Based on interview, record review, and facility document and policy review, the facility failed to protect 1 (Resident #286) of 7 residents reviewed for abuse from resident-to-resident abuse. Specifically, the facility failed to protect Resident #286's right to be free from physical abuse perpetrated by Resident #284 on 08/19/2023. Findings included: The facility's Resident Protection Plan, dated 09/15/2022, included a policy titled, Reporting Abuse to Facility Management that indicated, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. An admission Record revealed the facility admitted Resident #284 on 02/17/2023. According to the admission Record, the resident had a medical history that included diagnoses of moderate dementia with anxiety, need for assistance with personal care, depression, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2023, revealed Resident #284 had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. According to the MDS, the resident had no physical, verbal, or other behavioral symptoms directed towards others and wandered one to three days during the assessment look-back period. Resident #284's care plan included a focus area, initiated on 02/17/2023, that indicated the resident exhibited physical and verbal behaviors, refused medications at times, and had a history of physical aggression towards others. Resident #284's Progress Notes revealed an Incident Note, dated 08/19/2023 at 8:13 PM, that indicated Resident #284 hit Resident #286 across the face and then in the leg as Resident #286 was propelling around them. Per the note, Kentucky Medication Aide (KMA) #21 witnessed the altercation. An admission Record revealed the facility admitted Resident #286 on 02/13/2013. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, post-traumatic stress disorder (PTSD), major depressive disorder, and dementia in other diseases classified elsewhere with mood disturbance. A Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/13/2023 revealed Resident #286 had a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident had severe cognitive impairment. According to the MDS, the resident had no physical, verbal, or other behavioral symptoms directed towards others and wandered daily during the assessment look-back period. Resident #286's care plan included a focus area, initiated on 10/17/2022, that indicated the resident's psychosocial wellbeing was at risk due to dementia, confusion, and a new environment. Resident #286's Progress Notes revealed an Incident Note, dated 08/19/2023 at 6:10 PM, that indicated Resident #286 was propelling themselves in their wheelchair on the North Unit when one of the residents on the unit (Resident #284) hit Resident #286 on the right side of their face and kicked their right leg. A Facility Investigation-5 Day Final Report, dated 08/23/2023, revealed on 08/19/2023 at approximately 6:10 PM, Kentucky Medication Aide (KMA) #21 notified Licensed Practical Nurse (LPN) #23 that Resident #284 struck and kicked at Resident #286 as they passed them in the hallway. Per the report, KMA #21 and State Registered Nursing Assistant (SRNA) #24 witnessed the altercation, and the facility concluded the incident was verified and that it did occur. On 07/11/2024 at 12:02 PM, a call was placed to KMA #21. A voicemail was left, but no return call was received. During a telephone interview on 07/11/2024 at 12:09 PM, SRNA #24 stated she no longer worked at the facility. She stated she witnessed the incident between Resident #284 and Resident #286. She stated Resident #284 was in their wheelchair next to the day room doors, and Resident #286 rolled by, close to Resident #284, who swung and hit Resident #286. She stated Resident #284 slapped Resident #286's shoulder, but she did not see Resident #284 kick at Resident #286. SRNA #24 stated she immediately separated the residents and the incident occurred at the nurse's station so she called for the nurse to report what happened. SRNA #24 stated she could not recall who she reported the incident to. She further stated she had received abuse training from the facility while she was employed there and covered the different types of abuse and whom to report to. During an interview on 07/11/2024 at 4:22 PM, Registered Nurse (RN) #1 stated she was the Director of Nursing (DON) between July 2023 and October 2023, and had been with the facility since 2016 and had held various roles. She stated the facility provided abuse training frequently, the most recent being a couple months ago. She continued to state she recalled the incident between Resident #284 and Resident #286 and she stated the Administrator completed most of the investigation. RN #1 stated Resident #284 was placed on increased monitoring after the incident, specifically 1:1 supervision for a few days following the incident, followed by every 15-minute checks for a week. She stated the behavior and incident was odd and out of character for Resident #284, who had never done anything similar prior to the incident. She stated the physician came to examine Resident #284 and reviewed their medications for possible adjustments and Resident #286 had not been involved in any type of incident prior to or since the incident with Resident #284. RN #1 further stated she expected staff to follow the facility's