealed RI #1 had short- and long-term memory problems with severely impaired cognition. RI #1's care plan titled I sometimes have behaviors which include Shouting, Yelling during activities, with an initiated date of [DATE], revealed the following intervention . Speak to me unhurriedly and in a calm voice . On [DATE], the Alabama Department of Public Health Online Incident Reporting System received a second facility reported incident which revealed the Administrator, EI #1, was notified by the DNS, EI #2, she was informed by a team member EI #11 that EI #4, CNA put a washcloth in RI #1's mouth and told RI #2 to shut up. Review of the facility's investigative file revealed a written statement by EI #11 which documented the following: I (EI #11) as a volunteer at Windsor House (on) [DATE] @ [at] 1:30 pm was helping CNA (EI #4) in a resident room. Resident was screaming nonstop which occurs regularly when CNA grabbed resident by (his/her) head with both hands and told (him/her) to shut the F*** up and released (his/her) head. CNA turned up resident radio loud. CNA took a wash rag and folded it up like a burrito and stuffed it in resident's mouth. This volunteer removed wash rag from resident's mouth and went to activities and reported to my friend CNA (EI #7) over activities on the dementia unit . 10:00 pm This volunteer went to my mom nurse (EI #9) on Camelot and told her everything I had seen and heard through the day. My mom told her supervisor (EI #8) . On [DATE] at 1:00 PM, the surveyor conducted a telephone interview with EI #11. EI #11 said she was on the Memory Care unit when EI #4 came to get her to help her with RI #1. EI #11 said RI #1 was a person who yells and when RI #1 would not stop yelling EI #4 grabbed RI #1's head and told her to shut the fuck up. EI #11 said when RI #1 started screaming, EI #4 got a washcloth and put it in RI #1's mouth so RI #1 would stop screaming. EI #11 said she looked at RI #1 and took the washcloth out of his/her mouth and EI #4 looked at her (EI #11) angry like she had done something wrong. On [DATE] at 9:15 AM, a follow-up telephone interview was conducted with EI #11. When asked why she removed the washcloth from RI #1's mouth, EI #11 said RI #1 was turning red. EI #11 said when she removed the washcloth from RI #1's mouth RI #1 was trying to catch his/her breath. On [DATE] at 12:19 PM, a telephone interview was conducted with EI #9. EI #9 said on [DATE] at 10:00 PM, EI #11 informed her about EI #4 cursing RI #1 and placing a washcloth in RI #1's mouth. EI #9 said EI #11 said when EI #4 and herself went in RI #1's room, the resident was yelling. EI #9 said EI #11 said EI #4 grabbed RI #1 by the face with both of her hands and said shut the fuck up. EI #9 said EI #11 said EI #4 let RI #1's head go and RI #1 fell back into the bed. EI #9 said EI #11 said after that, EI #4 started to roll a washcloth like a burrito and proceeded to shove it into RI #1's mouth until RI #1 was gagging and turning red. EI #9 said the incident would be considered verbal, physical, and emotional abuse. On [DATE] at 8:30 PM, a telephone interview was conducted with EI #8. EI #8 said she was made aware on [DATE] around 10:30 PM that EI #4 told RI #1 to shut the fuck up and placed a washcloth in RI #1's mouth. EI #8 said the incident was physical, verbal and emotional abuse. On [DATE] at 6:09 PM, a telephone interview was conducted with EI #7, the Memory Care Director. EI #7 said EI #11 came into her office on [DATE] and said she (EI #11) had something to tell her, and EI #11 did not want EI #7 to say anything about the incident. EI #7 said EI #11 reported that EI #4 had asked her to go and help her with a resident. EI #7 said EI #11 said the resident was screaming and EI #4 shoved a washcloth in the resident's mouth. When asked what type of abuse would she consider this allegation to be, EI #7 said physical. On [DATE] at 12:10 PM, an interview was conducted with EI #2. EI #2 said she was made aware of the incident involving EI #4 cursing RI #1 and then placing a washcloth in RI #1's mouth on [DATE] by EI #7. EI #2 said informed EI #1 and EI #3, the Director of Clinical Operations. EI #2 said she came to the facility to start the investigation and all staff involved were put on administrative leave immediately. On [DATE] at 5:21 PM, an interview was conducted with EI #1. EI #1 said she became aware of the incident involving EI #4 cursing RI #1 and then placing a washcloth in RI #1's mouth on [DATE]. EI #1 said the facility's investigation substantiated that the incident did occur. A review of the Supplemental Narrative from the local police department's report, dated [DATE], revealed the following: . On [DATE] I received this case and made contact with the Windsor House administrator (EI #1). (EI #1) told me she was already investigating this case and had written statements from witnesses who stated they saw the offender (EI #4) physically abuse two different victims . 1) Victim (RI #2) was seen by (EI #5) being held down forcefully by (EI #4) sometime between [DATE]th and Aug (August) 6th 2023. The incident was not reported until [DATE]th 2023. (EI #1) said that (EI #5) said the patient (RI #2) made the statement as (his/her) wrists were being held down, please stop, you are hurting me. 2) Victim (RI #1) was seen by volunteer (EI #11) having (his/her) mouth stuffed with a folded washcloth by (EI #4). The witness also, wrote a statement about the offender (EI #4) grabbing (RI #1's) head with both hands and told (him/her) to shut the fuck up. The witness actually came in to remove the wash rag which was left in the victim's mouth . if the witness (RI #11) not intervened, serious bodily injury or death could have occurred involving the victim (RI #1). The actions (EI #4) did was reckless. (EI #4) shoved the rag in the mouth of (RI #1) in such a manner that (he/she) was gagging. This restriction of air could have caused suffocation leading to death or serious injury . Supplemental Narrative [DATE] . the offender's actions were intentional and no reasonable person would want the physical contact that the offender did to the victim . Review of a PROGRESSIVE DISCIPLINE FORM for EI #4 revealed the following: Name: (name of EI #4) . Position: CNA Date Administered: [DATE] Category 1 Violation: 1.1 Patient/resident abuse . Termination [DATE] Summary of Incident: . On Saturday [DATE] we were made aware of a concern that alleged you have abused a resident on Tuesday [DATE]. You were placed on administrative leave while we investigated into the allegation . Upon conclusion of the investigation we did substantiate the allegation of abuse, and the incident has been reported to state. Abuse, neglect, or misappropriation of any patient or resident is inexcusable and will not be tolerated. Based on the information found in the investigation, we have made the decision to terminate your employment immediately . A follow-up interview was conducted with EI #1, Administrator on [DATE] at 6:38 PM. EI #1 stated the potential harm of holding a resident's arms down aggressively when providing care was bruising, skin tears, possible broken bones, trauma, fear, anxiety, and depression. EI #1 stated the potential harm of placing a washcloth in a resident's mouth is the resident could choke, and cause resident to go into respiration distress. On [DATE] at 11:08 AM, a telephone interview was conducted with EI #14, the facility's Medical Director. When asked what type of harm could potentially occur to a resident when their hands/arms are being held while staff is attempting to provide care for the resident, EI #14 said bruising. EI #14 said depending on how forceful the resident was being held a bone could be break bones. EI #14 said someone could be hurt from actions like that. When asked what type of harm could potentially occur when a washcloth was placed in a resident's mouth to keep them from hollering, EI #14 said if not taken out of the mouth, the person could not breath and could become hypoxic. EI #14 said definitely this would be like abuse. On [DATE] at 10:06 AM, a telephone interview was conducted with RI #1's daughter/sponsor. RI #1's daughter said RI #1 had a stroke, has dementia and Parkinson's, required 24-hour care and was totally dependent on staff. When asked, from a reasonable person's view, how did she think it would have made RI #1 feel having the same person who cursed at him/her and placed a washcloth in his/her mouth continue to provide care to him/her. RI #1's daughter said RI #1 would have been scared. 3) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Multiple Sclerosis, Muscle Weakness, Other Lack of Coordination, Bed Confinement Status and Other Reduced Mobility. RI #4's Quarterly MDS with an ARD date of [DATE] indicated RI #4 had a BIMS of 13, which indicated RI #4 was cognitively intact. The Alabama Department of Public Health Online Incident Reporting System Form dated [DATE], documented, . (Name of RI #4) reported to (Name of EI #10) that on [DATE] (Name of EI #6, CNA) wrapped a call light around (his/her) neck. An undated typed statement from EI #1, Administrator, documented, . A full body audit was completed by (EI #10, RN) and documented that (RI #4) did have some bruising on the left side of (his/her) neck along with red areas on the right side of (his/her) neck. (RI #4) Interview with Administrator: Admin interviewed resident (RI #4) on [DATE] at 2:15pm regarding allegations (he/she) reported to nurse. (RI #4) said on Friday ([DATE]) around 2 to 3 pm this same CNA who resident reported was (EI #6) came in (his/her) room when (he/she) pushed (his/her) call light and shut the door behind her. (RI #4) as (he/she) was trying to get some water. Resident said (EI #6) told (him/her) I told you you're going somewhere because I am tired of you. (RI #4) said (he/she) was holding the call light in (his/her) left hand and (EI #6) pulled the call light out of the wall and wrestled it away from (him/her). (RI #4) said (EI #6) wrapped the call light around (his/her) neck multiple times and pulled (him/her) up then pushed (him/her) back down on the bed. (RI #4) said (he/she) tried yelling, but no one could hear (him/her). (RI #4) told Admin (EI #6) told (him/her) I don't want to be like you in the bed dying. (RI #4) said (EI #6) finally stopped choking (him/her) and threw call light on the floor by the entrance to (his/her) room. Admin asked who plugged (his/her) call light back in and resident could not tell Admin. Conclusion: Allegation of physical abuse with resident (RI #4) identified as the victim and CNA (EI #6) identified as the perpetrator is substantiated. (RI #4) had visible marks to (his/her) neck when assessed by assigned nurse, and (he/she) was consistent in (his/her) recollection of events . An interview was conducted with RI #4 on [DATE] at 6:17 PM. RI #4 stated on [DATE], EI #6 took him/her down to activities. RI #4 stated he/she was ready to go back to room and informed another staff member. RI #4 stated he was pushed back down the hallway and waited outside the room while EI #6 provided care for roommate. RI #4 stated, he/she was finally placed back in bed by EI #6 and another staff member. RI #4 stated once in bed he/she wanted some water, so he/she pushed the call light. RI #4 stated, EI #6 stormed back into the room and said homie don't play that, RI #4 stated they were wrestling for the call light. EI #6 left the room without giving RI #4 water. RI #4 stated he/she pressed the call light again thinking another staff would respond; however, EI #6 returned to the room. RI #4 stated he/she had a tight grip on the call light, but EI #6 was able to get call light out of RI #4 hands and wrapped it around RI #4's neck. RI #4 stated, EI #6 pulled the call light from out of the wall and went behind the top of the bed and was pulling back on the call light cord. RI #4 stated he/she was trying to say something, but he/she could not breathe. RI #4 stated he/she informed EI #10, Registered Nurse (RN), EI #12, CNA and EI #13, LPN of the incident soon after the incident. In a follow-up interview with RI #4 on [DATE] at 9:30 PM. RI #4 stated during the incident he/she was thinking he/she was going to die. A telephone interview was conducted with EI #10, RN on [DATE] at 5:38 PM. EI #10 stated on the evening of [DATE], RI #4 told him that EI #6 wrapped a call light around his/her neck and said abusive things to RI #4. EI #10 said RI #4 reported that EI #6 said she would not be like him/her and would not die in the bed. EI #10 stated a body audit was completed at the request of the administrator and results of the body audit showed some indention around the resident's neck. A telephone interview was conducted with EI #13, LPN on [DATE] at 8:41 PM. EI #13 stated on the evening of [DATE], RI #4 told her EI #6 came into the room to answer the call light. EI #13 stated RI #4 said EI #6 became angry took the cord and wrapped it around RI #4's neck and pulled RI #4 up and pushed him/her back down in the bed. A telephone interview was conducted with Investigator from local police Department on [DATE] at 8:20 AM. Investigator stated the case is ongoing. Investigator stated he talked with RI #4 on [DATE] and [DATE] and both times, RI #4's story was consistent. Investigator stated there was definitely a mark on RI #4's neck. An interview was conducted with EI #12, CNA on [DATE] at 2:30 PM. EI #12 stated when she went into RI #4's room on the early morning of [DATE], RI #4 told her, he/she wanted water on [DATE], so RI #4 pressed the call light and EI #6 came into the room and fought RI #4 for the call light then wrapped the call light around RI #4's neck and pulled up on it. EI #12 stated, RI #4 said after EI #6 did this she left the room. EI #12 stated she observed a couple of red spots on RI #4's neck. An interview was conducted with EI #1, Administrator on [DATE] at 5:21 PM. EI #1 stated she became aware of the allegation of physical abuse on [DATE]. EI #1 stated the allegation of physical abuse was substantiated due to RI #4 story remaining consistent and the body audit conducted by EI #10, documented a bruise on one side and redness on the other side of RI #4's neck. An interview was conducted with EI #1, Administrator on [DATE] at 6:38 PM. EI #1 stated the potential harm of holding a resident's arms down aggressively when providing care was bruising, skin tears, possible broken bones, trauma, fear, anxiety, and depression. EI #1 stated the potential harm of placing a washcloth in a resident's mouth was the resident could choke, and cause resident to go into respiration distress. EI #1 stated the potential harm wrapping a call light cord around a resident's neck was strangulation, fear, anxiety, social and psychological impact. This deficiency was cited as a result of the investigation of complaint/report number(s) AL00045242, AL00045244, and AL00045448. ******************************************************************* ******************************************************************* On [DATE] at 7:26 PM, the facility submitted an acceptable removal plan, which documented: F600 To the best of my knowledge and belief, as an agent of Windsor House, the following allegation of compliance constitutes a written plan demonstrating actions the Center took upon awareness of the deficient practice thus removing the Immediate Jeopardy cited on [DATE]. Preparation and execution of this allegation of compliance does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the alleged deficiencies. The allegation of compliance is prepared and/or executed solely because it is required by the provisions of Federal and State Law. Immediate Actions for All Residents Affected by Alleged Abuse: RI #2: o discharged from the center on [DATE] at end of hospice respite stay. o EI#4 (CNA) held resident's hands down and used profanity toward resident on [DATE]. It was observed by EI#5 (CNA.) o EI#5 (CNA) reported the incident to EI#9 on [DATE] who reported to Administrator on [DATE]. Due to delay of reporting EI#5 (CNA) was trained via phone. o Administrator notified ADPH on [DATE]. o Administrator notified MD on [DATE]. o Administrator notified Huntsville Police Department and attempted to notify family on [DATE]. o Hospice was notified on [DATE] via phone and [DATE] in person. o Ombudsman was notified on [DATE] via email and via phone on [DATE] and stated she will provide an in-service for the center. o EI#4 (CNA) was placed on Administrative Leave on [DATE] and investigation began. EI#4 (CNA) was terminated on [DATE]. o Full body audits conducted on residents on all halls with BIMS less than 8 on [DATE] with no significant findings. o Interviews conducted with residents on all halls with BIMS of 8 or greater on [DATE] with no significant findings. o Reported EI#4 (CNA) to CNA Registry and charges filed by Huntsville Police Department with upcoming court date on [DATE]. o EI#5(CNA) was placed on Administrative Leave on [DATE] and terminated on [DATE] for failing to report. Reported to CNA registry. o Additional signage added around center on [DATE] for reminders for team members to report incidents and contact information to abuse coordinator (Administrator). o Focused Quality Assurance meeting was held with Physician and Interdisciplinary Team in attendance on [DATE]. o All team members and center care partners in-serviced beginning [DATE] regarding abuse and neglect identification, residents' safety and protection, and reporting. (All team members and center care partners to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) o Team members and center care partners signed acknowledgement of receiving education and understanding the requirements of the Elder Justice Act training beginning on [DATE]. All team members and center care partners to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services. o Ombudsman, [NAME], provided training with team members and center care partners (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) regarding resident rights, abuse, neglect, and reporting on [DATE] at 7:00 am and 3:30 pm which allowed accessibility for all shifts to attend. RI#1: o EI#4 (CNA) placed the washcloth in RI#1 mouth, EI#11 (volunteer) removed wash cloth from her mouth and reported to EI#7 (memory care director) on [DATE]. o EI#9 (LPN) and EI#11 (volunteer) together told EI#8 (LPN/Unit Manager) about the incident on [DATE]. EI#8 (LPN/Unit Manager) reported to Administrator on [DATE]. Due delay in reporting EI#8 (LPN/Unit Manager), EI#9 (LPN), EI#11 (volunteer), EI#7 (Memory Care Director) were all placed on administrative leave pending investigation due to this incident, should have been reported immediately to the Administrator. In-services began on [DATE] to include abuse identification, reporting time frames, and providing safety for the residents. o Assessed RI#1 for injury by DNS and no injuries noted on [DATE]. o Huntsville Police Department notified on [DATE] and came to center to complete the initial report. o ADPH was notified on [DATE] of incident and investigation immediately initiated. o Focused Quality Assurance meeting was held with Physician and Interdisciplinary Team in attendance on [DATE]. Recommendations included retraining with the team (to include nurses, med techs, CNAs, department leaders/management, contracted therapy services, contract housekeeping services, contract dietary services.) All team members and center care partners were in-serviced regarding abuse and neglect identification, resident safety and protection, immediacy of reporting expectations, and care partner managers following the Elder Justice Act guideline/follow up on findings, with post-test for knowledge retention. Also, to include customer service training and handling residents exhibiting behaviors. o MD notified on [DATE] and assessed RI#1 on [DATE] with no significant findings. o Family notified of incident on [DATE]. o Huntsville Police Department Investigator came into center on [DATE] and observed resident along with interviewing staff and Administrator. Administrator received completed report from Investigator Gollop. o Ombudsman notified on [DATE] via email and via phone on [DATE] and stated she will provide an in-service for the center. o EI#4 (CNA) was placed on Administrative Leave on [DATE] and terminated on [DATE] for failing to report. o Reported EI#4 (CNA) to CNA registry and charges filed by Huntsville Police Department with upcoming court date on [DATE] for charges of assault. o EI#11 (volunteer) was suspended on [DATE] and terminated on [DATE] for failing to report. o EI#8 (LPN/Unit Manager) was placed on administrative leave on [DATE] and terminated on [DATE] for failing to report. EI#8 (LPN/Unit Manager) was reported to the Alabama Board of Nursing. o EI#9 (LPN) was placed on administrative leave on [DATE] and resigned without notice on [DATE]. EI#9 (LPN) was reported to the Alabama Board of Nursing. o EI#7 (Memory Care Director) was placed on administrative leave on [DATE] and terminated on [DATE] for failing to report. o Additional signage added around center on [DATE] to remind team members the requirements of reporting abuse/neglect allegations in a timely manner to the Abuse Coordinator/Administrator with contact information. o All team members and center care partners (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) in-serviced regarding abuse and neglect identification, residents' safety and protection, and reporting. Inservice initiated [DATE] and completed [DATE]. o Team members and center care partners (to include nurses, med techs, CNAs, team leaders/m [TRUNCATED]

Based on interviews, medical record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of Facility Reported Incidents (FRIs) received by the State Survey Agency, the facility failed to implement the facility's abuse policies when: 1) Employee Identifier (EI) #8, Licensed Practical Nurse (LPN), Unit Manager failed to report an allegation of sexual abuse to the Administrator and failed to implement immediate protective measures. On 07/28/2023 Resident Identifier (RI) #6's daughter reported to EI #8 that RI #7 had entered RI #6's room and touched his/her breast twice. 2) EI #5, Certified Nursing Assistant (CNA) failed to identify an incident as physical and verbal abuse and immediately report the incident to the administrator after she observed EI #4, CNA hold down RI #2's arms down while telling RI #2 to not fucking touch her on 08/06/2023. Further, no protective measures were implemented, and EI #4 provided resident care on 08/07/2023, 08/08/2023, 08/09/2023, 08/11/2023, and 08/12/2023. EI #4 perpetrated a second incident of verbal and physical abuse on 08/08/2023. 3) EI #11, facility volunteer failed to immediately report an allegation of physical and verbal abuse to the administrator after EI #11 witnessed an incident of abuse on 08/08/2023. EI #11 reported the incident to EI #7, Memory Care Director, EI #8, Unit Manager, and EI #9, LPN. EI #7, EI #8, and EI #9 failed to immediately report the allegation of abuse to the administrator. The facility staff further failed to implement protective measures to protect RI #1 and other vulnerable residents from further potential abuse. On 08/08/2023, EI #11, facility volunteer witnessed EI #4 take RI #1's head in her (EI #4's) hand and shake it while telling RI #1 to shut the fuck up. EI #11 said when RI #1 continued to yell out, EI #4 placed a washcloth in RI #1's mouth. EI #11 said she removed the washcloth from RI #1's mouth, left the room and immediately reported the incident to EI #7, the Memory Care Director around 1:30 PM. EI #11 said she later informed EI #9, LPN. EI #11 and EI #9 both informed EI #8, an LPN unit Manager, of the incident later on in the shift around 10:00 PM. EI #7 reported she was unaware of the incident until 08/11/2023. The incident was not reported to the facility's administrator until 08/12/2023. 4) EI #10, Registered Nurse (RN) and EI #13, LPN failed to identify an allegation of physical abuse, failed to immediately report the allegation to the administrator, and further failed to initiate an investigation when staff were unable to contact the administrator. On the evening of 09/01/2023 RI #4 reported to EI #10 and EI #13 that EI #6 had wrapped a call light around his/her neck and said abusive things to RI #4. No action was taken until 09/02/2023 around 6:00 AM. These deficient practices affected RI #s 1, 2, 4, and 6, four of eight sampled residents reviewed for abuse. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of J. On 09/18/2023 at 10:33 PM, the Administrator, the Director of Nursing Services (DNS) and the Director of Clinical Operations, EI #3 were given a copy of the Immediate Jeopardy (IJ) template and notified of the findings of immediate jeopardy; substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 607- Develop/Implement Abuse/Neglect, etc. Policies. Findings include: The facility's policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of 01/2019, revealed the following: Purpose: To prohibit and prevent abuse . and to ensure reporting and investigation of alleged violations . in accordance with Federal and State Laws . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse . 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. Alleged Violation: A situation or occurrence that is observed or reported by team member, resident, relative, visitor or others but has not yet been investigated . The following protocol has been established in the event of an allegation of abuse: 1. Protection First and foremost the resident/patient will be immediately assessed and removed from any potential harm . If the suspected perpetrator is another resident/patient, the Administrator/Director of Nursing or designee shall separate the resident/patients so they do not have access to each other until the circumstances of the alleged incident can be determined and assessment completed and if applicable interventions put in place. If the suspected perpetrator is a team member, the Administrator/Director of Nursing or designee shall place the team member on immediate investigatory suspension while completing the investigation . 4. Prevention Establish safe environment: Team members are required to report incidents of suspected abuse without fear or reprisal . 5. Identification If actual violation or alleged violation occurs the resident will immediately be assessed and removed from any potential harm . 6. Investigation If actual violation or alleged violation occurs the resident will immediately be assessed and removed from any potential harm (as applicable) . In the event an alleged violation/violation occurs when the Administrator or Director of Nursing are unavailable, the manager in charge is responsible for initiating the investigation procedure unless there is a conflict of interest or the person is implicated in the alleged violations. 7. Reporting/Response Alleged violations will be reported to the Administrator, designee immediately . 1) RI #6 was admitted to the facility on [DATE] with diagnoses of Muscle Weakness, Unsteadiness on Feet and Abnormalities of Gait and Mobility. RI #6's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/28/2023, indicated RI #6 was cognitively intact for daily decision making. RI #7 was admitted to the facility on [DATE] with diagnoses of Disorder of Brain, Unsteadiness on Feet and Cognitive Communication Deficit. RI #7's Admission MDS with an ARD of 07/24/2023 indicated RI #7 was severely impaired in cognitive skills for daily decision making. The facility reported the FRI to the State Agency on 07/30/2023. The report stated the Administrator was informed that resident (RI #6)'s daughter reported resident (RI #7) went into (RI #6)'s room and pulled his/her covers and touch his/her breast twice. The daughter stated that RI #7 was observed standing at RI #6 while the daughter was at the facility in early morning hours. A telephone interview was conducted on 09/14/2023 at 11:17 AM with EI #8, LPN/Unit Manager. She stated RI #6's daughter notified her of the incident on 07/28/2023 via text and phone. EI #8 said that RI #6's daughter said that RI #7 had touched RI #6's breast. EI #8 said she did not report the incident to Administrator. EI #8 said the staff were supposed keep RI #7 away from RI #6's room. EI #8 stated her last date of employment with the facility was 09/11/2023 and that she was terminated for failure to report the incident. An interview with the EI #2, DNS was conducted on 09/14/2023 at 5:30 PM. EI #2 said that on 07/30/2023 RI #6's daughter reported to her that RI #7 touched RI #6's breast. She said RI #6 called her and told her RI #7 pulled RI #6's covers at his/her feet and touch RI #6's breast. EI #2 said she immediately called EI #1 (Administrator) who suggested staff move EI #7 to the other hall, keep double doors close, and perform checks every 15 minutes. On 09/15/2023 at 6:38 PM, an interview was conducted with EI #1, the Administrator. EI #1 said protective measures were not implemented after RI #7 allegedly entered RI #6's room three times and touched his/her breast twice. This deficiency was cited as a result of the investigation of complaint/report number AL00045069. 2) RI #2 was admitted to the facility on [DATE] for Hospice Respite with diagnosis to include Alzheimer's Disease, Dementia, and Palliative Care. RI #2 Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2023, indicated RI #2's Brief Interview Mental Status (BIMS) was 03, which indicated the resident was cognitively impaired. The Alabama Department of Public Health Online Incident Reporting System form, dated 08/12/2023, documented, . Narrative summary of incident: (EI # 2, DNS) informed Admin (EI #5, CNA) told her about a previous incident (date unknown) where (EI #4, CNA) held patient (RI #2)'s arms down when providing care . A telephone interview was conducted with EI #5, CNA on 09/14/2023 at 3:20 PM regarding EI #4 holding RI #2's arms down and telling RI #2 to don't fucking touch her. EI #5 admitted after witnessing the incident between EI #4 and RI #2, she did nothing to protect RI #2 and other residents from further potential abuse. EI #5 stated did not report the incident until days later, because she thought it was not that big of a deal and did not immediately identify the incident as abuse. EI #5 stated she witnessed EI #4 holding RI #2's hands down and cursing at RI #2. EI #5 admitted she did not follow the facility's abuse policy when she failed to immediately report what she witnessed to the administrator. EI #5 stated the concern of not following the facility's abuse policy and reporting allegations of abuse immediately was not protecting the resident. EI #5 stated, EI #6 could have continued to hurt RI #2 or another resident. A review of a PROGRESSIVE DISCIPLINE FORM for EI #5 revealed the following: Name: (EI #5) . Position: CNA .Date Administered: 08/17/2023 .Category 1 Violation: 1.2 Failure to report any incident of patient/resident abuse .Termination 08/17/2023 .Summary of Incident: . Due to your failure to report the incident per our policy you failed to protect our residents and patients, and potentially provided an opportunity for the abuse to continue. Cased on this we have made the decision to separate employment effective immediately. An interview was conducted with EI #1 on 09/14/2023 at 5:21 PM. EI #1 said the facility's policy stated staff were to notify the abuse coordinator immediately of allegations. EI #1 said, EI #5 not reporting the incident involving RI #2 for several days was not timely reporting and the facility's policy was not followed. EI #1 stated the concern of not reporting timely was subjecting those residents to further abuse. 3) RI #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Aphasia, Cognitive Communication Deficit, Altered Mental Status, Vascular Dementia, Anxiety Disorder and Parkinson's Disease. RI #1's Admission MDS assessment, with an ARD of 06/21/2023, revealed RI #1 had short- and long-term memory problems with severely impaired cognition. On 08/12/2023, the Alabama Department of Public Health Online Incident Reporting System received a second FRI. The report indicated the Administrator, EI #1, was notified by the DNS, EI #2, she was informed by EI #11 that EI #4, a CNA put a washcloth in RI #1's mouth and told RI #2 to shut up. On 09/13/2023 at 1:00 PM, the surveyor conducted a telephone interview with EI #11, volunteer. EI #11 said she observed EI #4 grab RI #1's head, tell RI #1 to shut the fuck up, and place a washcloth in RI #1's mouth. EI #11 said she left out of the room and told EI #7, Memory Care Director. EI #11 said later that day she told EI #9 about EI #4 cursing at RI #1 and putting a washcloth in the resident's mouth. EI #9 said they needed to tell EI #8, the Unit Manager on the unit RI #1 resided. EI #11 reported that EI #9 and herself reported the allegation to EI #8. On 09/13/2023 at 12:19 PM, a telephone interview was conducted with EI #9. EI #9 said on 08/08/2023 at 10:00 PM, EI #11 informed her about EI #4 cursing RI #1 and placing a washcloth in RI #1's mouth. EI #9 said she and EI #11 told EI #8, Unit Manager what happened. EI #8 said it would be handled. On 09/14/2023 at 12:10 PM, an interview was conducted with EI #2, DNS. EI #2 said she was made aware of the incident involving EI #4 cursing RI #1 and then placing a washcloth in RI #1's mouth on 08/12/2023 when she was talking with EI #7, the Memory Care Director on the phone. EI #2 said EI #7 said EI #11 asked her not to report the allegation to the administrator. EI #2 said EI #8 also knew about the allegation and had not reported to the administrator either. EI #2 said everyone named (EI #7 and #8) knew the day of the incident, which was 08/08/2023, and no one had reported it to her or EI #1, who was the Abuse Coordinator. EI #2 said the facility's abuse policy indicated that alleged violations should be reported immediately. EI #2 said the policy indicated if the alleged perpetrator was a team member, the team member should be put on administrative leave immediately pending investigation. EI #2 said EI #4 was the identified perpetrator. EI #2 said EI #4's timecard indicated that she worked in the facility after the incident occurred with RI #1 for three days, 08/09/2023, 08/11/2023 and 8/12/2023, before she was suspended and terminated. EI #2 said when a perpetrator continued to have access to the victim, there could be a potential for more harm. EI #2 said with EI #4 working in the facility for three additional days after the incident occurred on 08/08/2023, RI #1 and other residents at the facility were not protected. On 09/13/2023 at 6:09 PM, a telephone interview was conducted with EI #7, the Memory Care Director. EI #7 said EI #11 reported to her the EI #4 had placed a washcloth in RI #1's mouth. EI #7 said this was reported to her on 08/11/2023. EI #7 said abuse should be reported immediately to the Abuse Coordinator who was EI #1. The review of the facility's investigative file contained a typed, signed statement by EI #2 the DON which revealed On 08/12/2023, I spoke with (EI #7), the memory care director to get an update on a resident on memory care. During our conversation (EI #7) voiced some concerns on the MCU (Memory Care Unit). She also reported that a volunteer, (EI #11) informed her that (EI #4), a CNA pushed a resident's head (RI #1) telling the resident to shut the f*** up, and put a washcloth in the resident's mouth. I asked (EI #7), Did you report it? (EI #7) stated No, (EI #11), the volunteer, did not want me to tell anyone. She did not want to get anyone in trouble. (EI #7) reported that the volunteer, (EI #11) reported the incident to (EI #9) LPN (Licensed Practical Nurse) and (EI #8) LPN on 08/08/2023 . A review of a PROGRESSIVE DISCIPLINE FORM for EI #7 revealed the following: Name: (name of RI #7) .Position: Memory Care Director . Date Administered: 08/16/2023 .Category 1 Violation: 1.2 Failure to report any incident of patient/resident abuse . Termination 08/16/2023 . Summary of Incident: . On 8/12/2023, during the course of an investigation involving suspected abuse of a resident, we were made aware that a team member reported this allegation of abuse to you on 8/8/2023, but you failed to report the allegation to the Center Administrator/Abuse Coordinator as you have been trained to do. We have concluded the investigation and substantiated the allegation of abuse. Due to your failure report the allegations per out policy you failed to protect our residents and patients, and potentially provided an opportunity for the abuse to continue. Based on this we have made the decision to separate employment effective immediately . On 09/13/2023 at 8:30 PM, a telephone interview was conducted with EI #8, Unit Manager. EI #8 said on 08/08/2023 around 10:30 PM she was made aware that EI #4 told RI #1 to shut the fuck up and placed a washcloth in RI #1's mouth. EI #8 said EI #9 and EI #11 had apparently told EI #7, prior to her being told. EI #8 said when she received the this information she tried to call EI #1 but EI #1 did not answer. EI #8 said she did not press the issue and assumed EI #1 would call her back. EI #1 said she got off at 3 or 4 AM that morning, went to bed and slept all day, EI #8 said this would have been 08/09/2023. EI #8 admitted to having opportunity on 08/10/2023 and 08/11/2023 to report to EI #1 the allegation but failed to report it. EI #8 said it should have been reported by EI #7 since EI #7 knew about it hours before she did. EI #8 said the time frame for reporting abuse when you are made aware of it is immediately and it should be reported to EI #1 the Abuse Coordinator. EI #8 said there was plenty of opportunity for everyone who knew about the incident to report it. EI #8 said it was important to report abuse immediately, especially when a perpetrator had been identified, to be sure the perpetrator was removed from the facility. When asked did she get written statements from EI #9 and EI #11, the volunteer who witnessed the incident, EI #8 said no she assumed EI #7 had done that since she was initially informed of the situation. Review of a PROGRESSIVE DISCIPLINE FORM for EI #8 revealed the following: Name: (name of RI #8) .Position: Unit Manager LPN . Date Administered: 08/16/2023 Category 1 Violation: 1.2 Failure to report any incident of patient/resident abuse . Termination 08/16/2023 .Summary of Incident: . On 8/12/2023, during the course of an investigation involving suspected abuse of a resident, we were made aware that a team member reported this allegation of abuse to you on 8/8/2023, but you failed to report the allegation to the Center Administrator/Abuse Coordinator as you have been trained to do. We have concluded the investigation and substantiated the allegation of abuse. Due to your failure to report the allegations per out policy you failed to protect our residents and patients, and potentially provided an opportunity for the abuse to continue. Based on this we have made the decision to separate employment effective immediately . On 09/16/2023 at 5:53 PM, a follow-up interview was conducted with EI #2. EI #2 said when the allegation was brought to EI #8's attention that EI #4 had cursed RI #1 and placed a washcloth in RI #1's mouth, EI #8 was Unit Manager and was considered to be in charge at that time. EI #2 said according to the facility's abuse policy, under the investigation component, EI #4 should have been put on leave immediately and EI #11 and EI #9's statements about the incident should have been obtained. On 09/14/2023 at 6:20 PM, an interview was conducted with EI #3, the Director of Clinical Operations. EI #3 said the facility's abuse policy said alleged violations should be reported immediately to the abuse coordinator. EI #3 said the facility did substantiate the abuse allegations involving EI #4, RI #1 and RI #2. EI #3 said since EI #4 continued to work in the facility for days after the alleged incident occurred, RI #2 and other residents at the facility were not protected. 4) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Multiple Sclerosis, Muscle Weakness, Other Lack of Coordination, Bed Confinement Status and Other Reduced Mobility. RI #4's Quarterly MDS with an ARD date of 09/08/2023 indicated RI #4 had a BIMS of 13, which indicated RI #4 was cognitively intact. The Alabama Department of Public Health Online Incident Reporting System Form dated 09/02/2023, documented, . (Name of RI #4) reported to (Name of EI #10) that on 09/01/2023 (Name of EI #6, CNA) wrapped a call light around (his/her) neck. Review of text messages between EI #10, RN and EI #1, dated 09/02/2023, revealed EI #10 sent initial notification of the allegation to EI #1 on 09/10/2023 at 3:23 AM. EI #1 responded on 09/10/2023 at 6:35 AM. A telephone interview was conducted with EI #10 on 09/14/2023 at 9:33 PM. EI #10 stated during his medication pass around 9 PM, RI #4 first reported that EI #6 wrapped a call light cord around his/her neck. EI #10 said it did not register in his mind that it was abuse. EI #10 said he knew the facility's abuse policy stated that an abuse allegation should be reported immediately. EI #10 stated around 2 AM, EI #12, CNA was talking about the incident and stated that it sounded like abuse. EI #10 said at that time, he went back to RI #4 for clarification and then reported the allegation to the administrator. A review of a PROGRESSIVE DISCIPLINE FORM for EI #10 revealed the following: Name: (name of EI #10) .Position: Date Administered: 09/16/2023 .Category 1 Violation: 1.2 Failure to report any incident of resident abuse .Administrative Leave 08/17/2023 Summary of Incident: . you failed to report abuse of a resident immediately to the abuse coordinator once you were informed of the allegations. You are required to call the abuse coordinator (Administrator) with any allegations of abuse and neglect immediately as discussed in the in-services on abuse, neglect, and the elder justice act. You cannot text the Administrator on allegations of abuse. You must call to report any allegations of resident/patient abuse, neglect, or misappropriation, and please CALL until you speak to someone, no texting or leaving voicemail. A telephone interview was conducted with EI #13, LPN on 09/12/2023 at 8:41 PM. EI #13 stated she became aware of the incident of EI #6 wrapping a call light cord around RI #4's neck, when RI #4 told her on 09/01/2023 around 9 PM. EI #13 stated she went and reported the incident to EI #10 because EI #10 was the supervisor for the night. An interview was conducted with EI #1 on 09/14/2023 at 5:21 PM. EI #1 stated after RI #4 informed EI #10 and EI #13 about the incident, they should have notified her no later than two hours after being informed. EI #1 stated the facility's policy stated staff were to notify abuse coordinator immediately of allegations. EI #1 admitted this was not timely reporting and the facility's policy was not followed. ******************************************************************** On 09/20/2023 at 7:26 PM, the facility submitted an acceptable removal plan, which documented: F 607 To the best of my knowledge and belief, as an agent of Windsor House, the following allegation of compliance constitutes a written plan demonstrating actions the Center took upon awareness of the deficient practice thus removing the Immediate Jeopardy cited on 09/18/23. Preparation and execution of this allegation of compliance does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the alleged deficiencies. The allegation of compliance is prepared and/or executed solely because it is required by the provisions of Federal and State Law. Immediate Actions for All Residents Potentially Affected: RI #6 and RI #7: o EI #8 (LPN/Unit Manager) was informed about the incident on 7/28/23. o On 7/28/23 RI #6 and RI #7 were separated, and RI#7 was redirected from the room. RI #6 later reported RI #7 had touched her inappropriately. o On 7/28/23 RI #7 had a care plan initiated for wandering to include anticipating and meeting residents needs and redirection by staff to assist resident with developing more appropriate methods of coping and interaction with peers. o On 7/30/23 Administrator was notified by DNS after DNS was notified of incident by RI #6 family member. o Administrated notified ADPH on 7/30/23 and immediately initiated an investigation. o Physician notified on 7/30/23 of alleged incident. o Huntsville Police Department notified on 7/30/23 and arrived at center on 8/2/23 to take initial police report. o Ombudsman notified via email on 7/30/23 and by phone on 7/31/23. o EI#8 (LPN Unit Manager) was placed on administrative leave on 8/12/23 and terminated due to failure to report alleged abuse. On 8/16/23 EI#8 (Unit Manager) was reported to Alabama Board of Nursing. o Additional signage was added around the center on 8/12/23 for reminders for team members to report incidents and contact information for abuse coordinator (Administrator). Instructing to report allegations to the abuse coordinator, contact information included on the signage. 9 signs placed throughout the center. o All team members and center care partners (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) in-serviced regarding abuse and neglect identification, residents' safety and protection, reporting. o Team members and center care partners (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) acknowledgement of receipt of Diversicare Elder Justice Act training on 8/25/23. Signed acknowledgement of receiving education and understanding the requirements of the Elder Justice Act training beginning on 8/25/23. o Ombudsman notified on 7/31/23 and discussed reeducation with all team members (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) o Ombudsman, [NAME], provided training with team members and center care partners (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) regarding resident rights, abuse, neglect, and reporting on 9/13/23 at 7:00 am and 3:30 pm which allowed accessibility for all shifts to attend. o RI#7 was referred to Remedy Behavioral Health and seen on 9/14/23 with recommendations to continue current medication regimen, monitor for medication efficacy and side effects, and Mini [NAME] evaluation. Follow up in one to two weeks. o RI#7 has been transferred to another facility with Memory Care Unit on 9/20/23. RI#7 has been sent to a center that has a male memory care unit due to Windsor House has a Female only memory care unit. RI #2: o discharged from the center on 8/6/2023 at end of Hospice Respite Stay. o EI#4 (CNA) held resident's hands down and used profanity toward resident on 8/6/23. It was observed by EI#5 (CNA.) o EI#5 (CNA) reported the incident to EI#9 on 8/12/23 who reported to Administrator on 8/12/23. Due to delay of reporting EI#5 (CNA) was trained via phone. o Administrator notified ADPH on 8/12/23. o Administrator notified MD on 8/12/23. o The administrator notified Huntsville Police Department and attempted to notify family on 8/12/23. o Hospice was notified on 8/12/23 via phone and 8/14/23 in person Ombudsman was notified on 8/12/23. o The Ombudsman was notified on 8/12/23 via email and via phone on 8/14/23 and stated she will provide an in-service for the center. o EI#4 (CNA) was placed on administrative leave on 8/12/23 and investigation began. EI#4 (CNA) was terminated on 8/16/23 due to substantiated abuse reports identifying EI#4 as aggressor. o Full body audits conducted on residents on all halls with BIMS less than 8 on 8/13/23 with no significant findings. o Interviews conducted with residents on all halls with BIMS of 8 or greater on 8/14/23 with no significant findings. o Reported EI#4 (CNA) to CNA Registry and charges filed by Huntsville Police Department with upcoming court date on 10/15/23. o EI#5(CNA) was placed on Administrative Leave on 8/12/23 and terminated on 8/16/23. Reported to CNA registry. o Additional signage was added around the center on 8/12/23 for reminders for team members to report incidents and contact information for abuse coordinator (Administrator). o Focused Quality Assurance meeting was held with Physician and Interdisciplinary Team in attendance on 08/12/23. o All team members and center care partners in-serviced beginning 8/12/23 regarding abuse and neglect identification, residents' safety and protection, and reporting. (All team members and center care partners to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) o Team members and center care partners signed acknowledgement of receiving education and understanding the requirements of the Elder Justice Act training beginning on 8/25/23. All team members and center care partners include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services. o Ombudsman, [NAME], provided training with team members and center care partners (to include nurses, med techs, CNAs, team leaders/management, contract therapy service providers, contract housekeeping services, and contract dietary services.) regarding resident rights, abuse, neglect, and reporting on 9/13/23 at 7:00 am and 3:30 pm which allowed accessibility for all shifts to attend. RI#1: o EI#4 (CNA) placed the washcloth in RI#1 mouth, EI#11 (volunteer) removed wash cloth from her mouth and reported to EI#7 (memory care director) on 8/8/23. o EI#9 (LPN) and EI#11 (volunteer) together told EI#8 (LPN/Unit Manager) about the incident on 8/8/23. EI#8 (LPN/Unit Manager) reported to Administrator on 8/12/23. Due to delay in reporting EI#8 (LPN/Unit Manager), EI#9 (LPN), EI#11 (volunteer), EI#7 (Memory Care Director) were all placed on administrative leave pending investigation due to this incident, should have been reported immediately to the Administrator. In-services began on 8/13/23 to include abuse identification, reporting time frames, and providing safety for the residents. o Assessed RI#1 for injury by DNS and no injuries noted on 8/12/23. o Huntsville Police Department notified on 8/12/23 and came to Center to complete the report. o ADPH was notified on 8/12/23 of the incident and investigation initiated. o Focused Quality Assurance meeting was held with Physician and Interdisciplinary Team in attendance on 08/12/23. Recommendations included retraining with the team (to include nurses, med techs, CNAs, department leaders/management, contracted therapy services, contract housekeeping services, contract dietary services.) All team members and center care partners were in-serviced regarding abuse and neglect identification, resident safety and protection, immediacy of reporting expectations, and care partner managers following the Elder Justice Act guideline/follow up on findings, with post-test for knowledge retention. Also, to include customer service training and handling residents exhibiting behaviors. o MD notified on 8/12/23 and assessed RI#1 on 8/14/23 with no significant findings. o Family notified of incident on 8/12/23. o Huntsville Police Department Investigator came into center on 8/14/23 and observed resident along with interviewing staff and Administrator. Administrator received completed report from Investigator Gollop. o Ombudsman notified on 8/12/23 via email and via phone on 8/14/23 and stated she will provide an in-service for the center. o EI#4 was placed on Administrative Leave on 8/12/23 and terminated on 8/16/23 due to substantiated abuse allegations identifying EI#4 as the aggressor. o Reported EI#4 to CNA Registry and charges filed by Huntsville Police Department with upcoming court date on 10/15/23. o EI#11 (volunteer) was suspended on 8/12/23 and terminated on 8/16/23 due to failure to report. o EI#8 (LPN/Unit Manager) was placed on administrative [TRUNCATED]

Based on interviews, record review and review of a facility policy titled Change of Resident Room/Roommate, the facility failed to notify Resident identifier (RI) #7's representative when RI #7 was transferred to a different room on 07/28/2023. This deficient practice affected RI #7, one of two residents sampled for notification. Findings include: A facility policy titled Change of Resident Room/Roommate, with an effective date of 05/01/2012, revealed the following: . PROCEDURE . 2. Consent must be received from the resident and/or their legally authorized representative. 3. The notification will be documented in the progress notes . RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Disorder of the Brain, Muscle Weakness, Unsteadiness on Feet, Lack of Coordination, Cognitive Communication Deficit and Alcohol Dependence. RI #7's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) 07/24/2023, identified RI #7 as scoring a 5 on the Brief Interview for Mental Status (BIMS) indicating RI #7 had severely impaired cognition. RI #7 was also coded as needing supervision with walking in the corridor, with locomotion on and off the unit, and used a wheelchair. A review of a facility Census List, with dates and times of room changes for RI #7, revealed the following: 1) admitted to facility on 07/19/2023 to RL #4 2) Moved to room RL #1 on 07/24/2023 3) Moved to room RL #5 on 07/28/2023 A review of RI #7's Progress Notes revealed the following: . 7/24/2023 . Note Text: Room changed to Room Locator (RL) #1 . Family and supervisor aware of room change . Further review of RI #7's Progress Notes revealed there was no documentation in the Progress Notes indicating RI #7 moved to room RL #5 on 07/28/2023; or RI #7's representative have been notified of the room change. A review of RI #7's Progress Notes revealed there was no documentation on 07/28/2023, indicating RI #7 was moved to a different room or RI #7's representative had been notified of the room change. An interview was conducted with EI #2, DON on 09/16/2023 at 5:08 PM. EI #2 stated she could not keep up with how many times RI #7 had changed rooms since being admitted to the facility on [DATE]. EI #2 stated she was aware of RI #7's room change to RL #1 and RL #4. EI #2 stated, she does not know why RI #7 was moved to room RL #5 on 07/28/2023. EI #2 stated she is not sure if RI #7's representative was notified regarding the move. EI #2 stated she does not know where the documentation was of representative being notified of RI #7's room change to RL #5. EI #2 stated, usually the social worker, nurse or administrator will notify the family of room changes and document in resident's progress notes. EI #2 admitted RI #7's representative should have been notified. An interview was conducted with RI #7's representative on 09/19/2023 at 1:15 PM. RI #7's representative stated she only knew of one time RI #7's room had been moved. This deficiency was cited as a result of the investigation of complaint/report number AL00045069.

Based on interview and review of Resident Identifier (RI) #7's medical record, the facility failed to identify and address the behavioral health care needs of RI #7, a resident with repeated incidents of wandering. In addition, the facility further failed to ensure their Behavioral Assessment policy/procedure was followed to direct the staff on how to assess the resident behaviors, utilizing the Behavioral Assessment Tool to help determine the factors contributing to identified behavior problems. The facility also did not identify specific behavioral interventions for RI #7, to deal effectively with the situation of wandering, after it was document, the resident continued to wander in/out other residents' rooms. This deficient practice affected RI #7; one of three sampled residents reviewed for wandering behaviors. Findings include: The facility Behavioral Policy and Procedure with an effected date of May 1, 2012 identified, Behavioral Assessment .PURPOSE it is the policy of this facility to assess a resident behavior, utilizing the Behavior Assessment Tool to help determine the factor(s) contributing to identified resident behavior problem(s) . PROCEDURE Social Service/Nursing completes the Behavioral Assessment Tool whenever . danger to harm others .The Behavior Assessment Tool is used to explore possible cause for the resident behavior. RI #7 was readmitted to the facility on [DATE] with an admitting diagnosis of Disorder of Brain, Unsteadiness on Feet and Cognitive Communication Deficit. The Admission Minimum Data Set for RI #7, with an assessment reference date of 07/24/2023 indicated RI #7 was severely impaired in cognitive skills for daily decision making. According to this MDS, RI #7 displayed no physical behavioral symptoms directed toward others. The facility's Progress Notes for RI #7 identified the follow episodes of wandering into other resident's rooms without successful interventions being implemented: 07/24/2023 at 5:47 PM written by Employee Identifier (EI #9), a Licensed Practical Nurse, documented Room changed to 302A D/T resident going to glass doors. Redirection unsuccessful resident is sitting by the glass doors at this time. This nurse asked resident what he was doing down their resident stated, just looking. 07/25/2023 at 1:10 PM written by Employee Identifier (EI #9), a Licensed Practical Nurse, documented Resident is roaming the hallways going to glass doors and pushing the handles. Resident has been noted to be going into all the other resident s room on the hall. Redirection unsuccessful continues to enter other residents' room unwanted. 07/26/2023 at 6:59 PM written by Employee Identifier (EI #9), a Licensed Practical Nurse, documented . Self propels in wheelchair into other residents' room and has complaints of resident rumbling through things in other resident's rooms. Redirection unsuccessful wandering continues. 07/27/2023 at 5:47 PM written by Employee Identifier (EI #8), a RN Unit Manager, documented . Propels self in w/c in hallways with frequent redirection needed due to entering other residents' rooms uninvited . 07/28/2023 at 12:35 PM written by Employee Identifier (EI #16), a Director Care Coordinator documented . Care plan with patient and (him/her) family . They also stated that a patient would often enter (RI # 6's) room wandering around lost . 07/29/2023 at 1:05 PM written by Employee Identifier (EI) #9, a Licensed Practical Nurse, documented .Resident ambulates self in room without calling for assistance. Self-propels in wheelchair into other resident's rooms has been placed on 15 min watch. The facility initiated a care plan on 07/28/2023 for RI #7's wandering with three interventions, one intervention was added while survey was in progress. The interventions documented in care plan were to, . Anticipate and meet the resident's needs. Date initiated: 07/28/2023 .Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feeling appropriately. Date initiated: 07/28/2023 Revision on: 09/18/2023 . Resident placed on 1:1 supervision. Dated initiated: 09/17/2023 Revision on: 09/17/2023. None of the interventions listed were specific to address wandering in/out of resident rooms. On 08/14/2023 the facility received verbal consent from RI #7's sponsor for referral to Remedy Behavioral Health however, behavioral did not visit the resident until 09/14/2023. Behavioral Health documented, Initial visit w/Remedy Behavioral health to evaluate cognition and behaviors It is my opinion the patient is good candidate and would benefit from Psychiatric services and treatment. An interview with the Remedy Behavioral Health CRNP (Certified Registered Nurse Practitioner) on 09/16/2023 at 12:00 PM, confirmed she did not receive the referral until 09/14/2023. My recommendation was to do a Mini Mental Status Exam, but I did not do it because he was so distracted. 09/17/2023 in the early AM a note was placed under DON door that RI #7 wandered had into RI #9 a female resident's room and he/she refusal to stay out of him/her room The note also documented that RI #7 was also wandering into other resident room. A review the progress notes revealed the LPN did not document this behavior and only left the note for the DON regarding RI #7 behaviors. On 09/14/2023 and interview was conducted with EI #5 (CNA) a direct care staff member who identified RI #7 was known to wander. EI #5 said one intervention used was to transfer RI #7 to another room because of a complaint of him/her wandering to into RI #6's room. On 09/16/2023 1:00 PM, an interview was conducted with EI #18 Social Services Director (SSD) regarding the Behavioral Assessment Tool to explore possible causal or RI #7 behavior. EI #18 said she was not made aware of the incident until the police showed up. EI #18 said the Behavioral Assessment should be implemented Quarterly or after an incident has taken place. EI #18 said in a normally run facility Social Services completes the assessment. EI #18 did say in the interview that the Behavioral Assessment Tool should have been completed when the incident occurred but was not completed. EI #18 said she was told not to complete the Behavioral Assessment Tool because the Administrator was handling it. EI #18 said it would have been important for her to complete the assessment because it would have allowed her to monitor the resident. An interview was conducted on 09/17/2023 at 1:00 PM, with Director of Nursing Services (DNS) EI #2 regarding RI #7 Behavioral Assessment Tool. EI #2 said, the tool is used to establish possible causes of the behavior. Usually, if a resident has a behavior the nurse should document the behavior and the Social Worker assist the care plan staff in updating the care plan. EI #2 said, she did not think the Behavioral Assessment Tool was completed on RI #7. The DNS said the Social Worker was responsible for completing the Behavioral Assessment Tool and was responsible for behavioral monitoring/management. EI #2 said once EI #13 became aware of RI #7's recent behavior of wandering she should have documented the behavior and placed RI #7 on one to one and make sure he/she did not wander into another resident's room. An interview was conducted with the Administrator (EI #1) on 09/18/2023 at 01:30 PM, regarding RI #7's wandering behavior. EI #1 said it was a collaboration of everyone to revise the care measure to prevent reoccurring behavior and the measure should be documented. EI #1 said that specific intervention used with RI #7 were to increased activities involvement, do every 15 minutes checks for medical issues and notify the physician of new behaviors. This deficiency was cited as a result of the investigation of complaint/report number AL00045069.

Based on interviews, record review and review of a facility policy titled Means of Egress, the facility failed to maintain an environment that was free of accident hazardous. Resident Identifier (RI) #7, a resident with a history of wandering in and out of other resident's room, began to exhibit more frequent wandering behaviors, and on 07/28/2023, facility staff built a barricade across the hallway to prevent the resident from wandering. This affected RI #7, one of three sampled residents care planned for wandering, and had the potential to affect all residents residing in Room locators (RL) 2-5. Findings include: Review of a facility policy titled Means of Egress, with an effective date of 09/01/2014, revealed the following: . PURPOSE To safeguard residents, visitors, and personnel by ensuring all emergency egress paths and exits are clear, unobstructed, completely accessible and illuminated from any residential area within the center to a public way . PROCEDURE . 1. Clean linen, soiled linen bins, housekeeping carts, computers on wheels, food carts, etc. are permitted while in use - 30 minutes or less Walking surface must be . unobstructed at all times . RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Disorder of the Brain, Muscle Weakness, Unsteadiness on Feet, Lack of Coordination, Cognitive Communication Deficit and Alcohol Dependence. RI #7's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/24/2023, identified RI #7 as scoring a 5 on the Brief Interview for Mental Status (BIMS) indicating RI #7 had severely impaired cognition. RI #7's Progress Notes revealed the following: . Effective Date: 07/25/2023 . Type: Behavior Charting . Resident has been noted to be going into all the other resident's room on the hall. Redirection unsuccessful continues to enter other residents' room unwanted . Effective Date: 07/26/2023 . Type: Daily skilled Nurses Note Summary: . Self propels in wheelchair into other residents' room and has complaints of resident rumbling through things in other residents' rooms. Redirection unsuccessful wandering continues . Effective Date: 07/29/2023 . Type: Daily skilled Nurses Note Summary: . Self propels in wheelchair into other residents' rooms . RI #6 was admitted to the facility on [DATE] with diagnoses to include Muscle Weakness and Unsteadiness on Feet. RI #6's MDS assessment, with an ARD of 07/28/2023 revealed RI #6 scored a 14 on the BIMS indicating RI #6 was cognitively intact. On 09/12/2023 at 5:00 PM a telephone interview was conducted with RI #6. RI #6 said RI #7 had wandered into his/her room twice and a barricade had been made to keep RI #7 out of his/her room. RI #6 said the barricade was made with a nurses' cart and an ice chest. On 09/16/2023 at 12:27 PM, an interview was conducted with Employee (EI) #1, the Administrator. EI #1 was shown a picture received by the State Agency of the barricade. EI #1 said the picture looked like the facility, and based off the chandelier in the picture, it looked like it was in the unit where RI #7 resided. EI #1 identified nurses' carts, an ice chest, and a linen cart in the picture blocking anyone attempting to leave RL #'s 2-5. RI #7 was residing in RL #5. EI #1 said the harm of the barricade was the residents could knock the barricade over and fall. On 09/16/2023 at 5:08 PM, an interview was conducted with EI #2, the Director of Nursing. EI #2 was shown the picture received by the State Agency of the barricade. EI #2 said the residents have attempted to get through the barrier and fall. EI #2 said that would not be safe. This deficiency was cited as a result of the investigation of complaint/report number AL00045069.

Based on observations, interviews, and facility policies titled Types of Maintenance and Room Audit the facility failed to provide necessary maintenance services to maintain good repair of equipment and a home like environment. This deficient practice was observed on 1 of 4 days of the survey and had the potential to affect Resident Identifier (RI) #19 and RI #20 and the residents residing on the 100 hall and 200 hall, two of three halls in the facility. Findings include: An undated facility policy titled TYPES OF MAINTENANCE documented: . 1. Preventative Maintenance . is focused on preserving the physical integrity and value of the property. Preventative maintenance consists of regular maintenance activities and routine inspections that are done to prevent problems . 3. Corrective Maintenance These are actual repairs that keep the property functioning normally and usually need to be done as soon as possible. This type of maintenance includes . fixing a dripping faucet, unclogging drains . repairing a non-functioning toilet . A facility policy titled Room Audit with an effective date of 9/1/2014 documented: . Purpose To assess residents rooms to identify items that should be repaired, replaced or addressed to ensure a home-like standard that meets acceptable standards . On 8/23/2023 at 9:33 AM the surveyor began making observations of environmental concerns in the facility. Handrails on the 100 and 200 halls were scrapped and discolored. There were cracked and broken floor tiles on the 100 hall, and discolored ceiling tiles on the 200 hall. RI #20 who resided in room [ROOM NUMBER] stated the paint in the bathroom was chipped and peeling, the sink drained slowly and held water, and the toilet leaked when flushed. RI #20 stated he/she had told maintenance about the issues in the room but the concerns had not been addressed. The surveyor observed the slow draining sink, leaking toilet, and chipped and peeling paint in room [ROOM NUMBER]. RI #19 who resided in room [ROOM NUMBER] said, the paint in the bathroom was chipped and peeling, the sink faucet dripped, and the toilet was loose and leaked when flushed. RI #19 said, he/she had told maintenance about the concerns but they had not been addressed. The surveyor observed the leaking faucet, leaking toilet, and chipped and peeling paint in room [ROOM NUMBER]. An interview was conducted with Employee Identifier (EI) #12, Maintenance Supervisor, on 8/23/2023 at 2:45 PM. EI #12 said, his duties included repairs and ongoing maintenance of the building. EI #12 said, he became aware on 8/22/2023 of the concerns in room [ROOM NUMBER]. EI #12 said he was not aware of the concerns in room [ROOM NUMBER]. EI #12 was asked why the sinks and toilets should be in working order in a resident's room. EI #12 said this was their home and they should have working sinks and toilets. EI #12 said, he did not consider chipped paint, leaking toilets, leaking faucets, and slow draining sinks to be a homelike environment for the residents. EI #12 was asked about the maintenance of the hand rails and he said, it was part of routine maintenance. EI #12 said, the handrails were scrapped and discolored due to wear and tear from the residents holding the rails. EI #12 stated, the handrails were not homelike and needed to be sanded, painted or stained. EI #12 said, the facility should be homelike because it was the resident's home. On 8/23/2023 at 3:15 PM the surveyor with EI #12, Maintance Supervisor, observed the scrapped and discolored hand rails on the 100 and 200 halls, broken tile on the 100 hall, room [ROOM NUMBER] and 115 sink and bathroom concerns and discolored ceiling tiles on the 200 hall. EI #12 said, the tile needed to be repaired in front of the shower room and he would start working on the concerns in room [ROOM NUMBER] and room [ROOM NUMBER]. This deficiency was cited as a result of the investigation of complaint/report numbers AL00043510 and AL00044803.

Based on observations, interviews, and review of a facility policy titled Medication Administration the facility failed to ensure Employee Identifier (EI) #4 prepared medications for administration in accordance with good nursing principles and practices and disposed of medications according to facility policy and procedure. On 8/22/2023 EI #4 was observed sitting at the nurses station with medications she was preparing for two different residents, Resident Identifier (RI) #16 and RI #17. EI #4 said she was confused and was unable to describe what medications were in each of the two cups that she had prepared to administer, and threw the cups of prepared medication into the trash bag on the medication cart. EI #4 was one of three nurses observed during medication administration and had the potential to affect RI #16 and RI #17, two of four residents for whom medications were observed being prepared and administered. Findings include: A facility policy titled Medication Administration with a review date of 4/2022 documented: POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices . Personal authorized to administer medications do so only after they have familiarized themselves with the medications. PROCEDURE: Medications are prepared, administered, and recorded . A facility policy titled Medication Destruction with a review date of 4/2022 documented . POLICY: . All medications are destroyed on facility premises or are to be picked up and destroyed by an environmental agency. Procedure: . The refusal and wasting of medication MUST be documented . Documentation should include: Date Reason for refusal and disposal Nurse's signature . RI #16 was admitted to the facility on [DATE]. RI #17 was admitted to the facility on [DATE]. On 8/22/2023 at 9:30 AM EI #4, Licensed Practical Nurse (LPN) was observed sitting behind the nurses station with the medication cart open and pulled up behind her. EI #4 had two medication cups in front of her on the counter, a medication card in her right hand, and was placing medication in the cup on her right. When asked if it was time to administer medications, EI #4 said, she was getting these 2 (two) ready. EI #4 returned the medication card to the cart and stood up. When asked who the residents were she was preparing medication for, EI #4 picked up both medication cups, one in each hand. EI #4 lifted her right hand and said that was RI #16's and nodded to her left hand and said that was RI #17's. When asked what medications were in the cup in her right hand and who it was for, EI #4 said, it was for RI #16 and there was an Eliquis and four magnesium oxide in the cup. When asked what was in the other cup and who it was for, EI #4 said, I cannot remember, you have confused me. EI #4 was asked again what medications were in the cup in her left hand, and who it was for. EI #4 said, I am confused. EI #4 then took both cups of medication and threw them in the trash bag on the trash bin of the medication cart. When asked what the policy was for passing medications, EI #4 did not reply. When asked what the policy was for discarding medications not given, EI #4 stated, you are trying to nail someone to the wall. On 8/22/23 at 11:19 AM a follow-up interview was conducted with EI #4 LPN. When asked how medications should be passed, EI #4 said, an hour before or an hour after it was scheduled. When asked if she should prepare two medications at one time, EI #4 said no, she should not. When asked about potential harm of preparing and giving two medications at one time, EI #4 said, they could get switched up and the wrong medication could be administered. When EI #4 was asked about the potential negative outcome of not disposing of medication properly per facility policy, EI #4 said, someone or a resident could get the medication if not disposed of properly. On 8/23/2023 at 2:30 PM EI #2, Director of Nursing (DON) was asked about the policy for preparing and giving medications. EI #2 said, the nurse was to roll the medication cart to the resident's door, sanitize hands, prepare the medication according to the Medication Administration Record (MAR), give the medication, sign out the medication as given, then sanitize hands and go to the next resident. EI #2 said, the nurse should roll the cart to the resident room and not be sitting at the station preparing medications. When asked what the potential harm would be in preparing two resident medications at the same time, EI #2 replied, she could get them mixed up and give the wrong medication to the residents. EI #2 was asked about the method of discarding of medication used by EI #4. EI #2 said, they discard medications not given to a resident in the destroyer solution. When asked about the potential harm in placing the medications in the trash on the medication cart, EI #2 said, the risk was for someone to get it from the trash and take it. On 8/24/2023 at 11:10 AM, EI #3 Pharmacist was asked about the observation of EI #4 from 8/22/2023. EI #3 said, medication for only one resident at the time should be prepared because the risk was becoming confused about the medication. When informed about EI #4 discarding medications in the trash bag on the medication cart, EI #3 said, that was not the policy for destroying medication and it should go in the destroyer bottle.

Based on interviews and resident record reviews, the facility failed to ensure: Employee Identifier (EI) #7 documented Activity of Daily Living (ADL) on 5/26/2023 in the medical record for Resident Identifier (RI) #7; EI #8 documented ADL on 5/27/2023 and 5/29/2023 in the medical record for RI #7; and EI #9 documented ADL on 5/23/2023, 5/24/2023, 5/26/2023, 5/30/2023, and 5/31/2023 in the medical record for RI #7. This had the potential to affect RI #7 one of fifteen residents for whom records were reviewed. Findings include: RI #7 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #7's Documentation Survey Report for May 2023 had blank spaces for ADL Bathing from 5/23/2023 through 5/31/2023. There was not any documentation in the record to reflect that baths had been provided for that time frame. On 8/23/2023 at 4:49 PM, an interview was conducted with EI #7, Certified Nursing Assistant (CNA). EI #7 stated she was assigned to RI #7 on 05/26/2023 and provided a bath for the resident on that date but did not document because she did not have access to the computer system. On 8/23/2023 at 4:55 PM, an interview was conducted with EI #8, CNA. EI #8 stated he was assigned to RI #7 on 05/27/2023 and 05/29/2023 and provided a bath for the resident on those dates but just forgot to document. On 8/24/2023 at 11:29 AM, an interview was conducted with EI #9, CNA. EI #9 stated she was assigned to RI #7 on 5/23/2023, 5/24/2023, 5/26/2023, 5/30/2023, and 5/31/2023 and provided a bath for the resident on those days. When asked why she did not document the bath, EI #9 stated, she was unable to log into the computer system. On 08/24/2023 at 3:06 PM, an interview was conducted with EI #2 Director of Nursing (DON). EI #2 stated that baths were not documented on 5/23/2023, 5/24/2023, 5/25/2023, 5/26/2023, 5/27/2023, 5/28/2023, 5/29/2023, 5/30/2023, and 5/31/2023 and the baths should have been documented. EI #2 stated, the risk of not documenting the baths was they would not know if it was provided or not.

Based on observations, interviews, resident record review, and review of a facility policy titled Handwashing/Hand Hygiene the facility failed to ensure Employee Identifier (EI) #6, Certified Nursing Assistant (CNA), did not create the potential for cross-contamination during meal delivery on 8/23/2023 when she was observed not washing or sanitizing her hands after handling a dirty meal tray before touching the clean tray cart and coffee service container. This had the potential to affect residents who received meal trays on unit one. Findings include: A facility policy titled Handwashing/Hand Hygiene with an effective date of 11/1/2017 documented the following: . POLICY This center considers hand hygiene the primary means to prevent the spread of infections. POLICY INTERPRETATION AND IMPLEMENTATION . 5. Use an alcohol-based hand rub or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . m. Before and after eating or handling food; . On 8/23/2023 at 7:58 AM, EI #6 CNA was observed with a dirty breakfast tray in her bare hands, walking down the hall to put the dirty tray on a cart. EI #6 then walked to the clean breakfast tray cart and started pushing it down the hallway without sanitizing or washing her hands. EI #6 then picked up the coffee pot and set it down, then opened the clean food cart door, all before washing or sanitizing her hands. On 8/23/2023 at 8:10 AM EI #6 CNA was asked, when was she supposed to wash or sanitize her hands. EI #6 responded, before entering and after leaving every room. EI #6 stated, that the facility policy was to wash or sanitize hands before entering and after leaving every room. EI #6 stated, she did not sanitize or wash her hands before touching the clean cart after handling the dirty tray. EI #6 stated, the risk of not washing or sanitizing her hands after touching a dirty tray was the spread of germs and infections. EI #6 stated, she should have washed or sanitized her hands after touching the dirty tray. On 8/24/2023 at 3:06 PM EI #2 Director of Nursing (DON) was asked, according to policy when should staff wash or sanitize their hands. EI #2 responded, before entering a room, when visibly dirty, when in contact with a resident, when leaving the room, and when delivering or picking up the trays. EI #2 stated, the risk for what EI #6 had done, was contamination of everything she touched. EI #2 stated, she should have set the dirty tray down and then she should have washed or sanitized her hands.

Based on interviews, record review, a review of a facility policy titled, Customer Concern (Grievance) Policy, the facility failed to ensure the grievance process was followed when Resident Identifier (RI) #5 reported that a staff member refused to get him/her some ice. This deficient practice affected RI #5 one of three residents reviewed for grievances. Findings include: A review of a facility policy titled, Customer Concern (Grievance) Policy, with an effective date of July 2018 revealed: .PURPOSE Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution. PROCESS: . Customer concerns will have a prompt response. The concern will be recorded on the Customer Concern Form either by the team member who has received the concern or by the customer (patient/resident). Administrator or designee will enter information from the form to the Customer Concern Log. The completed Customer Concern Form will be retained in the Administrator's office for a period of three years. RI #5 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/27/2022, documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. On 8/23/22 at 8:15 AM, an interview was conducted with RI #5. When asked about the staff, RI #5 stated that he/she asked an aide (Certified Nursing Assistant/CNA) to get him/her some ice some time back and was told that he/she could walk so, he/she could get it him/herself. RI #5 stated that he/she had reported the incident, but nobody had ever came back and told him/her anything about it. On 8/23/22 at 3:35 PM, surveyor requested Grievance Log for the last six months from Employee Identifier (EI) #2, Registered Nurse (RN)/Director of Nursing (DON) and she said she would go get it. On 8/23/22 at 4:11 PM, EI #2, RN/DON, came back and said There is no Grievance Log. I was told we just address grievances as they occur but don't keep a log. On 8/25/22 at 5:15 PM, an interview was conducted with EI #1, Administrator. When asked what the facility policy about the concern/grievance process was, she said that if there was a grievance they were supposed to write it up on a form, put it on a log, resolve the issue and then go back and write how it was resolved and if they were able to satisfy the resident. When asked if it had been reported to her that RI #5 had asked for a CNA to get him/her ice and was told that he/she could walk and to get it him/herself, EI #1 said no. When asked if the grievance process/policy had been followed, EI #1 said no, because there was no log or record of any concerns/grievances being addressed.

Based on an observation, interviews, review of medical records, and review of a facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Resident Identifier (RI) #1's Injuries of Unknown Source were reported to the State Agency within twenty-four hours after the facility staff became aware on 2/25/2022 and 5/5/2022. This affected one of four residents sampled for abuse. Findings Include: A review of a facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed: Purpose: To prohibit and prevent abuse, neglect, . and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, .) in accordance with Federal and State Laws. Definitions: . Injuries of Unknown Source: When both of the following criteria are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or location of the injury . or the number of injuries observed at one particular point in time or the incidence of injuries over time. The following protocol has been established in the event of an allegation of abuse: . 7. Reporting/Response . Immediately reporting all alleged violations to the . state agency . within specified timeframes. When . Alleged Violations . All alleged violations- immediately but not later than 1. 2 hours if the alleged violation involves abuse or results in serious bodily injury 2. 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. RI # 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A closed medical record review documented the following Progress Notes: . Created Date: 2/25/2022 10:40 Effective Date: 2/25/2022 08:47 Type: General Notes Note Text: CNA reported to nurse resident had some swelling and bruising. Upon assessment resident noted to have swollen right thumb red and purple in color. Area tender to touch. Resident also noted to have swelling to left forearm no discoloration noted and tender to touch. Created Date: 5/5/2022 08:51 Effective Date: 5/5/2022 08:49 Type: General Notes Note Text: Resident noted to have red raised area to right lower lip with discoloration. Resident also has discoloration to inside of right lower lip dark in color. Resident has noted discoloration and small amount of swelling to right cheek. A review of incidents reported to the State in the last six months provided by the Administrator revealed that no incidents were reported for RI #1 on 2/25/2022 or 5/5/2022. RI #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/25/2022, documented RI #1 was severely impaired for Cognitive Skills for Daily Decision Making and required extensive assistance of staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. RI #1 was assessed as being totally dependent on staff for bathing. On 8/25/22 at 3:28 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Director of Nursing. EI #2 was asked what injuries of unknown source were and she replied, an injury that was unwitnessed and the source of the injury could not be explained by the resident and was suspicious. When asked when those injuries should be reported, she said within two hours or 24 hours depending on the severity. When asked to review the incident report on 2/25/2022 and describe the injuries documented for RI #1, she stated, swollen and discolored right thumb with swollen left forearm, there was no known cause, and it would have been suspicious since there was also injury to the left forearm in addition to the right thumb. When asked to review the progress note on 5/5/2022 regarding RI #1 having a red raised area to right lower lip with discoloration, swelling to right cheek and discoloration to inside of right lower lip dark in color, and asked should those injuries have been considered injuries of unknown source, EI #2 said yes. When asked if the injuries of unknown source on 2/25/2022 and 5/5/2022 were reported to the State, EI #2 said no. On 8/25/22 at 5:15 PM, an interview was conducted with EI #1, Administrator (ADM). When asked what injuries of unknown source were and what should be done about them, she stated if the source of injury was not witnessed and could not be explained by the resident and was suspicious to extent or location of the injury, they should be reported to State within two hours if major injury and within 24 hours if not a major injury. When asked if RI #1's injuries of a swollen right thumb that was red and purple in color and tender to touch and swelling to left forearm that was tender to touch that was documented on 2/25/2022 met the definition of unknown source since the resident was unable to describe what happened and the nurse could not determine what happened, EI #1 said yes. When asked if she reported it to the State, EI #1 said no, but she should have. When asked if RI #1's injuries documented on 5/5/2022 of a red raised area to right lower lip with discoloration, swelling to right cheek and discoloration to inside of right lower lip dark in color should have been considered injuries of unknown source, EI #1 said yes and she should have reported them, but she did not. When asked what the concern with those injuries not being reported was, EI #1 said not following reporting guidelines from our abuse policy and we did not document an investigation like we would have with a five-day if it had been reported. This deficiency was cited as a result of investigation AL 001.

Based on interviews, record reviews, a review of Potter and Perry, Fundamentals of Nursing, a review of NINTH EDITION, and Facility's form titled Clean Dressing Change the facility failed to document wound treatments on Resident Identifier (RI) #2, #3, #4, #5 and #6 April 2022 Treatment Administration Records (TAR). This affected RI #2, #3, #4, #5 and #6, five of six residents sampled for wound concerns. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 370, revealed the following: .Chapter 26 Documentation and Informatics .Informatics and Information Management In Health Care .A nurse's electronic or handwritten signature on an entry in a record designates accountability for the contents of that entry . Review of undated facility's form titled Clean Dressing Change documented .20. Document procedure . 1) RI #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2's TAR for April 2022 documented Clean wound to sacrum with normal saline, pat dry, apply hydrogel with gauze, and cover with [MEDICATION(S)] border gauze daily and prn. One time a day for wound treatment-Order Date- 01/26/2022 . A review of the April 2022 TAR revealed missing documentation for wound care on the following days, 04/05/22, 04/09/22, 04/16/22, 04/19/22, 04/22/22, 04/28/22, 04/29/22 and 04/30/22. On 05/06/22 at 11:45 AM, an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/Wound Treatment Nurse. EI #2 stated she was assigned to RI #2 on 04/5/22, 04/16/22, 04/19/22, 04/22/22, 04/28/22 and 04/29/22 and provided wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It just slipped my mind. I did the treatments just didn't chart it. On 05/06/2020 at 12:21 PM, a telephone interview was conducted EI #6, LPN. EI #6 stated she was assigned to RI #2 on 04/09/22 and 04/30/22 and provided wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, Sometimes in nursing you get sidetrack with something more important. 2) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #3's TAR for April 2022 documented DuoDerm CGF Border Miscellaneous (Control Gel Formula Dressing) Apply to Coccyx topically one time a day every 7 day(s) for wound healing- Order Date- 11/12/2021 . A review of the April 2022 TAR revealed missing documentation for wound care on the following days, 04/16/22 and 04/30/22. On 05/06/22 at 12:03 PM, an interview was conducted with EI #1 Registered Nurse (RN), Director of Nursing (DON). EI #1 stated was assigned to RI #3 on 04/30/22 and conducted wound care treatment. EI #1 admitted she did not documented treatment performed on RI #3's TAR. She stated, I don't why I didn't chart either I forgot to go back and do it or got interrupted in the middle of the process. On 05/06/22 at 12:21 PM, a telephone interview was conducted with EI #6, LPN. EI #6 stated she provided wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #6 admitted she did not document treatment on RI #3's TAR. She stated, Sometimes in nursing you get sidetrack with something more important. 3) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #4's TAR for April 2022 documented Clean sacrum area with normal saline, pat dry, apply hydrogel with gauze, and cover with [MEDICATION(S)] border gauze daily and prn until healed. One time a day for wound treatment .-Order Date- 01/26/2022 . A review of the April 2022 TAR revealed missing documentation for wound care on the following days 04/02/22, 04/03/22, 04/06/22, 04/12/22, 04/16/22, and 04/30/22. On 05/06/22 at 11:45 AM, an interview was conducted with EI #2, LPN/ Wound Treatment Nurse. EI #2 stated she was assigned to RI #4 on 04/03/22, 04/06/22 and 04/12/22 and provided wound treatment on those dates. When asked why she didn't document the treatment she provided, EI #2 stated, Just got overwhelmed in doing other jobs. It just slipped my mind. I did the treatments just didn't chart it. On 05/06/22 at 12:03 PM, an interview was conducted with EI #1, RN, DON. EI #1 stated she was assigned to RI #4 on 04/02/22 and 04/30/22 and provided wound care treatment to resident. EI #1 admitted she did not documented treatment performed on RI #4's TAR. She stated, I don't why I didn't chart either I forgot to go back and do it or got interrupted in the middle of the process. On 05/06/22 at 12:21 PM, a telephone interview was conducted with EI #6, LPN. EI #6 stated she provided wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #6 admitted she did not document treatment on RI #4's TAR. She stated, Sometimes in nursing you get sidetrack with something more important. 4) RI #5 was admitted to the facility on [DATE] and readmitted [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5's TAR for April 2022 documented Clean area to lower back with normal saline, pat dry, apply [MEDICATION(S)] packing stip, cover with border gauze daily until healed. One time a day - Order Date- 03/25/22 .Clean Sacrum with normal saline, pat dry, apply hydrogel with gauze daily and cover with border gauze until healed. One time a day- Order Date- 03/13/2022 . A review of the April 2022 TAR revealed missing documentation for wound care on the following days 04/01/22, 04/02/22, 04/03/22, 04/04/22, 04/05/22, 04/08/22, 04/09/22, 04/10/22, 04/11/22, 04/12/22, 04/13/22, 04/16/22, 04/17/22, 04/18/22, 04/19/22, 04/20/22, 04/21/22, 04/22/22, 04/23/22, 04/24/22, 04/25/22, 04/26/22, 04/27/22, 04/28/22, 04/29/22, and 04/30/22. On 05/06/22 at 10:05 AM, a telephone interview was conducted with EI #7, LPN. She stated she was assigned to work with RI #5 on 04/09/22, 04/10/22, 04/16/22, 04/17/22, 04/23/22, 04/24/22 and 04/30/22. EI #7 stated she provided wound care for RI #5 and admitted she did not document treatment on TAR. EI #7 stated, To be honest I don't have an excuse . On 05/06/22 at 11:45 AM, an interview was conducted with EI #2, LPN/ Wound Treatment Nurse. EI #2 stated she was assigned to RI #5 on 04/01/22, 04/04/22, 04/05/22, 04/08/22, 04/09/22, 04/11/22, 04/12/22, 04/13/22, 04/18/22, 04/19/22, 04/20/22, 04/21/22, 04/22/22, 04/25/22, 04/26/22, 04/27/22, 04/28/22 and 04/29/22. She stated, she provided wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It just slipped my mind. I did the treatments just didn't chart it. 5) RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #6's TAR for April 2022 documented, Clean left heel with normal saline, pat dry and apply hydrogel with gauze daily, Cover with [MEDICATION(S)] until healed. One time a day -Order Date- 03/25/22 .Clean sacrum wound with normal saline, pat dry, apply hydrogel with gauze, and cover with mepliplex border gauze daily until healed, and prn. One time a day for wound treatment- Order Date- 01/26/22 . A review of the April 2022 TAR revealed missing documentation for wound care on the following days 04/02/22, 04/03/22, 04/06/22, 04/12/22, 04/16/22, 04/17/22 and 04/30/22. On 05/06/22 at 11:45 AM, an interview was conducted with EI #2, LPN/ Wound Treatment Nurse. EI #2 stated she was assigned to RI #6 on 04/03/22, 04/06/22, and 04/12/22. She stated, she provided wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It just slipped my mind. I did the treatments just didn't chart it. On 05/06/22 at 12:03 PM, an interview was conducted with EI #1, RN, DON. EI #1 stated she with was assigned to RI #6 on 04/02/22, 04/17/22 and 04/30/22. She stated she provided wound care treatment to resident. EI #1 admitted she did not documented treatment performed on RI #6's TAR. She stated, I don't why I didn't chart either I forgot to go back and do it or got interrupted in the middle of the process. EI #1 admitted the facility has had a problem with staff completing documentation for care provided to resident. EI #1 stated education has been provided to staff and an in-service was done a few months ago. On 05/06/22 at 12:21 PM, a telephone interview was conducted with EI #6, LPN. EI #6 stated she was assigned to RI #6 on 04/16/22 and provided wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, Sometimes in nursing you get sidetrack with something more important. This deficiency was cited as a result of investigation AL 802.

Based on record review and interviews and a review of Policy titled Notification of change in Patients/Resident Health Status, the facility failed to ensure Resident Identifier (RI) #1's sponsor was notified when RI #1 was transferred to the hospital on 4/26/22. This deficient practice affected RI #1; 1of 5 residents sampled for wound care. Findings Include: RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 has a BIMs of 11. On 05/02/2022, the Alabama State Survey Agency received a complaint which revealed the following: . resident transferred to Huntsville hospital for [CONDITION(S)] and leg pain. It was found upon arrival and assessment by the physician resident had multiple wounds with a maggot infestation overflowing from the wounds and crawling on his legs, feet and between his toes . A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was coded as requiring the assistance of one-person physical assist with dressing, bathing, personal hygiene and walking. On 05/04/22 at 9:05 p.m., an interview was conducted with RI #1's legal guardian's representative, (Name). The legal guardian of record for RI #1 stated he/she was not notified by the facility of RI #1 transfer out of the facility to the Hospital on 4/26/22. On 05/05/22 at 2:15 p.m., an interview was conducted with Employee Identifier (EI) #3, the Nurse who sent RI #1 to the hospital. The surveyor asked EI #3 was RI #1's legal guardian notified that RI #1 was sent to the hospital on 4/26/2022. EI #3 said no. When asked should the legal guardian have been notified, EI #3 said yes. On 05/05/22 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON), EI #1. When asked if RI #1's sponsor should have been notified when RI#1 was transferred to the hospital. EI#1 stated yes. EI#1 was asked what the facilities policy on notification of change in resident health status is. EI#1 stated, just that we have to notify the sponsor. EI#1 was asked, did you follow the facilities policy on notification. EI#1 stated no. This deficiency was cited as a result of the investigation of complaint/report #AL 802.

Based on interviews, record reviews, and a review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION, the Nursing staff failed to ensure treatment was provided to Resident Identifier (RI) #3, #4, and #6 per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected three of six residents sampled for Pressure Ulcer treatment. Findings Include: Review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 31, revealed the following: .Chapter 23 Legal Implication in Nursing Practice .Health Care Provider's Orders. The health care provider (physician .) is responsible for directing medical treatment. Nurses follow health care provider's orders unless they believe the orders are in error or harm patients . 1) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #3's Treatment Administration Record, (TAR) for April 2022 documented DuoDerm CGF Border Miscellaneous (Control Gel Formula Dressing) Apply to Coccyx topically one time a day every 7 day(s) for wound healing . 2) RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #4's Treatment Administration Record for April 2022 documented Clean sacrum area with normal saline, pat dry, apply hydrogel with gauze, and cover with [MEDICATION(S)] border gauze daily and prn until healed. One time a day for wound treatment . 3) RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #6's Treatment Administration Record for April 2022 documented, Clean left heel with normal saline, pat dry and apply hydrogel with gauze daily, Cover with [MEDICATION(S)] until healed. One time a day . Clean sacrum wound with normal saline, pat dry, apply hydrogel with gauze, and cover with [MEDICATION(S)] border gauze daily until healed, and prn. One time a day for wound treatment . On 05/06/22 at 11:12 AM, a telephone interview was conducted with Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN). EI #4 stated she was assigned to work with RI #3, #4 and #6 on 04/23/22 day shift from 7am-3PM. EI #4 stated she did not provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/06/22 at 2:26 PM, a telephone interview was conducted with EI # 5, LPN. EI #5 admitted she was assigned RI #3, #4, and #6 on 04/23/22, but stated she doesn't remember providing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dayshift person usually does the treatment and if it wasn't done, no one passed it off to her. On 05/06/22 at 2:48 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was informed both EI #4 and EI #5 stated they did not provide care for RI #3, #4 and #6 on 04/23/22 and there is no documentation on TAR. EI #1 was asked was treatment provided, EI #1 stated, not for that day. EI #1 admitted physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficiency was cited as a result of investigation AL 802.

Based on interviews, record review, and review of a facility policy titled Weight Loss Interventions, the facility failed to notify Resident Identifier (RI) #36's responsible party when RI #36, a resident with a history of weight loss, lost a severe amount of weight from October 2020 through March 2021. RI #36 went from 169.9 pounds to 132.0 pounds without the family being made aware of the continued weight loss. This deficient practice affected RI #36; one of three residents sampled for weight loss. Findings include: The facility's policy titled Weight Loss Interventions, with an effective date of 3/16/2021, documented PURPOSE To ensure adequate nutrition for those at risk for weight loss, etc. PROCEDURE . 6. If weight has not stabilized or if the resident has lost 5% in one month . the . responsible party shall be notified . 8. The . responsible party shall be notified if weight loss continues . RI #36 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #36's weights over a six-month period revealed the following: On 10/14/2020, RI #36 weighed 169.9 pounds On 11/25/2020, RI #36 weighed 157.4 pounds, a severe loss of 7.3% in one month On 12/17/2020, RI #36 weighed 149 pounds, a severe loss of 5.3% in one month On 1/18/2021, RI #36 weighed 137.9 pounds, a severe loss of 7.4% in one month On 2/10/2021, RI #36 weighed 134 pounds, a loss of 2.8% in one month On 3/15/2021, RI #36 weighed 132 pounds, a loss of 1.9% in one month In an interview on 5/26/2021 at 5:56 PM, Employee Identifier (EI) #1, the Director of Nursing (DON) was asked who notifies the family of a resident's weight loss. EI #1 stated nursing. EI #1 said if the family was notified it should be in the nurses or dietary notes. A review of RI #36's nurses and dietary notes revealed no documentation of RI #36's responsible party being notified of the resident's weight loss. In a follow-up interview on 5/27/2021 at 11:00 AM, EI #1 said she was not sure if RI #36's family had been notified of the resident's weight lost but they should have been. During a telephone interview on 5/27/2021 at 11:51 AM, RI #36's responsible party stated she had never been notified of RI #36's weight losses.

Based on interviews, review of Resident Identifier (RI) #81's medical record, the facility's POSITION DESCRIPTION and the FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #4, the Health Information Management Coordinator (HIMC) transcribed RI #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to transcribe the order resulted in RI #81's suprapubic catheter not being changed as ordered by the physician for three months. On 5/22/2021, RI #81 was sent to the local hospital's emergency room after complaining of abdominal pain and sediment being noted in the suprapubic catheter tubing. This deficient practice affected RI #81, one of 14 sampled residents who physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: On 5/24/2021, the State Agency received a complaint which alleged RI #81's catheter was not changed monthly as ordered by the physician. Page 311 of Chapter 23 titled Legal Implications in Nursing Practice of FUNDAMENTALS OF NURSING, with a copyright date of 2017, documented: . Health Care Provider's Orders . Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. Therefore you need to assess all orders; if you find one to be erroneous or harmful, further clarification from the health care provider is necessary . RI #81 was admitted to the facility on [DATE] with a principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #81 has a medical history to include a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Change Foley whenever the tubing gets filled with sediment or monthly - whichever comes first . A review of RI #81's March, April and May 2021 TARs revealed the order for the catheter (suprapubic) change was not transcribed to the TAR, therefore the resident's suprapubic catheter had not been changed in three months. The Windsor House Progress Notes for RI #81 dated 5/22/2021 written by EI #5, a Registered Nurse (RN), documented Resident was found crying and reported a 10/10 abdominal pain. Upon examination of resident's catheter, this nurse saw milky white cloudy urine in the catheter tubing. More cloudy white urine noted upon irrigation of catheter. Resident requested to be sent to the hospital . RI #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/28/2021 at 7:57 AM, the surveyor conducted an interview with EI #5, a RN. EI #5 was asked who wrote the order on 2/12/2021 for RI #81 to have his/her catheter changed. EI #5 said he was not sure. When asked how often was the order written for RI #81's suprapubic catheter to be changed, EI #5 said he had never seen the order but it was written for RI #81 to have his/her suprapubic changed every month and PRN (as needed). When asked who would be responsible for ensuring the order was transcribed to the TAR, EI #5 said EI #3, the HIMC and EI #2, the Assistant Director of Nursing (ADON). On 5/28/2021 at 10:42 AM, the surveyor conducted an interview with EI #3, the HIMC. EI #3 was asked when a physician wrote an order, what her responsibility was for that order. EI #3 said if was a treatment order she would enter the order into the computer and make sure the order was transcribed to the TAR. EI #3 said she remembered the Medical Director (MD) writing the order for RI #81 on 2/12/2021. EI #3 said the order was to change RI #81's Foley (suprapubic catheter) whenever the tubing was filled with sediment or monthly which ever came first. EI #3 said if the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if she saw the treatment orders on the March, April or May 2021 treatment records of RI #81, EI #3 said she did not. EI #3 said when she received the order she read it like it said she needed to see the orders per the Urologist for it to be an order because Center for Disease Control and Prevention (CDC) recommends change the suprapubic catheter only as needed. The facility's POSITION DESCRIPTION for the Health Information Management Coordinator dated September 2020, documented . KEY RESPONSIBILITIES: . 2. Oversees the transcription of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/28/2021 at 2:14 PM, the surveyor conducted an interview with the EI #4, the MD. When asked why she wrote the order for RI #81 on 2/12/2021, EI #4 said from what she recalled she and the resident were concerned that the facility was not changing the catheter. The surveyor asked EI #4 when she wrote the order did she write it with the expectation the facility would change the suprapubic catheter according to how the order was written. EI #4 said yes. EI #4 said she would expect the facility to do what her orders said. On 5/29/2021 at 12:53 PM, the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1, on 02/12/21, did the doctor write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 said yes. When asked how would the nursing staff know to follow this order, EI #1 said it would need to be put on the TAR. The surveyor asked EI #1, looking at RI #81's March, April and May 2021 TARs, was the order to change the suprapubic catheter on the TARs. EI #1 said no. When asked who would have been responsible for placing the order on the TAR, EI #1 said EI #3, the HIMC. The surveyor asked why RI #81 was sent to the hospital on 5/22/2021. EI #1 said RI #81 was having abdominal pain and puss like urine in his/her catheter tubing. When asked why would it have been important for RI #81's suprapubic catheter to be changed as ordered by the physician, EI #1 said for the prevention of infection. RI #81's medical record from the local hospital with an admitted [DATE] documented . (RI #81) . with a past medical history significant fro [CONDITION(S)], chronic UTIs with suprapubic catheter, [CONDITION(S)] bladder . The patient resides at Windsor House and presented to the ED (Emergency Department) with abdominal pain and clogged suprapubic catheter. (He/She) reported noticing that (his/her) urine had a thick consistency, (he/she) also reported abdominal pain . (He/She) reported that suprapubic catheter had not been changed in 2 months . In the ED . Suprapubic catheter was changed. Infectious disease was consulted for complicated UTI . This deficiency was cited as a result of the investigation of complaint/report number AL 387.

Based on interviews, review of Resident Identifier (RI) #36's medical record, and the facility's policy titled Weight Loss Interventions, the facility failed to ensure nutritional interventions were implemented when RI #36 experienced a severe weight loss from November 2020 to January 2021. Beginning 11/25/2020, RI #36 experienced a severe weight loss of 7.3% in one month. There were no nutritional interventions to address the resident's weight loss until 1/18/2021. This deficient practice affected RI #36; one of three residents reviewed for weight loss. Findings include: RI #36 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #36's care plan titled I am at risk for altered nutritional status related to Dementia with an initiated date of 9/30/2019, had an intervention of Consult RD PRN (as needed) . RI #36's Quarterly Minimum Data Set with an assessment reference date of 11/20/2020 indicated the resident was moderately impaired in cognitive skills with long- and short-term memory problems. The resident was assessed as requiring supervision with eating. A review of RI #36's weights over a six-month period revealed the following: On 10/14/2020, RI #36 weighed 169.9 pounds On 11/25/2020, RI #36 weighed 157.4 pounds, a severe loss of 7.3% in one month On 12/17/2020, RI #36 weighed 149 pounds, a severe loss of 5.3% in one month On 1/18/2021, RI #36 weighed 137.9 pounds, a severe loss of 7.4% in one month On 2/10/2021, RI #36 weighed 134 pounds, a loss of 2.8% in one month On 3/15/2021, RI #36 weighed 132 pounds, a loss of 1.9% in one month RI #36's Quarterly Minimum Data Set with an assessment reference date of 2/18/2021 indicated the resident was moderately impaired in cognitive skills with long- and short-term memory problems. The resident was assessed as requiring limited assistance with eating. The facility's policy titled Weight Loss Interventions, with an effective date of 3/16/2021, documented PURPOSE To ensure adequate nutrition for those at risk for weight loss, etc. PROCEDURE . When a resident loses 3% or more in one month . the following steps shall be taken: . 2. At the weekly Focus Meetings all possible causes for poor consumption shall be reviewed including: . d) Need to review and update of the resident's personal food preferences . 6. If weight has not stabilized or if the resident has lost 5% in one month . the RD . shall be notified and a revised plan shall be suggested, such as: A high calorie/protein snack, such as peanut butter, cheese, cottage cheese, etc. may be provided as an extra H.S. (bed time) snack . 13. The RD will enter a progress note and will write monthly progress notes until the problem is resolved. They will enter documentation in the progress note describing the status of the residents condition related to nutritional therapy . A review of RI #36's dietary notes revealed there was no progress notes addressing nutritional interventions for RI #36's severe weight loss of 7.3% in one month on 11/25/2020, or the severe weight loss of 5.3% in one month on 12/17/2020. During an interview on 5/27/2021 at 11:00 AM, Employee Identifier (EI) #1, the Director of Nursing was asked had RI #36 had any weight loss. EI #1 said yes. According to EI #1 on 10/14/2020, RI #36 weighed 169.9 pounds and RI #36's next month's weight on 11/25/2020, was 157.4 pounds. EI #1 said that was a 12.5-pound weight loss over a month. When asked was the RD, EI #8, consulted for the weight loss at that time, EI #1 said that would be something EI #9, the Dietary Manager (DM) does. EI #1 said she was not sure this was done. EI #1 said RI #36's next month's weight was 149 pounds on 12/17/2020. EI #1 said this was a loss of 8.4 pound over a month. When asked was this weight loss addressed by the RD, EI #1 said no but it should have been. EI #1 stated she attributes the resident's weight loss to COVID-19 and the constant walking he/she does. EI #1 explained the resident is constantly walking and that [CONDITION(S)] calories. According to RI #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] In a telephone interview with RI #36's emergency contact, she stated RI #36 usually body weight is between 130 and 140 pounds. While RI #36's emergency contact was not aware of the resident's weight loss, she had no concerns regarding the care the resident has received at the facility. On 5/27/2021 at 3:52 PM, a telephone interview was conducted with EI #8, the Consulting RD. EI #8 was asked if she was familiar with RI 36 and she said yes. E #8 stated RI #36 had been in the facility since 2019 and when the resident was first admitted , the resident weighed 131 pounds. When asked how often residents are weighed at the facility, EI #8 replied on admission to establish his/her weight, then weekly or monthly. According to EI #8, RI #36's ideal body weight is between 117 and 143 pounds. When the RD Nutritional Assessment was done on 10/14/2020, this was the annual assessment and RI #36 weighed 169.9 pounds; the resident was above his/her ideal body weight. Then on 11/25/2020, RI #36's weight was listed as 157.4, which is a 7.4% weight loss from the previous month. EI #8 stated she didn't implement any interventions at this time because the resident was above his/her ideal body weight and the resident was a walker and that may have been a contributing factor. EI #8 stated then on 12/17/2020, the resident's weight was 149 pounds. EI #8 stated this was a 5.3% weight loss in one month; however, she was not aware of this weight. EI #8 stated while the resident was still within his/her ideal body weight, she would have recommended to review the resident's food preferences to see if the staff could get the resident to eat more of his/her meals. RI #36's next weight of 137.9 was recorded on 1/18/2021. This was a 7.4% weight loss in one month. When asked what interventions were implemented as the result of this weight loss, EI #8 stated fortified food. EI #8 was asked what could she attribute RI #36's weight loss to. EI #8 replied, it could have been from the resident's increased activity of walking. EI #8 stated she reviewed the resident's intake and it ranged from 25% to 100%. EI #8 stated she could not give a definitive reason/explanation for the resident's weight loss. Since the weight loss, appropriate interventions have been implemented and the resident has maintained his/her weight in the ideal body weight range. In a follow-up telephone interview on 5/29/2021 at 6:06 PM, EI #8 stated again that she was not made aware of RI #36's weight of 157.4 pounds on 11/25/2020 but she should have been because it was a weight loss over 5% in one month. EI #8 stated had she been aware, she would have recommended some form of food preference or snack intervention. If the resident was not eating, she would have recommended a supplement. If the resident was eating, she would have recommended a snack. A telephone call/interview with the facility's Dietary Manager, EI #9, on 5/29/2021 was unsuccessful. From 5/25/2021 to 5/29/2021, RI #36 was observed for breakfast, lunch and dinner meals by the survey team. The resident was provided the correct, palatable diet with nutritional interventions. The staff provided verbal cues and assistance during each meal and the resident consumed 50% to 75% of each meal.

Based on interview and record review, the facility failed to provide a notice of bed-hold to the resident and/or their representative when Resident Identifier (RI) #59 and RI #78 were transferred to the local hospital. This deficient practice affected RI #59 and RI #78, two of three sampled residents reviewed for hospitalization , with the potential to affect all residents that are transferred to the hospital. Findings include: RI #59 was admitted to the facility on [DATE]. A review of RI #59's medical record indicated the resident was transferred to the local hospital on 12/1/2020, 1/30/2021 and 3/28/2021. RI #78 was admitted to the facility on [DATE]. A review of RI #78's medical record indicated the resident was transferred to the local hospital on 3/24/2021, 4/1/2021, and 4/7/2021. In an interview on 5/26/2021 at 5:36 PM, Employee Identifier (EI) #18, the facility's Administrator stated the facility does not issue a notice of bed-hold when a resident is transferred to the hospital. According to EI #18, the only time a notice of bed-hold was discussed was during the admission process.

Based on interview, review of Resident Identifier (RI) #36's medical record and the facility's policy titled Weight Loss Interventions, the facility failed to consistently document the meal intake of RI #36, a resident with a history of weight loss. This deficient practice affected RI #36; one of three residents reviewed for weight loss. Findings include: RI #36 was admitted to the facility on [DATE] with an admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #36's Windsor House Documentation Survey Report v2 (Flow Sheet), under the task of Nutrition - Amount, revealed there was no documented percentage of RI #36's meal consumption for seven of 90 meals served during October 2020. A review of RI #36's Windsor House Documentation Survey Report v2, under the task of Nutrition - Amount, revealed there was no documented percentage of RI #36's meal consumption for 27 of 90 meals served during November 2020. A review of RI #36's Windsor House Documentation Survey Report v2, under the task of Nutrition - Amount, revealed there was no documented percentage of RI #36's meal consumption for 68 of 90 meals served during December 2020. A review of RI #36's Windsor House Documentation Survey Report v2, under the task of Nutrition - Amount, revealed there was no documented percentage of RI #36's meal consumption for 24 of 90 meals served during January 2021. A review of RI #36's Windsor House Documentation Survey Report v2, under the task of Nutrition - Amount, revealed there was no documented percentage of RI #36's meal consumption for 34 of 84 meals served during February 2021. A review of RI #36's Windsor House Documentation Survey Report v2, under the task of Nutrition - Amount, revealed there was no documented percentage of RI #36's meal consumption for 35 of 90 meals served during March 2021. The facility's policy titled Weight Loss Interventions, with an effective date of 3/16/2021, documented PURPOSE To ensure adequate nutrition for those at risk for weight loss, etc. PROCEDURE . 4. The CNA (Certified Nursing Assistant) will document on the Flow Sheet, the percentage of consumption of each meal . During a telephone interview that began on 5/26/2021 at 4:26 PM, Employee Identifier (EI) #14, a Licensed Practical Nurse was asked where are RI #36's meal percentage charted. EI #14 said in the computer under RI #36's Activities of Daily Living portion of eating. When asked who was responsible for charting RI #36's meal percentage, EI #14 said the Certified Nursing Assistants. When asked why it was important for the meal percentage to be recorded, EI #14 said it showed how much the resident did or did not eat.

Based on observation, interviews and review of Resident Identifier (RI) #28's medical record, the facility failed to maintain the ceiling in RI #28's room. RI #28's ceiling was observed with different color paint and water spots. This deficient practice affected RI #28, one of 39 sampled residents. Findings include: RI #28 was admitted to the facility on [DATE]. RI #28's Quarterly Minimum Data Set with an assessment reference date of 2/17/2021 indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. On 4/11/2021 at 3:48 PM, RI #28 stated he/she would like the ceiling painted. An observation of the ceiling in RI #28's room revealed the ceiling had two colors of paint and spots over the resident's bed that resembled water spots. RI #28 stated he/she had spoken to the facility's Administrator about the ceiling, but nothing had been done about painting it. On 4/12/2021 at 9:03 AM, Employee Identifier (EI) #17, the Maintenance Director stated he observed RI #28's ceiling and it needed to be painted. During an interview on 4/12/2021 at 9:54 AM, EI #18, the Administrator stated she didn't remember being calling to look at RI #28's ceiling. EI #18 stated she will look at it and have it painted.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight for three (3) of eight (8) residents sampled for nutrition (Resident #36, Resident #18 and Resident #19) out of 37 sampled residents. The facility failed to provide timely interventions for weight loss, failed to follow-up on the RD's recommendation for fortified foods, failed to cue and/or assist the resident with their meals and failed to consistently monitor the resident's meal intake for Resident #18. The facility failed to provide timely interventions for weight loss, failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to provide timely interventions for weight loss when Resident #19 experienced a decline in nutritional intake. Findings include: Review of the facility's Weight Loss Interventions policy, dated 3/16/21; supersedes: 12/1/10, revealed Purpose: To ensure adequate nutrition for those at risk for weight loss, etc. Policy Statement: Nutritional supplements will be provided for residents as ordered by the physician when: a) Supplements are required to maintain nutritional adequacy. b) The resident suffers from weight loss and other means of improving nutrition and/or intake. Procedure: When a resident loses 3% or more in one month, or is significantly below ideal/usual body weight, the following steps shall be taken: 1. If the weight is questionable, the resident will be re-weighed. 2. At the weekly Focus Meeting, all possible causes for poor consumption shall be reviewed including: a. Location of the resident during meals (i.e., dining room, resident room, etc.) b. Need for change of diet consistency. c. Use of medications which could decrease the appetite. d. Need of review and update of the resident's personal food preferences. e. Need for additional assistance/encouragement at mealtimes. f. Possible environment factors in the dining areas such as seating/ tablemate selection, location, etc. g. Need for adaptive equipment. h. Need for more time at mealtime for resident who eat slowly. i. Need for assessment of functional positioning during meals. j. Recent illness. 3. When factors contributing to poor appetite have been identified, appropriate interventions will be implemented to promote appetite and nutritional intake. The physician and resident or responsible party will be notified of the nutritional problems including the interventions being implemented to assist in improving the resident's nutritional status. 4. The Charge Nurse will indicate on the CNA assignment that the resident requires special assistance and monitoring at mealtime. The CNA will document on the Flow Sheet the percentage of consumption of each meal. It is important to monitor not only the percentage consumed, but what the resident is not eating, such as milk, meat (protein), etc. 5. The resident will be weighed weekly for four weeks to evaluate the effectiveness of the above measures. Weights will be done on the same day of the week, at the same time of the day, when possible. 6. If weight has not stabilized or if the resident has lost 5% in one month, 7.5% in 3 months, or 10% in 6 months, the physician, RD, and responsible party shall be notified, and a revised plan shall be suggested. 7. The resident will again be weighed weekly for four weeks to evaluate effectiveness of actions. 8. The physician, RD, and responsible party shall be notified if weight loss continues, and orders may be written for a supplement, 9. Use of prepared supplement (or other house supplement) will be documented through either the MAR (medication administration record) or POC (plan of care) tasks. The resident will continue to be weighed weekly until weight is table or the physician directs otherwise. 10. If weight has not stabilized, the physician will be contacted for consideration of other alternatives, such as feeding tube. 11. If, at any time, the resident exhibits signs and symptoms of dehydration or skin breakdown, the physician will be notified. 12. Weight loss will be entered into the MDS/Care Plan as a problem. 13. The RD will enter a progress note and will write monthly progress notes until the problem is resolved. They will enter documentation in the progress note describing the status of the resident's condition related to nutritional therapy. 14. The RD will review monthly the residents who are receiving nutritional supplements and will ensure that supplements are used appropriately. 15. When the resident's weight has stabilized within ideal/usual body weight range for three months, the physician shall be notified, and an order obtained to discontinue the supplement. Essential Point: In order to promote full consumption of the prescribed diet, any commercially prepared supplement will not be served with meals. When supplements are ordered, such as 2 Cal. Supplement, they will be given during medication administration times. 1. Review of Resident #36's clinical record revealed an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident was unable to be tested . The resident had short and long-term memory problems, had modified decision making skills, displayed inattention and disorganized thinking that fluctuated, had a mood score indicating no depression and displayed no behaviors. The MDS revealed Resident #36 required supervision of one (1) staff with bed mobility, transfers, ambulation, locomotion, and eating. The resident required limited assistance of one (1) staff with dressing, toileting, and personal hygiene. The MDS revealed the resident weighed 168 pounds (lbs.), had no swallowing disorders, weight loss or dental problems. The resident did not receive nutritional approaches. Review of the Care Area Assessment (CAA) for Nutrition dated 9/2/2020 revealed Resident #36 had an elevated Body Mass Index (BMI) of 31. Staff monitored the resident's weight monthly and monitored meal consumption daily. Review of the CAA for Activities of Daily Living (ADLs) dated 9/2/2020 revealed Resident #36 was not able to participate in the activities he/she used to enjoy. Resident #36 was moderately cognitively impaired due to Dementia. Review of the Care Plan, initiated on 9/31/19 and last reviewed on 2/19/21, listed the problem resident was at risk for altered nutritional status with the intervention to offer alternate meal and snacks when requested, serve diet as ordered and weights per protocol. Review of Resident #36's Weight List in the clinical record revealed the following weights in lbs.: 10/14/2020 - 169.9; 11/25/2020 - 157.4; 12/17/2020 - 149.0; 1/18/21 - 137.9; 2/10/21 - 134.0; 3/15/21 - 132.0; 3/22/21 - 129.0; and 3/29/21 - 126.0. There was a total weight loss of 21.13 percent from 10/14/2020 to 2/10/21 and a total weight loss of 25.84 percent from 10/14/2020 to 3/29/21. Review of Resident #36's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Nutritional Screening, completed by the Dietary Manager (DM) dated 6/12/2020, revealed the resident weighed 170 lbs. and his/her usual body weight was 160 to 170 lbs. Resident #36 would continue on a regular diet and would be referred to the Registered Dietician (RD) as needed. Review of the RD's Nutritional assessment dated [DATE] revealed the RD used the weight obtained on 10/14/2020 of 169.9 lbs. and not the weight obtained on 11/25/2020 of 157.4 lbs., a decrease of 17.5 pounds in one (1) month. The RD documented this was an annual nutritional review and the resident's weight was stable. No recommendations were made. Review of the DM's Nutritional Screening dated 12/3/2020 revealed the most recent weight of 169.9 lbs. on 10/14/2020. The DM did not use the weight of 157.4 lbs. on 11/25/2020. The DM documented Resident #36 continued on a regular diet and his/her weight was 170 lbs. The resident did not have a significant change in weight in the past 30 days. Will refer to RD as needed. Review of Resident #36's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Order dated 1/21/21 for fortified foods with breakfast was started after the resident lost 32 lbs.; Order dated 2/24/21 for Speech Therapy (ST) four (4) times per week times four (4) weeks for oropharyngeal dysphagia and weight loss was started after the resident lost 35.9 lbs.; Order dated 3/1/21 for Med Pass (nutritional supplement) 120 cubic centimeters (cc) two (2) times per day was started after the resident lost 35.9 lbs.; Order dated 3/1/21 for Nutrition consult secondary to weight loss and house supplements (nutritional supplement) two (2) times a day; Order dated 3/24/21 to continue ST four (4) times per week for four (4) weeks for oropharyngeal dysphagia; and Order dated 4/7/21 for unintended weight loss, check weights times four (4) week cycle, check [CONDITION(S)] Stimulating Hormone and Prealbumin levels, discontinue Trazadone (antidepressant) and start Mirtazine (antidepressant and also used to stimulate appetite) 15 milligrams at bedtime. Review of the clinical record and after request for all nutritional assessments and screenings revealed the facility did not follow the 3/1/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Nurse's Note dated 10/20/2020 at 10:44 p.m. revealed at 3:15 p.m. Resident #36 came to the Nurse and gave him/her their left front tooth implant/bridge, two (2) connected teeth were noted with a post extending from the root of one (1) tooth. The resident denied pain and no bleeding was noted. The root of the left tooth was visible from the gumline. Will continue plan of care. Further review of the Nurses' Notes from 3/30/2020 to 4/13/21 at 8:58 p.m. lacked documentation regarding eating for Resident #36. Review of Resident #36's Diet Slip on 4/12/21, revealed the resident received a regular diet with regular texture and received super cereal at breakfast. Review of Resident #36's Nutritional Analysis for Oatmeal or Cream of Wheat and Super Cereal revealed the Super Cereal had 299.432 kilocalories more than the Oatmeal or Cream of Wheat. Review of Resident #36's ADL Meal Consumption Record revealed: On 2/21, staff did not document the meal consumption for 35 of the 84 meals provided. On 3/21, staff did not document meal consumption for 36 of the 93 meals provided. On 4/1/21 to 4/14/21 at 5:00 p.m., staff did not document meal consumption for 26 of the 41 meals provided. Review of Resident #36's laboratory results dated [DATE] revealed a normal comprehensive metabolic panel (CMP), a normal hemoglobin A1C (blood sugar level over a period of time), and a normal hemoglobin and hematocrit. Observation on 4/12/21 from 8:35 a.m. to 10:30 a.m. and from 11:15 a.m. to 11:43 a.m. Resident #36 wandered the halls of the locked Special Care Unit. Observation on 4/12/21 at 11:46 a.m. revealed the staff served the resident his/her lunch tray of cornbread, broccoli, meat, baked potato, brownie, and iced tea. The resident picked up the cornbread and took a bite. Staff left the room after setting up the tray. Observation at 11:52 a.m. revealed the resident wandered up and down the hall and followed the surveyor into his/her room. The resident picked up the brownie, ate it and then left the room and wandered up and down the halls. At 12:14 p.m. staff removed the lunch tray. The resident ate ½ piece of cornbread, 95 percent of the brownie and drank eight (8) ounces of tea. Observation during the meal revealed staff did not encourage the resident to eat. Observation on 4/13/21 of the lunch meal beginning at 12:14 p.m. revealed Resident #36 ate approximately 50 percent of the meal with staff encouragement in his/her room. Further observation revealed when the staff left the room, the resident followed the staff out of the room but would return to the room with staff encouragement to eat. Interview with Licensed Practical Nurse (LPN) #5 on 4/13/21 at 9:16 a.m. revealed the Certified Nursing Assistants (CNAs) documented the meal intakes in their computer program. Interview with the DM on 4/13/21 at 1:15 p.m. revealed the kitchen provided snacks for the Special Care Unit at 10:00 a.m. and 2:00 p.m. The snacks were not labelled with specific resident names. The nutrition assessment process consisted of the DM completed the nutritional assessment on admission and quarterly and the RD assessed the residents on admission and annually. The RD reviewed the DM's notes and made recommendations as needed. Further interview with the DM on 4/14/21 at 9:37 a.m. regarding fortified foods revealed they start with the resident's best meal for intake, and for Resident #36 they started with Super Cereal at breakfast. Interview with the RD on 4/14/21 at 10:04 a.m. revealed the RD assessed the residents within 30 days of admission and then annually. The RD stated he/she reviewed the weights on a weekly basis and as requested by the facility. The RD stated the DM would notify him/her of any changes in the residents. Regarding Resident #36, he/she had a big weight loss towards the end of last year but I believe [he/she] is holding steady. The facility used Med Pass and House Supplements interchangeably and I usually recommend 120 cc but the amount may vary. Interview with the Director of Nursing (DON) on 4/14/21 at 3:03 p.m. revealed during the morning meetings, held Monday through Friday, the Administrator would ask if any residents had a weight loss. For Resident #36, when I documented his/her weights in the computer, the computer was supposed to turn the weight red if there was a significant weight change and it did not. It was a computer error. The DON also stated Resident #36 was a picky eater and ate better without distractions. Resident #36 required assistance with eating and the DON did not know if the resident ate snacks or not. The DON did not know about the resident losing his/her bridge and teeth and did not know if he/she was assessed by a Dentist. 2. Review of Resident #18's clinical record revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three (3) of 15 indicating severe cognitive impairment. The resident did not display signs or symptoms of [CONDITION(S)], behaviors, or signs of depression. The resident required limited assistance of one (1) person with bed mobility and transfers, required supervision with ambulation and required set-up assistance with eating. The MDS revealed the resident had no difficulty with swallowing, was on a mechanically altered diet, weighed 126 pounds (lbs.) and had experienced a five (5) percent weight loss in the last month or ten (10) percent weight loss in the last six (6) months. The resident was not on a prescribed weight loss regimen. Review of the Care Area Assessment (CAA) for Nutrition dated 2/8/21 revealed the resident received a mechanical soft diet and had experienced a ten (10) percent weight loss over the past 180 days. Review of Resident #18's Care Plan revealed a nutritional risk problem related to Hypertension, [CONDITION(S)], Dementia, and mechanically altered diet order, with the start date of 2/19/18. The following interventions were listed: Assist in feeding as needed, allow the resident time to eat, diet as ordered, offer alternate foods for those uneaten, supplements as ordered, and weigh per protocol schedule and as needed, document, and report weight changes. The Care Plan for physical functioning deficit with the start date of 2/19/18 listed the intervention for staff to provide assistance with transfers, dressing, meal tray set-up, feeding, toileting, personal hygiene, and bathing. Review of Resident #18's Weight List in the clinical record revealed the following weights in pounds (lbs.): 9/15/2020 - 143.6; 10/19/2020 - 137.0; 11/19/2020 - 131.6; 12/17/2020 - 128; 1/15/21 - 125.9; 2/10/21 - 126.0; and 3/15/21 - 126.0. There was a total weight loss of a 12.26 percent from 9/15/2020 to 3/15/21. Review of the Quarterly Dietary Manager (DM) Nutritional Note, dated 8/10/2020, revealed Resident #18 remained on a mechanical soft, no added salt diet. The resident also received a frozen nutritional treat one (1) time a day as a supplement. His/her weight was 142 lbs. and did not have a significant weight change in the past 30 or 180 days. Would refer to the Registered Dietician (RD), as needed. Review of the Quarterly DM Nutritional Note dated 11/10/2020 revealed Resident #18 remained on a mechanical soft diet with one (1) frozen nutritional treat daily. Would refer to the RD as needed. Review of the RD's Annual Nutritional Note dated 12/20/2020 revealed Resident #18 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . over an approximate six (6) months. The resident received a mechanical soft diet with a frozen nutritional treat with lunch and a House Shake (nutritional supplement) one (1) time a day. The RD made no recommendations. Review of the RD's Nutritional Review dated 1/17/21 revealed the resident had a significant weight loss of 8.1 percent in approximately three (3) months and 11.1 percent in approximately six (6) months. Resident #18 may benefit from the addition of fortified foods. Review of the DM's Nutritional Note dated 2/9/21 revealed Resident #18 received a mechanical soft diet with a frozen nutritional treat two (2) times a day. The resident had experienced a ten (10) percent weight loss over the past 180 days. Would refer to the RD as needed. Review of the RD's Annual Nutritional Review dated 2/21/21 revealed Resident #18 had a significant weight loss of approximately 8.1 percent in three (3) months and approximately 11.1 percent in six (6) months. The resident received a mechanical soft diet with varied intake. The resident also received a nutritional treat on the lunch tray. The resident may benefit from the addition of fortified foods. Review of the clinical record lacked evidence the facility followed-up on the recommendation for fortified foods. Review of the RD's Weight Note dated 3/18/21 revealed Resident #18 had a significant weight loss in approximately six (6) months. The RD would continue to monitor. No new recommendations were made. Review of the Resident #18's Dietary Slip on 4/12/21 revealed the resident received a regular mechanically soft diet with a frozen nutrition treat at lunch and dinner. The Dietary Slip lacked documentation regarding fortified foods. Review of Resident #18's laboratory results dated [DATE] revealed normal levels of [MEDICATION(S)], total protein, hemoglobin and hematocrit. Review of Resident #18's ADL Meal Consumption Record revealed: On 2/2021, staff did not document meal consumption for 49 of the 84 meals provided. On 3/2021, staff did not document meal consumption for 61 of the 93 meals provided. On 4/1/21 to 4/14/21 at 5:00 p.m., staff did not document meal consumption for 30 of the 41 meals provided. Observation on 4/12/21 at 11:40 a.m. revealed Resident #18 laid in bed and staff served the lunch tray which consisted of a baked potato, chopped meat, cauliflower, brownie, frozen nutritional treat, cornbread, and iced tea. The resident reached for and began to eat the brownie. Staff set-up the tray and then left the room. Observation at 11:55 a.m. revealed there was no staff present to assist the resident with the noon meal. Observation at 12:17 a.m. revealed staff entered the room to take the lunch tray and the resident stated to leave the tray. The resident had eaten the frozen nutritional treat, ½ piece of cornbread, ½ of the baked potato and 100 percent of the brownie. The resident drank eight (8) ounces of iced tea. Observation of the noon meal revealed staff did not encourage or assist Resident #18 with eating. Observation on 4/13/21 at 11:47 a.m. revealed staff brought the lunch tray consisting of chopped meat, roll, brussels sprouts, desert, water and juice to Resident #18's room. The staff placed it on the bedside table and then left the room. Observation at 11:50 a.m. revealed the resident's head of the bed was flat and the resident laid on his/her right side. The resident propped him/herself up with the right arm and attempted to eat his/her meal. Observation at 12:00 p.m. revealed the resident drank the eight (8) ounces of water and iced tea and ate ½ of the roll. Staff entered the room at 12:12 p.m. and removed the tray. Staff did not ask the resident if he/she wanted something else to eat. Interview with Licensed Practical Nurse (LPN) #5 on 4/13/21 at 9:16 a.m. revealed the Certified Nursing Assistants (CNAs) documented the meal intakes in their computer program. Interview with the DM on 4/13/21 at 1:15 p.m. revealed the kitchen provided snacks to the Special Care Unit at 10:00 a.m. and 2:00 p.m. The snacks were not labelled with specific resident names. The nutrition assessment process consisted of the DM completing the nutritional assessment on admission and quarterly and the RD assessed the residents on admission and annually. The RD reviewed the DM's notes and made recommendations as needed. Interview with the DON on 4/13/21 at 2:30 p.m. revealed the staff should supervise and cue the residents to eat. Interview with the RD on 4/14/21 at 10:04 a.m., via telephone, revealed the RD assessed the residents within 30 days of admission and then annually. The RD stated he/she reviewed the weights on a weekly basis and as requested by the facility. The RD stated the DM would notify him/her of any changes in the residents. The RD stated he/she could not remember anything about Resident #18 and weight loss. Continued interview with the DON on 4/14/21 at 3:03 p.m. revealed during the morning meetings, held Monday through Friday, the Administrator would ask if any residents had weight loss. The DON stated, If there were residents with weight loss, we would discuss them as a team and initiate new interventions. 3. Review of Resident #19's undated Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short/long-term memory problems and had modified independence in cognitive skills for daily decision-making. Resident #19 required limited physical assistance of one (1) person for eating. The resident did not have any swallowing disorders. Resident #19 was assessed as having a significant weight loss and was not on a prescribed weight-loss regiment. No oral/dental concerns. No special treatments were received. Review of Resident #19's Care Area Assessment (CAA) dated 2/8/21 revealed the following triggers: cognitive loss/dementia, communication, activities of daily living functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury and [CONDITION(S)] drug use. All triggers were to be care planned. Review of Resident #19's Care Plan initiated on 3/10/18 revealed Focus: I have a potential for Involuntary Weight Loss related to Depression. Goal: My weight will remain stable through the next review. Target Date: 6/6/21. Interventions: Diet as ordered; Dietary Manager to obtain preferences and offer preferences as ordered as diet allows; monitor meal consumption daily; monthly weights; provide food substitutes; screen/evaluation by rehab services prn (as needed); and vitamin/mineral supplements as ordered. Review of Resident #19's Care Plan initiated on 3/6/20 revealed Focus: I have a potential for alteration in nutritional status related to diseases of the stomach and duodenum, and depression. Goal: I will have no significant weight change through the next review: Target date: 6/6/21. Interventions: Diet as ordered; honor food preferences; supplements as ordered; and weights per protocol. Observation on 4/12/21 at 11:45 a.m. during lunch revealed Resident #19 sitting up in bed being assisted with feeding. Resident was tolerating the meal well. Resident was observed taking a few bites of his/her meal and not wanting any more. Staff observed removing the tray. No substitution was offered. Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (weight) loss, 2) weekly wights, 3) Med (Medication) Pass PO (by mouth) BID (two times a day) between meals. Review of Resident #19's medical records revealed no documentation showing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #19's weights revealed the following: 10/20/20 = 167.0; 11/3/2020 = 157.2; 11/10/20 = 154.4; 11/12/20 = 157.2; 11/17/20 = 153.4; 12/17/20 = 147.1; 1/15/21= 143.2; 2/10/21 = 142.0; 3/3/21 = 139.4; and 4/14/21 = 146.3. Review of the Nutritional Screening dated 2/9/21 revealed Resident #19 continues on a regular diet order. Additionally, he receives a frozen nutritional treat 1x/day. His weight is 143# (pounds) and height is 71 (inches). His BMI (Body Mass Index) is 20.0, normal. He/she has experienced a 10% weight loss over the past 180 days. No noted skin breakdown. Dining services will continue to monitor and refer to RD (Registered Dietician) as needed. Review of the Nutritional Review dated 3/21/21 revealed CBW (current body weight) 139.4#, BMI 19.4, wt. (weight) loss noted, no significant wt. loss x ~1 mo. (month), x ~3 mo., significant wt. loss -16.5% in ~ 6 months. Weight range over past ~6 months ~142-164#. Receiving PT (Physical Therapy)/OT (Occupational Therapy)/ST (Speech Therapy). Meds reviewed, note Senna, MVI (multivitamin), [MEDICATION(S)], [MEDICATION(S)]. Regular diet w(with)/frozen nutritional treat w/lunch, ice cream w/dinner, varied po intake 50-100%. Resident may benefit from addition of 2 Cal. supplement. RD will continue to monitor. Review of the Weight Note dated 2/28/21 revealed Frozen nutritional treat added to lunch tray. RD will continue to monitor. Review of the Nutritional Review dated 11/30/20 revealed CBW 153.4# BMI 21.4, resident has had a significant wt. loss -8.1% in ~ 1 month. Weight range over past ~6 months ~162-167#. Receiving PT/OT/ST. Meds reviewed, note Senna, MVI, [MEDICATION(S)], [MEDICATION(S)]. Regular diet w/ice cream BID, 25-100%, mostly 75-100%. Resident may benefit from addition of fortified foods to aid w/intake. RD will continue to monitor. Review of Resident #19's medical record revealed there was no documented evidence that the RD recommendations were reviewed, discussed or implemented. Review of Resident #19's Meal Consumption Record for February 2021 revealed the following: -On 2/1/21, 2/2/21 and 2/12/21 at 6:00 p.m., Resident #19 consumed 76 - 100% of his/her meal. -On 2/7/21 at 9:00 a.m., Resident #19 consumed 26 - 50% his/her meal. -On 2/7/21 at 1:00 p.m. Resident #19 refused his/her meal. -On 2/11/21, 2/16/21, 2/17/21, 2/18/21, 2/20/21, 2/21/21, 2/25/21, 2/26/21, and 2/21/21 at 6:00 p.m., Resident #19 consumed 51 - 75% of his/her meal. All other days for the month of February 2021 were blank. Review of Resident #19's Meal Consumption Record for March 2021 revealed the following: -On 3/3/21 at 9:00 a.m. and 1:00 p.m.; 3/10/21, 3/22/21 and 3/26/21 at 6:00 p.m., Resident #19 consumed 26 - 50% of his/her meal. -On 3/1/21, 3/5/21, 3/8/21, 3/12/21, 3/15/21, 3/23/21, and 3/28/21 at 6:00 p.m., Resident #19 consumed 51 - 75% of his/her meal. -On 3/3/21, 3/4/21, 3/9/21, 3/11/21, 3/16/21 and 3/21/21 at 6:00 p.m., Resident #19 consumed 76 - 100% of his/her meal. -On 3/17/21 at 6:00 p.m., NA (not available) was entered. All other days for the month of March 2021 were blank. Review of Resident #19's Meal Consumption Record for April 2021 revealed the following: -On 4/3/21, 4/4/21, 4/5/21 and 4/7/21 at 9:00 a.m., 1:00 p.m. and 6:00 p.m.; 4/6/21 at 6:00 p.m. and 4/7/21 at 9:00 a.m., Resident #19 consumed 0 - 25% of his/her meal. -On 4/9/21, 4/10/21 - 4/13/21 at 9:00 a.m.; 4/1/21, 4/7/21, 4/9/21 - 4/14/21 at 1:00 p.m.; and 4/8/21 and 4/10/21 at 6:00 p.m., Resident #19 consumed 26 - 50% of his/her meal. -On 4/1/21, 4/2/21, and 4/14/21 at 9:00 a.m.; 4/2/21 at 1:00 p.m.; and 4/1/21, 4/2/21, 4/7/21, 4/11/21, and 4/12/21 at 6:00 p.m., Resident #19 consumed 76 - 100% of his/her meal. Interview on 4/13/21 at 11:00 a.m. with Licensed Practical Nurse (LPN) #1 revealed the order was written by one of the doctor's interns. He/she stated when the doctor or the intern writes an order, they will sit the chart on the desk for the order to be taken off. He/she stated when he/she received a new order, he/she removed it and took it to Medical Records for the order to be put in the system. He/she stated if it was a dietary order, a communication form was filled out and given to the Dietary Manager. If it was a supplement, it was also put on the MAR (Medication Administration Record). He/she stated sometimes medical records would come up and check to see if there were any new orders that needed to be put in the computer. He/she stated there was no 24-hour chart checks because they mostly used electronic records. Interview on 4/13/21 at 11:20 a.m. with the Director of Nursing (DON) revealed when an order was placed on the chart, it should be referred to Medical Records to be put into the chart. He/she stated medical records put in all the orders. He/she stated the nurses or medical records should be checking the hard charts for orders on doctor days. He/she stated the nutritional reviews were printed out by the dietary manager for nursing to review any recommendations and possible referral to the physician. He/she stated if the recommendation were accepted, the order was obtained and put in the records. He/she stated Resident#19 was currently being assisted by staff with feeding. He/she stated he/she noticed that the recommendation from the Dietician was for 2 Cal. Supplement. He/she stated the facility used Med Pass 2.0. He/she stated he/she would look into the issue and make corrections to the process as needed. Interview on 4/13/21 at 12:55 p.m. with Certified Nursing Assistant (CNA) #2 revealed he/she did not assist the resident with eating today, but he/she did yesterday. He/she stated the resident only ate a couple of bites and did not want any more food. He/she stated Resident #19 ate a lot of junk food He/she stated on the side of the bed, the resident had chips, cakes, candy, and Mountain Dew sodas which the resident's family provided. He/she stated the resident ate those all day so when it was time to eat real food, he/she did not eat a lot. He/she stated he/she did not know if the resident had any supplements. He/she stated he/she usually did not offer the resident substitutes because he/she knew the resident would not eat it. Interview on 4/13/21 at 1:40 p.m. with the Dietary Manager (DM) revealed when the Dietician wrote suggestions/recommendations on his/her reviews, they had a discussion about what was written to see if the resident would eat it or not. We also discussed wha [TRUNCATED]

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents with pressure ulcers received necessary care and services to promote healing and prevent new ulcers from developing for three (3) of three (3) residents identified with pressure ulcers out of 37 sampled residents (Resident #70, Resident #77, and Resident #81). The facility failed to reposition Resident #70 every two (2) hours and failed to elevate the heels off the bed and the resident developed an unstageable pressure ulcer to the left heel. The facility failed to reassess the resident's nutritional status after the development of the pressure ulcer and failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #77 had a pressure ulcer to the sacral area and the facility failed to reposition the resident in bed per the care plan to address the skin deficit and prevent further skin breakdown. The facility failed to reposition Resident #81 every two (2) hours, failed to transfer the resident from the bed to a chair, and failed to provide the physician ordered treatment in accordance with professional standards of practice. Findings include: Review of the facility's policy titled Skin Care Guideline (dated July 2018) revealed the purpose was to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. Processes developed to address the risk for skin deficits for all residents included: 1. All residents admitted will be observed for baseline skin conditioned and evaluated for risk of skin breakdown within 24 hours of admission and those findings will be documented in the electronic medical record. 2. Initiate positioning schedule as necessary to meet individual needs and minimize concentrated pressure to skin. 3. DON or designee will be responsible to implement and monitor the skin integrity program. 4. The plan of care will address problem goals, and interventions directed toward prevention of pressure sores in those at risk. Processes developed to address when a resident has an open area identified, required the immediate implementation of resident specific interventions including: 1. Specialty mattress/pressure reduction mattress on bed. 2. Pressure redistribution cushion in wheelchair. 3. Individualized repositioning. 4. Pain management evaluation and interventions. 5. Notify physician and document notification. 6. Notify patient representative and document notification. 7. Complete new risk assessment, Braden scale, to determine what risk factors may have changed and help establish plan. 8. Update care plan to address change in condition including interventions for each problem/risk factors. 9. Update care giver guide. Review of the Clean Dressing Change Observation Form, undated, revealed step by step guidance for nurses regarding how to perform wound care and avoid infection control breeches when removing/applying dressings. The form included staff should wash their hands before and after donning or doffing a pair of gloves and throughout the removal and application of wound care dressings/treatment. Additionally, all prescribed medications should be applied using a clean tongue blade or Q-tip. 1. Review of Resident #70's clinical record revealed an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #70's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long-term memory impairment, had modified impairment with decision making, had disorganized thinking that fluctuated and displayed physical and verbal behaviors one (1) to three (3) days since admission. The MDS identified the resident required extensive assistance of one (1) staff with bed mobility, dressing, eating and personal hygiene. The resident required total assistance of two (2) staff with transfers and toileting and did not ambulate. Resident #70 had impairment in range of motion of the bilateral lower extremities and utilized a wheelchair. The resident was always incontinent of bowel and bladder, was at risk for the development of pressure ulcers and did not have a pressure ulcer at the time of the assessment. The resident had a pressure reducing mattress for the bed, but the MDS did not document the resident had a pressure reducing device for the wheelchair or was on a turn and repositioning program. Review of Resident #70's Care Area Assessment (CAA) for Pressure Ulcers dated 3/29/21 revealed the resident was at risk for skin breakdown due to the resident required extensive assistance with bed mobility and was dependent with transfers. The resident also had impaired cognition due to dementia and was incontinent. Review of Resident #70's CAA for Activities of Daily Living (ADLs) dated 3/29/21 revealed the resident required extensive to total care with all ADLs due to history of falls, impaired cognition related to Alzheimer's Disease, medications, recent fracture of the left femur head and arthroplasty and the resident was dependent with transfers and required extensive assist with bed mobility. Review of Resident #70's Care Plan dated 3/29/21 revealed, the resident had the potential for further skin breakdown due to impaired mobility. The interventions included: Complete Braden Scale per facility policy; conduct weekly skin inspection; observe for signs and symptoms of infection such as swelling, redness, warmth, discharge, and odor and notify the physician of significant findings; provide pressure reducing wheelchair cushion; provide pressure reduction/relieving mattress; skin assessment per facility's policy; and treatments as ordered. Resident #70's Care Plan also listed the resident had self-care performance deficit and included the intervention for staff to provide appropriate assistance with bed mobility, transfers, eating, personal hygiene, and toilet use. Review of the Admission Progress Note, late entry, for 3/20/21 at 5:21 p.m. revealed the resident was incontinent of bowel and bladder and wore briefs. Staff would turn the resident every two (2) hours and as needed. The resident had no open areas to the skin but had multiple bruises on the bilateral arms. The resident could not make his/her needs known due to confusion. The note further documented the resident had an immobilizer on his/her left leg from a previous hip surgery and revision surgery on the same leg. The resident required total care from the staff. Review of Resident #70's Braden Scale for Predicting Pressure Ulcers dated 3/24/21 revealed a score of 15 indicating the resident was at risk for the development of pressure ulcers. Review of Resident #70's Nurses' Notes revealed: On 3/22/21 at 1:51 p.m., resident had an immobilizer on his/her left leg related to a previous fall. Skin integrity was intact. On 3/25/21 at 12:57 p.m., skin integrity was intact. Review of the weekly Body Audit dated 4/2/21 revealed an area noted to the left heel. No measurements or description of the area was documented. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nutritional Screening dated 4/5/21 revealed Resident #70 was admitted on a puree diet. The resident had no skin breakdown and staff would refer to the Registered Dietician (RD) as needed. Review of the RD Nutrition Review assessment dated [DATE] revealed there was no documentation regarding skin breakdown and no recommendations were made. Further review of the Nurses' Notes revealed: On 4/12/21 at 2:53 p.m. area noted to left heel. The area is dark in color, but no open area noted. Treatment in place for prophylaxis. On 4/12/21 at 4:33 p.m. resident with unstageable dark wound to left heel which measured 3 by 4 centimeters. Treatment in place and heels floated. Review of the clinical record revealed there was no documented evidence that Resident #70's nutritional status was assessed after the development of the pressure ulcer. Observation of Resident #70 on 4/11/21 at 3:09 p.m. revealed the resident laid in bed on his/her back, with a left leg brace on and his/her heels laid directly on the bed. The bed had a pressure reducing mattress present. On the wall above Resident #70's bed was a picture of a leg in a leg brace and documentation that said to rest the leg on two (2) pillows to decrease pressure on heels. Observation of Resident #70 on 4/12/21 at 9:13 a.m. revealed the resident sat in a high back wheelchair, with a pressure reducing cushion, with a leg brace on the left leg and the left foot rested directly on the wheelchair footrest, in the day room. The right foot rested on the floor. Further observation revealed the resident remained in the same position at 10:20 a.m. and 11:16 a.m. Observation at 11:42 a.m. revealed therapy worked with the resident but did not provide repositioning. Observation at 11:46 a.m. therapy wheeled the resident back to the day room and assisted the resident with lunch. Further observation at 12:00 p.m. and 12:11 p.m. revealed no change in the resident's position. The surveyor asked for a skin check at 12:11 p.m. Observation at 1:00 p.m. revealed Certified Nursing Assistant (CNA) #6 and CNA #7 used the Hoyer Lift and transferred the resident to his/her bed. The resident's buttocks were red but blanched and no open areas were noted on the buttocks. Staff placed a pillow between the resident's legs, but the heels were in contact with the mattress. Observations revealed staff did not reposition the resident for three (3) hours and 47 minutes on 4/12/21. Observation on 4/13/21 at 8:41 a.m. revealed Resident #70 sat in the high back wheelchair in the day room. Further observation at 9:30 a.m., 10:00 a.m., 10:30 a.m., and 11:05 a.m. revealed no change in position. At 11:20 a.m. Occupational Therapy (OT) wheeled Resident #70 to his/her room, but no change in position was noted. Further observation at 11:50 a.m., and 12:18 p.m. revealed the resident was still in the same position. At 12:23 p.m. OT wheeled the resident back to the day room, but no change in position was provided. At 12:25 p.m. the surveyor asked Licensed Practical Nurse (LPN) #5 for a skin check of Resident #70 since the resident had not been repositioned. At that time CNA #5 reported that him/her and the OT had checked the resident for incontinence and repositioned the resident prior to lunch. Interview with the OT at 12:30 p.m. revealed they had not repositioned the resident and the CNA had only pulled the front part of the resident's slacks down to observe the line on the incontinence brief while the resident sat in the wheelchair. Observation on 4/13/21 at 12:49 p.m. revealed staff wheeled Resident #70 to his/her room and by each one placing an arm under Resident #70's arm/shoulder area and each holding onto the resident's slacks in the back, transferred the resident from the wheelchair to the bed. Observation at that time revealed the resident's feet were on the floor and the resident yelled out. Further observation at that time revealed a dressing on the left heel. Observations revealed that staff did not reposition the resident for four (4) hours and eight (8) minutes on 4/13/21. Observation on 4/13/21 at 1:05 p.m. revealed LPN #5 provided a dressing change to Resident #70's left heel. LPN #5 placed the dressing supplies directly on the resident's bed, donned gloves, removed the old dressing from the left heel, applied [MEDICATION(S)] Advance to the necrotic area and then covered the heel with a foam dressing using the same gloves. Observation at that time revealed a black necrotic area to the left heel. The nurse did not cleanse the pressure ulcer with normal saline as ordered by the physician. LPN #5 stated he/she did not know if Resident #70 was admitted with the pressure ulcer or if it developed there. Interview with CNA #6 on 4/12/21 at 12:22 p.m. revealed Resident #70 required total assistance with ADLs. The resident was turned and repositioned every two (2) hours. Interview with CNA #5 on 4/13/21 at 9:04 a.m. revealed Resident #70 was total care and staff should reposition him/her every two (2) hours. Interview with the Director of Nursing (DON) on 4/13/21 at 2:00 p.m. revealed the staff should change gloves and wash their hands between removing the old dressing, cleaning the wound, and applying the new dressing. Further interview with the DON revealed staff should reposition Resident #70 every two (2) hours. The DON stated he/she was unaware of the sign above Resident #70's bed instructing the staff to use two (2) pillows under the resident's lower legs to keep the heels off the bed, but that was what the staff should do. The DON stated the pressure ulcer program consisted of body audits completed weekly by the nurse. The admission Braden Scale was completed in the morning meeting two (2) days after the resident was admitted to the facility. All the department heads were in the morning meeting and the team completed the Braden Scale together. If the resident was assessed to be at risk, the staff should use barrier creams and wedges or pillows to position the resident. Further interview with the DON on 4/14/21 at 2:53 p.m. revealed he/she did not know where the documentation about pressure ulcers were kept. Interview with the LPN #2, Treatment Nurse on 4/14/21 at 3:20 p.m. revealed he/she did not know Resident #70 had a pressure sore and would go down and assess the area. He/she further stated there was no system to let him/her know if a resident developed a pressure ulcer. Review of the Resident #70's Body Audit dated 4/14/21, provided by the LPN #2, Treatment Nurse, revealed the resident had an unstageable pressure ulcer that measured 4.9 by 3.7, the unit of measurement was not documented, to the left heel. 2. Resident #77 was admitted to the facility on [DATE] and readmitted from an acute care stay on 1/26/21. The resident's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was assessed by staff to be moderately impaired in cognitive skills for daily decision making. The resident was assessed to require total assistance of one (1) staff with bed mobility and transfers (surface to surface) did not occur during the review period. Resident #77 was assessed to have one (1) Stage 2 pressure ulcer that was present on admission and at risk for further skin breakdown. Skin and ulcer/injury treatments identified on the MDS assessment included a turning and repositioning program. ADL functional status and pressure ulcers triggered on the Care Area Assessment (CAA) for further review and a decision made to proceed to the care plan. Review of a quarterly MDS assessment dated [DATE] revealed Resident #77 had returned to the facility on [DATE] after an acute care stay. The Stage 2 pressure ulcer present during the admission MDS assessment had worsened. Resident #77 was assessed to have a Stage IV (4) pressure ulcer. The quarterly MDS assessment no longer identified a turning and repositioning program as a skin and ulcer/injury treatment. Review of Resident #77's Care Plan (initiated 7/24/2020) revealed a problem deficit of an actual pressure ulcer and at risk for further skin breakdown due to bedfast, bowel incontinence, and obesity. Interventions included a turning and reposition schedule, per assessment. Further review of the care plan revealed Resident #77 had an ADL self-care performance deficit related to fatigue, limited mobility, and limited range of motion (ROM). Interventions included turning the resident every two (2) hours, and as needed. Review of the Documentation Survey Report used by Certified Nursing Assistants (CNAs) to document the provision of ADL interventions/tasks revealed the ADL task of providing bed mobility for Resident #77 was not consistently documented as being completed during the month of March 2021. Assistance with bed mobility was not documented as being done during the first shift (7:00 a.m. to 3:00 p.m.) on 3/11/21, 3/12/21, 3/18/21, and 3/28/21. Documentation for the second shift (3:00 p.m. to 11:00 p.m.) revealed assistance with bed mobility was not documented as being completed on 3/18/21 through 3/28/2021. The night shift (11:00 p.m. to 7:00 a.m.) documentation reflected bed mobility assistance was not provided on 3/1/21, 3/4/21, 3/7/21, 3/8/21, and 3/15/21. Review of the ADL interventions/tasks documentation for the provision of assistance with bed mobility during April 2021 revealed the care was not documented as occurring during the night shift (11:00 p.m. to 7:00 a.m.) on 4/1/21, 4/3/21, 4/5/21, 4/7/21, 4/9/21, 4/10/21, and 4/11/21. Review of Resident #77's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The new order specified staff should clean the wound to the sacrum with NS (normal saline), pack with hydrogel impregnated gauze and apply non-adherent foam dressing, every day and as needed. Review of the weekly Body Audits documented by Licensed Practical Nurse (LPN) #2 who also served as the treatment nurse revealed the wound to Resident #77's sacral area was assessed on 4/12/21. The assessment identified an open area that measured 7.3 centimeters (cm) in length by 5.3 cm in width, and 4.6 cm depth. These measurements reflected an improvement in wound status since the initial assessment of the wound that was completed when Resident #77 was readmitted on [DATE] from an acute care stay. At that time the wound to Resident #77's sacral area measured 8.7 cm in length by 7.1 cm width, and 6.3 depth. Resident #77's wound care, provided by LPN #2 Treatment Nurse, was observed on 4/14/21 at 10:00 a.m. CNA #4 and LPN #3 were also present during the wound care observation. LPN #2 was observed to wash his/her hands and don gloves prior to initiating the wound care. The LPN removed the old dressing, removed his/her gloves, and washed his/her hands before donning a clean pair of gloves. The wound to Resident #77's sacral area was noted to be beefy red with no slough on the wound. Red drainage was noted to be on the old dressing that was removed by LPN #2. LPN #2 cleaned the wound with one swipe, in a circular motion. The LPN then removed the gloves, washed his/her hands and donned a clean pair of gloves. LPN #2 packed the wound with a soaked [hydrogel impregnated] gauze. The LPN removed the gloves, washed his/her hands and covered the dressing. The dressing was dated and initialed by the LPN. LPN #2 removed the gloves and washed his/her hands. Observation on 4/12/21 at 9:37 a.m. revealed Resident #77 was lying in bed on his/her back. The head of the bed was elevated approximately 35 degrees. The resident stated he/she does have a sore on his/her bottom. The resident was questioned regarding assistance with turning in bed and the resident responded he/she could not remember them doing it. Resident #77 continued to be observed throughout the morning of 4/12/21. Observations at 11:15 a.m., 11:28 a.m.,11:44 a.m., and 12:00 p.m. revealed the resident remained in bed on his/her back during each observation. At 12:00 p.m. two (2) CNAs were observed to enter Resident #77's room to provide ADL care and reposition the resident in bed. An interview was conducted on 4/12/21 at 9:46 a.m. with the Certified Nursing Assistant (CNA) #3 assigned to care for Resident #77. The CNA stated the resident could at times make his/her needs known. CNA #3 stated due to a large resident assignment (20 residents) and no second CNA assigned to assist, residents who were total care were not being offered assistance with getting out of bed or turning/repositioning in bed. The CNA stated Resident #77 had not been provided assistance that morning (4/12/21) with turning and repositioning in bed since he/she (CNA) #3 had started the shift (7:00 a.m.). Based on CNA #3's statement and observations it was determined Resident #77 had remained in bed on his/her back for a minimum of five (5) hours. An interview was conducted on 4/13/21 at 2:48 p.m. with CNA #4. The CNA confirmed information obtained from the interview with CNA #3. CNA #4 stated he/she was staying over to work a double shift due to a shortage of available CNAs to work. CNA #4 stated it was common to have one (1) CNA assigned to care for up to 20 residents. When this occurred, it was impossible for the CNA to assist total care residents with getting out of bed or to provide total assistance with turning and repositioning in bed as frequently as required. 3. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE]. The resident's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15 indicating independence in cognitive skills for daily decision making. The MDS assessment identified the resident required extensive assistance of two (2) staff with bed mobility and total assistance of two (2) staff with transfers; however, the resident had been transferred only one (1) to two (2) times during the two (2) week review period. The assessment indicated the resident was not steady, only able to stabilize with staff assistance when transfers (bed to chair) did occur. Resident #81 had functional limitations in range of motion (ROM) to both sides and in both the upper and lower extremities. The resident was assessed to have two (2) Stage 3 pressure ulcers which were present upon admission. ADL functional status and pressure ulcers triggered for further review on the Care Area Assessment (CAA) and a decision was made to proceed to the care plan. Review of Resident #81's Care Plan (revised 3/25/21) revealed required assistance with ADL care was identified as a problem deficit. A goal was established to provide assistance through the next review date (6/6/21). Interventions planned included staff to provide assistance with bed mobility and transfers. Staff were to provide total lift with transfers and a Z-slider for bed positioning. A risk for falls was identified on the care plan with an intervention for staff to get the resident out of bed and into a posture pedic chair. The presence of actual pressure ulcers related to extensive assistance for bed mobility, bedfast status, obesity, and pressure ulcers present on admission was identified as a problem deficit on the care plan. Goals established included Resident #81 remaining free from further skin breakdown and healing of current pressure ulcers, without complications. Interventions included repositioning the resident every two (2) hours and providing wound care as ordered. Review of Resident #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Fill wound with [MEDICATION(S)] wound filler and gauze and cover with a non-occlusive dressing once daily. Every day-shift for wound care. Review of the medical record revealed the LPN #2 Treatment Nurse documented weekly body audits. Review of the weekly body audit documented on 4/7/21 revealed the nurse recorded a coccyx wound measurement of 2.3 cm (centimeters) wide x (by) 1.4 cm long x 1.7 cm deep. Resident #81 was observed on 4/11/21 at 2:38 p.m. lying in bed on his/her right, back side. The resident stated he/she required assistance from staff with turning and repositioning in bed. The resident was aware this should occur at least every two (2) hours. The resident stated he/she didn't think anyone had assisted him/her with bed mobility since around 7:00 p.m. the previous evening. Resident #81 stated staff did not offer to assist him/her with getting out of bed because it took two (2) people to transfer him/her and there was never enough staff to help. According to the resident, staff had assisted him/her to get out of bed and into a wheelchair the previous Monday because family members had come to visit. Resident #81 was observed on 4/12/21 at 9:40 a.m. lying in bed on his/her back. Continued observations of the resident throughout the morning, including mealtime at approximately 11:35 a.m. revealed Resident #81 remained on his/her back while lying in bed. Resident #81 stated during one observation that the staff had to get him/her out of bed soon because visitors were expected to come in the afternoon. Observation of wound care on 4/13/21 from 1:16 p.m. until 1:28 p.m. revealed the following: - LPN #2 washed his/her hands and applied clean gloves, removed and discarded the soiled dressing, and changed gloves without cleaning his/her hands. - LPN #2 then placed a barrier sheet on the bed under the resident's buttocks and changed gloves without cleaning his/her hands. - LPN #2 cleaned the coccyx wound with gauze soaked in normal saline with gloved fingers and changed gloves without cleaning his/her hands. - LPN #2 cleaned the lower gluteal wound using gloved fingers and changed gloves without cleaning his/her hands. - LPN #2 measured the wounds using gloved fingers and changed gloves without cleaning his/her hands. - LPN #2 packed the coccyx wound with the appropriate treatment using a Q-tip. LPN #2 packed the gluteal wound using gloved fingers. During interview on 4/13/21 at 1:31 p.m. LPN #2 stated s/he cleaned his/her hands and changed his/her gloves, as often as possible, after a dirty procedure .I should have washed my hands a whole lot more than what I did and [should have] used a Q-tip to pack both wounds. During interview on 4/13/21 at 2:00 p.m., the Director of Nursing (DON) stated every time a nurse removes gloves, they should clean their hands. The DON further stated, We never use fingers to pack wounds, only the long Q-tips. Interview was conducted on 4/12/21 at 9:46 a.m. with the Certified Nursing Assistant (CNA) #3 assigned to care for Resident #81. CNA #3 stated the resident had remained on his/her back throughout the morning because he/she was assigned to provide care for 20 residents and there was no second staff person available to assist with providing care for residents who required total assistance. The CNA stated Resident #81 was scheduled to have visitors at 3:00 p.m. that afternoon and would have to be provided assistance with getting out of bed and to a wheelchair. CNA #3 stated if the resident did not have visitors coming, he/she would not be offered assistance to get out of bed because the resident was a two (2) person total lift. An interview was conducted on 4/12/21 at 10:55 a.m. with LPN #2 who was assigned to care for Resident #81. The LPN stated he/she was also the facility's treatment nurse. LPN #2 stated the CNAs did occasionally report they were not able to turn and reposition total care residents while in bed. The LPN stated he/she helped the CNAs with providing residents assistance with care, however, his/her duties did not allow for time to assist every time help was needed.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a person-centered, comprehensive care plan was implemented for nine (9) of 37 sampled residents. Resident #70 was not provided the care planned assistance with bed mobility, transfers, positioning, and incontinence care in accordance with the care planned interventions. Resident #36 experienced a weight loss and care planned interventions were not implemented to address and/or prevent the weight loss from occurring. Resident #18 experienced a weight loss and recommended care plan interventions were not implemented to address the weight loss. Care planned interventions were not implemented to address the nutritional status for Resident #19 related to a potential for weight loss. Resident #55 was not assisted with bed mobility and transfers from the bed to wheelchair as planned to address an Activities of Daily Living (ADL) and an activities deficit as identified and planned on the care plan. Resident #59 experienced numerous falls and care planned interventions were not implemented to prevent further falls from occurring. Resident #77 had a pressure ulcer to the sacrum and was not assisted with bed mobility in accordance with the comprehensive care plan interventions. Resident #78 required staff assistance with grooming and hygiene and the care planned interventions were not implemented to ensure the resident's needs were met. Resident #81 was not provided assistance with bathing, bed mobility, and transfers per the assessed requirements and in accordance with the comprehensive care plan. Findings include: A request was made for the facility policy regarding the development and implementation of resident care plans. The Administrator provided a written statement that specified the facility used the Resident Assessment Instrument (RAI) Manual as a guide to develop and implement care plans. Interview with the Director of Nursing (DON) on 4/13/21 at 2:27 p.m. revealed in the past the facility utilized Care Guides to direct the Certified Nursing Assistants (CNAs) regarding care needs of their assigned residents. The DON stated the facility no longer used the Care Guides to communicate the care needs of the residents. Interview with the MDS Coordinator on 4/14/21 at 3:50 p.m. revealed the care plans were not specific but the Care Guides would be specific and told the staff what interventions were needed for the resident. The MDS Coordinator did not know the facility no longer used the Care Guides. 1. Review of Resident #70's clinical record revealed an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #70's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long-term memory impairment, had modified impairment with decision making, had disorganized thinking that fluctuated and displayed physical and verbal behaviors one (1) to three (3) days since admission. The MDS identified the resident required extensive assistance of one (1) staff with bed mobility, dressing, eating and personal hygiene. The resident required total assistance of two (2) staff with transfers and toileting and did not ambulate. Resident #70 had impairment in range of motion of the bilateral lower extremities and utilized a wheelchair. The resident was always incontinent of bowel and bladder, was at risk for the development of pressure ulcers and did not have a pressure ulcer at the time of the assessment. The resident had a pressure reducing mattress on the bed, but the MDS assessment did not document the resident had a pressure reducing device for the wheelchair or was on a turning and repositioning program. Review of Resident #70's Care Plan dated 3/29/21 revealed the resident had the potential for further skin breakdown due to impaired mobility. The interventions included: Complete Braden Scale per facility policy; conduct weekly skin inspection; observe for signs and symptoms of infection such as swelling, redness, warmth, discharge, and odor and notify the physician of significant finding; provide pressure reducing wheelchair cushion; provide pressure reduction/relieving mattress; skin assessment per facility's policy; and treatments as ordered. Resident #70's Care Plan also listed the resident had self-care performance deficit and included the interventions for staff to provide appropriate assistance with bed mobility, transfers, eating, personal hygiene, and toilet use. Resident #70's Care Plan revealed the resident had alteration in elimination of bowel and bladder and the interventions included for staff to offer toileting approximately every two (2) hours. Review of the Admission Progress Note, late entry, for 3/20/21 at 5:21 p.m. revealed the resident was incontinent of bowel and bladder and wore briefs. Staff would turn the resident every two (2) hours and as needed. Further review of the Nurses' Notes revealed: On 4/12/21 at 2:53 p.m. area noted to left heel. The area was dark in color, but no open area noted. Treatment was in place for prophylaxis. On 4/12/21 at 4:33 p.m. resident with unstageable dark wound to left heel which measured 3 by 4 centimeters. Treatment in place and heels floated. Observation of Resident #70 on 4/11/21 at 3:09 p.m. revealed the resident laid in bed on his/her back, with a left leg brace on and his/her heels laid directly on the bed. The bed had a pressure reducing mattress. On the wall above Resident #70's bed was a picture of a leg in a leg brace and documentation that said to rest the leg on two (2) pillows to decrease pressure on heels. Observation of Resident #70 on 4/12/21 at 9:13 a.m. revealed the resident sat in a high back wheelchair, with a pressure reducing cushion, with a leg brace on the left leg and the left foot rested directly on the wheelchair footrest, in the day room. The right foot rested on the floor. Further observation revealed the resident remained in the same position at 10:20 a.m. and 11:16 a.m. Observation at 11:42 a.m. revealed therapy worked with the resident but did not provide repositioning. Observation at 11:46 a.m. revealed therapy wheeled the resident back to the day room and assisted the resident with lunch. Further observation at 12:00 p.m. and 12:11 p.m. revealed there was no change in the resident's position. The surveyor asked for a skin check at 12:11 p.m. Observation at 1:00 p.m. revealed Certified Nursing Assistant (CNA) #6 and CNA #7 used the Hoyer Lift and transferred the resident to his/her bed. Staff removed the resident's slacks and the incontinence brief. The brief had a small amount of stool and the resident had dried stool on his/her buttocks. Staff used disposable wipes and had to rub at the dried-on stool to remove the stool. Staff then applied barrier cream and the incontinence brief. Staff placed a pillow between the resident's legs, but the heels were in contact with the mattress. The staff did not reposition or check for incontinence for this dependent and cognitively impaired resident for three (3) hours and 47 minutes on 4/12/21. Observation on 4/13/21 at 8:41 a.m. revealed the resident sat in the high back wheelchair in the day room. Further observation at 9:30 a.m., 10:00 a.m., 10:30 a.m., and 11:05 a.m. revealed no change in position. At 11:20 a.m. Occupational Therapy (OT) wheeled Resident #70 to his/her room, but no change in position was noted. Further observation at 11:50 a.m., and 12:18 p.m. revealed no change in position. At 12:23 p.m. OT wheeled the resident back to the day room, but no change in position was provided. At 12:25 p.m. the surveyor asked Licensed Practical Nurse (LPN) #5 for a skin check of Resident #70 since the resident had not been repositioned. Observation on 4/13/21 at 12:49 p.m. revealed CNA #5 and CNA #6 wheeled Resident #70 to his/her room and by each staff member placing an arm under Resident #70's arm/shoulder area and each holding onto the resident's slacks in the back transferred the resident from the wheelchair to the bed. Observation at that time revealed the resident's feet were on the floor and the resident yelled out. Further observation at that time revealed a dressing on the left heel. This staff removed the resident's slacks and incontinence brief. Observation at that time revealed the incontinence brief was wet with urine. Staff used one disposable wipe to swipe one time between the frontal area. Staff then turned the resident to his/her side and using another disposable wipe cleansed both buttocks and then between the buttocks without changing the position of the wipe. Brown stains were noted on the disposable wipe. Staff then placed peri guard to the buttocks and applied a new incontinence brief. Observations on 4/13/21 revealed staff did not reposition or check this resident for incontinence for four (4) hours and eight (8) minutes. Observation on 4/13/21 at 1:05 p.m. revealed LPN #5 provided a dressing change to Resident #70's left heel. Observation at that time revealed a black necrotic area to the left heel. Interview with CNA #6 on 4/12/21 at 12:22 p.m. revealed Resident #70 required total assistance with ADLs. The resident was turned and repositioned and checked for incontinence every two (2) hours. Interview with CNA #5 on 4/13/21 at 9:04 a.m. revealed Resident #70 required total care and staff should reposition and provide incontinence care for him/her every two (2) hours. Interview with the Director of Nursing (DON) on 4/13/21 at 2:27 p.m. revealed, on admission therapy assessed the resident and then reported in the morning meeting how the staff should transfer a resident. The MDS Coordinator would then add it to the care plan. Interview with the Physical Therapist (PT) on 4/14/21 at 3:40 p.m. revealed if a resident was an orthopedic resident, they would check their weight bearing status. Resident #70 was on non-weight bearing status. Also, the facility was a no lift facility so the staff should use the Hoyer Lift when transferring Resident #70. The PT stated this information was discussed in the morning meeting and the nurses in the meeting should communicate this information to the floor nurses. The Care Plan lacked documentation regarding the frequency of turning and repositioning and the use of the Hoyer lift for transfers and the staff failed to follow the care plan for checking for incontinence every two (2) hours. 2. Review of Resident #36's clinical record revealed an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 99 (indicating not able to test). The resident had short and long-term memory impairment, had modified decision making skills, displayed inattention and disorganized thinking that fluctuated, had a mood score indicating no depression and displayed no behaviors. The MDS revealed Resident #36 required supervision of one (1) staff with bed mobility, transfers, ambulation, locomotion, and eating. The resident required limited assistance of one (1) staff with dressing, toileting, and personal hygiene. The MDS revealed the resident weighed 168 pounds (lbs.), had no swallowing disorders, weight loss or dental problems. The resident did not receive nutritional approaches. Review of the Care Plan initiated on 9/31/19 and last reviewed on 2/19/21, listed the problem, resident was at risk for altered nutritional status with the intervention to offer alternate meal and snacks when requested, serve diet as ordered and weights per protocol. Review of the clinical record's Weight List revealed the following weights in lbs.: 10/14/2020 - 169.9; 11/25/2020 - 157.4; 12/17/2020 - 149.0; 1/18/21 - 137.9; 2/10/21 - 134.0; 3/15/21 - 132.0; 3/22/21 - 129.0; and 3/29/21 - 126.0. This consisted of a 21.13 percent weight loss from 10/14/2020 to 2/10/21 and a 25.84 percent weight loss from 10/14/2020 to 3/29/21. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/21/21 - Fortified foods with breakfast. (started after the resident lost 32 lbs.) 2/24/21 - Speech Therapy (ST) four (4) times per week times four (4) weeks for oropharyngeal dysphagia, weight loss. (started after the resident lost 35.9 lbs.) 3/1/21 - Med Pass (nutritional supplement) 120 cubic centimeters (cc) two (2) times per day (started after the resident lost 35.9 lbs.) 3/1/21 - Consult Nutrition secondary to weight loss and House Supplements (nutritional supplement) two (2) times a day. 3/24/21 - Continue ST four (4) times per week for four (4) weeks for oropharyngeal dysphagia. 4/7/21 - Unintended weight loss, check weights times four (4) week cycle, check [CONDITION(S)] Stimulating Hormone and Prealbumin level, and discontinue Trazadone (antidepressant) and start Mirtazine (antidepressant and used to stimulate appetite) 15 milligrams (mg) at bedtime. Review of the clinical record and after request for all Nutritional Assessments and Screenings revealed the facility did not follow the 3/1/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Nurse's Note dated 10/20/2020 at 10:44 p.m. revealed at 3:15 p.m. Resident #36 came to the Nurse and gave him/her their left front tooth implant/bridge, two (2) connected teeth were noted with a post extending from the root of one (1). The resident denied pain and no bleeding noted. The root of the left tooth was visible from the gumline. Will continue plan of care. Review of Resident #36's Diet Slip on 4/12/21, revealed the resident received a regular diet with regular texture and received super cereal at breakfast. Review of the ADL Meal Consumption Record revealed: On 2/2021 staff did not document meal consumption for 35 of the 84 meals provided. On 3/2021 staff did not document meal consumption for 36 of the 93 meals provided. From 4/1/21 to 4/14/21 at 5:00 p.m. staff did not document meal consumption for 26 of the 41 meals provided. Observation on 4/12/21 from 8:35 a.m. to 10:30 a.m. and from 11:15 a.m. to 11:43 a.m. revealed the resident wandered the halls of the locked Special Care Unit. Observation on 4/12/21 at 11:46 a.m. the staff served the resident his/her lunch tray of cornbread, broccoli, meat, baked potato, brownie, and iced tea. The resident picked up the cornbread and took a bite. Staff left the room after setting up the tray. Observation at 11:52 a.m. revealed the resident wandered down the hall and followed the surveyor into his/her room. The resident picked up the brownie, ate it and then left the room and wandered up and down the halls. At 12:14 p.m. staff removed the lunch tray. The resident ate ½ piece of cornbread, 95 percent of the brownie and eight (8) ounces of tea. Observation during the meal revealed staff did not encourage the resident to eat. Observation on 4/13/21 of the lunch meal beginning at 12:14 p.m. revealed Resident #36 ate approximately 50 percent of the noon meal with staff encouragement in his/her room. Further observation revealed when the staff left the room, the resident followed the staff out but returned to the room with staff encouragement to eat. Interview with the Dietary Manager (DM) on 4/14/21 at 9:37 a.m. regarding fortified foods revealed they start with the resident's best meal and for Resident #36 they started with Super Cereal at breakfast. Interview with the Registered Dietician (RD) on 4/14/21 at 10:04 a.m. revealed the RD assessed the residents within 30 days of admission and then annually. The RD stated he/she reviewed the weights on a weekly basis and as requested by the facility. The RD stated the DM would notify him/her of any changes in the residents. Regarding Resident #36, he/she had a big weight loss towards the end of last year but I believe [he/she] is holding steady. The facility used Med Pass and House Supplement interchangeably and he/she usually recommended 120 cc, but the amount may vary. Interview with the Director of Nursing (DON) on 4/14/21 at 3:03 p.m. revealed during the morning meetings, Monday through Friday, the Administrator would ask if any residents had a weight loss. For Resident #36, when I documented his/her weights in the computer, the computer was supposed to turn the weight red if there was a significant weight change and it did not. It was a computer error. Resident #36 is a picky eater and ate better without distractions. Resident #36 required assistance with eating and the DON did not know if the resident ate snacks or not. The DON did not know about the resident losing his/her bridge and teeth and did not know if he/she was assessed by a Dentist. 3. Review of Resident #18's clinical record revealed an admitted [DATE] and the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three (3) of 15 indicating severe cognitive impairment. The resident did not display signs or symptoms of [CONDITION(S)], behaviors, or signs of depression. The resident required limited assistance of one (1) staff with bed mobility and transfers, required supervision with ambulation and required set-up assistance with eating. The MDS revealed the resident had no difficulty with swallowing, was on a mechanically altered diet, weighed 126 pounds (lbs.) and had experienced a five (5) percent weight loss in the last month or ten (10) percent weight loss in the last six (6) months. The resident was not on a prescribed weight loss regimen. Review of Resident #18's Care Plan for nutritional risk due to Hypertension, [CONDITION(S)], Dementia and mechanically altered diet order, initiated on 2/19/18 and reviewed after the 2/8/21 Annual MDS revealed the following interventions: assist in feeding as needed, allow time for the resident to eat, diet as ordered, offer alternate foods for those uneaten, supplements as ordered, weigh per protocol, schedule, and as needed, document the weights and report weight changes. The Care Plan lacked individualized interventions for the prevention of weight loss for this cognitively impaired and dependent resident. Review of the clinical record's Weight List revealed the following weight in pounds (lbs.): 9/15/2020 - 143.6; 10/19/2020 - 137.0; 11/19/2020 - 131.6; 12/17/2020 - 128; 1/15/21 - 125.9; 2/10/21 - 126.0; and 3/15/21 - 126.0. This consisted of a 12.26 percent loss from 9/15/2020 to 3/15/21. Review of the RD's Annual Nutritional Review dated 2/21/21 revealed Resident #18 had a significant weight loss of approximately 8.1 percent in three (3) months and approximately 11.1 percent in six (6) months. The resident received a mechanical soft diet with varied intake. The resident also received a nutrition treat (high calorie) on the lunch tray. The resident may benefit from the addition of fortified foods. Review of the clinical record lacked evidence the facility followed-up on the recommendation for fortified foods. Review of the Resident #18's Dietary Slip on 4/12/21 revealed the resident received a regular mechanically soft diet with a frozen nutrition treat at lunch and dinner. The Dietary Slip lacked documentation regarding fortified foods. Review of the ADL Meal Consumption Record revealed: On 2/2021 staff did not document meal consumption for 49 of the 84 meals provided. On 3/2021 staff did not document meal consumption for 61 of the 93 meals provided. From 4/1/21 to 4/14/21 at 5:00 p.m. staff did not document meal consumption for 30 of the 41 meals provided. Observation on 4/12/21 at 11:40 a.m. the resident laid in bed and staff served the lunch tray which consisted of a baked potato, chopped meat, cauliflower, brownie, frozen nutritional treat, cornbread, and iced tea. The resident reached for and began to eat the brownie. Staff set-up the tray and then left the room. Observation at 11:55 a.m. revealed staff were not present to assist the resident with the noon meal. Observation at 12:17 a.m. revealed staff entered the room to take the lunch tray, the resident stated to leave the tray. The resident had eaten the frozen nutritional treat, ½ piece of cornbread, ½ of the baked potato and 100 percent of the brownie. The resident drank eight (8) ounces of iced tea. Observation of the noon meal revealed staff did not encourage or assist Resident #18 to eat. Observation on 4/13/21 at 11:47 a.m. revealed the staff brought the lunch tray consisting of chopped meat, roll, brussels sprouts, desert, water and juice to Resident #18's room. The staff placed it on the bedside table and then left the room. Observation at 11:50 a.m. revealed the resident's head of bed flat and the resident laid on his/her right side. The resident propped him/herself up with the right arm and attempted to eat his/her meal. Observation at 12:00 p.m. revealed the resident had drank the eight (8) ounces of water and iced tea and had eaten ½ of the roll. Staff entered the room at 12:12 p.m. and removed the tray. Staff did not ask the resident if he/she wanted something else to eat. 4. Review of Resident #19's undated Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident had short/long-term memory problems and had modified independence in cognitive skills for daily decision-making. Resident #19 required limited physical assistance of one (1) person for eating. The resident did not have any swallowing disorders. Resident #19 was assessed as having a significant weight loss and was not on a prescribed weight-loss regimen. The resident had no oral/dental concerns and no special treatments were received. Review of Resident #19's Care Area Assessment (CAA) dated 2/8/21 revealed the following triggers: cognitive loss/dementia, communication, activities of daily living functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury and [CONDITION(S)] drug use. All triggers were to be care planned. Review of Resident #19's Care Plan initiated on 3/10/18 revealed Focus: I have a potential for Involuntary Weight Loss related to Depression. Goal: My weight will remain stable through the next review. Target Date: 6/6/21. Interventions: Diet as ordered; Dietary Manager to obtain preferences and offer preferences as ordered diet allows; monitor meal consumption daily; monthly weights; provide food substitutes; screen/evaluation by rehab services prn (as needed);and vitamin/mineral supplements as ordered. Review of Resident #19's weights revealed the following: 10/20/20 - 167.0; 11/3/2020 - 157.2; 11/10/20 - 154.4; 11/12/20 - 157.2; 11/17/20 - 153.4; 12/17/20 - 147.1; 1/15/21 - 143.2; 2/10/21 - 142.0; 3/3/21 - 139.4; and 4/14/21 - 146.3. Review of the Nutritional Review dated 3/21/21 revealed CBW (current body weight) 139.4#, BMI 19.4, wt. (weight) loss noted, no significant wt. loss x ~1 mo. (month), x ~3 mo., significant wt. loss -16.5% in ~ 6 months. Weight range over past ~6 months ~142-164#. Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (weight) loss, 2) weekly weights, 3) Med (Medication) Pass PO (by mouth) BID (two times a day) between meals. Review of Resident #19's medical records revealed no documentation showing the order was implemented. Observation on 4/12/21 at 11:45 a.m. during lunch revealed Resident #19 was sitting up in bed being assisted with feeding. The resident was tolerating the meal well. Resident #19 was observed taking a few bites of his/her meal and not wanting any more. Staff was observed removing the tray. No substitution was offered. Review of Resident #19's Meal Consumption Record for February 2021 revealed the following: On 2/1/21, 2/2/21 and 2/12/21 at 6:00 p.m., Resident #19 consumed 76 - 100% of his/her meal. On 2/7/21 at 9:00 a.m., Resident #19 consumed 26 - 50% of his/her meal. On 2/7/21 at 1:00 p.m. Resident #19 refused his/her meal. On 2/11/21, 2/16/21, 2/17/21, 2/18/21, 2/20/21, 2/21/21, 2/25/21, and 2/26/21 at 6:00 p.m., Resident #19 consumed 51 - 75% of his/her meal. All other days for the month of February 2021 were blank. Review of Resident #19's Meal Consumption Record for March 2021 revealed the following: On 3/3/21 at 9:00 a.m. and 1:00 p.m.; 3/10/21, 3/22/21 and 3/26/21 at 6:00 p.m., Resident #19 consumed 26 - 50% of his/her meal. On 3/1/21, 3/5/21, 3/8/21, 3/12/21, 3/15/21, 3/23/21, and 3/28/21 at 6:00 p.m., Resident #19 consumed 51 - 75% of his/her meal. On 3/3/21, 3/4/21, 3/9/21, 3/11/21, 3/16/21 and 3/21/21 at 6:00 p.m., Resident #19 consumed 76 - 100% of his/her meal. On 3/17/21 at 6:00 p.m., NA (not available) was entered. All other days for the month of March 2021 were blank. Review of Resident #19's Meal Consumption Record for April 2021 revealed the following: On 4/3/21, 4/4/21, 4/5/21 and 4/7/21 at 9:00 a.m., 1:00 p.m. and 6:00 p.m.; 4/6/21 at 6:00 p.m. and 4/7/21 at 9:00 a.m., Resident #19 consumed 0 - 25% of his/her meal. On 4/9/21, 4/10/21 - 4/13/21 at 9:00 a.m.; 4/1/21, 4/7/21, 4/9/21 - 4/14/21 at 1:00 p.m.; and 4/8/21 and 4/10/21 at 6:00 p.m., Resident #19 consumed 26 - 50% of his/her meal. On 4/1/21, 4/2/21, and 4/14/21 at 9:00 a.m.; 4/2/21 at 1:00 p.m.; and 4/1/21, 4/2/21, 4/7/21, 4/11/21, and 4/12/21 at 6:00 p.m., Resident #19 consumed 76 - 100% of his/her meal. Interview on 4/13/21 at 12:55 p.m. with Certified Nursing Assistant (CNA) #2 revealed he/she did not assist the resident with eating today, but he/she did yesterday. He/she stated the resident only ate a couple of bites and did not want any more food. He/she stated Resident #19 ate a lot of junk food. He/she stated on the side of the bed the resident had chips, cakes, candy, and Mountain Dew sodas which the resident's family provided. He/she stated the resident ate those all day so when it was time to eat real food, he/she did not eat a lot. He/she stated he/she did not know if the resident had any supplements. He/she stated he/she usually did not offer the resident substitutes because he/she knew the resident would not eat it. Interview on 4/14/21 at 5:20 p.m. with the DON revealed if a resident ate less than 50% of their foods, staff should offer them a substitute, a snack, or a supplement. 5. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. The resident's current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating independence in cognitive skills for daily decision making. The resident was assessed to require extensive assistance of one (1) staff with bed mobility and be totally dependent on two (2) staff persons with transfers (bed to chair). Review of a Quarterly MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of 12 which indicated the resident was cognitively intact. The resident continued to require extensive assistance of one (1) staff with bed mobility. Transfers from the bed to chair did not occur during the review period (14-day look back period). Review of Resident #55's Care Plan (revised 1/28/21) revealed the problem of an ADL self-care performance deficit related to bilateral [CONDITION(S)] and activity intolerance. The established goal was for all the resident's ADL needs to be met through the next review date. Interventions included staff to assist with bed mobility and transfer with mechanical lift. Continued review of the care plan revealed ensuring the resident's recreational interests/patterns were provided was developed as a focus by the interdisciplinary team (IDT). The goals established included the resident would participate in group activities of interest through the next review date. Planned interventions to attain the established goal included to invite/encourage the resident to attend activities of interest and offer to assist/escort the resident to activities of his/her choice. Resident #55 was observed on 4/11/21 at 2:38 p.m. lying on his/her back in bed. The resident stated he/she spent most days in bed. The resident couldn't remember the last time he/she had received assistance with getting out of the bed. The resident stated staff did not ask if he/she wanted assistance with getting out of the bed. Resident #55 stated he/she did need help with turning and repositioning in bed, but staff rarely provided assistance with bed mobility. Resident #55 was observed on 4/12/21 at 9:40 a.m., 10:20 a.m., and 11:55 a.m. lying in bed on his/her back. The resident had not been provided assistance with turning and repositioning in bed. Observation on 4/13/21 at 12:55 p.m. revealed Resident #55 was awake while lying in bed on his/her back. The resident stated no one had offered to assist him/her with getting out of bed. Observation at 1:20 p.m. revealed the resident remained on his/her back in bed while a group activity was occurring in the unit dining room. At 1:25 p.m. an interview with the resident revealed he/she was unaware the group activity was occurring. The resident stated he/she wanted assistance with getting out of bed to attend the on-going group activity. Interview with the Activities Director (AD) on 4/13/21 at 1:30 p.m. revealed Resident #55 was in bed and so had not been invited to attend the group activity. The AD stated the nursing staff were responsible for getting residents out of bed. There was no communication between nursing and activity staff regarding the upcoming planned group activities. An interview was conducted on 4/13/21 at 1:50 p.m. with the Director of Nursing (DON). The DON stated there was no mechanism in place for coordinating planned group activities between the activity staff and nursing staff. As a result, residents were not always provided assistance with getting out of bed before a planned activity. An interview was conducted on 4/12/21 at 9:46 a.m. with the Certified Nursing Assistant (CNA) #3 that was assigned to care for Resident #55. CNA #3 stated he/she was assigned to care for 20 residents and had to prioritize the care provided. The CNA stated residents who required assistance with turning and repositioning or getting out of bed could not always be provided the planned services. 6. Review of Resident #59's clinical record revealed an initial admitted [DATE] and a readmitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident resided on the locked Special Care Unit. Review of Resident #59's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required supervision of one (1) staff with bed mobility, transfers, ambulation [TRUNCATED]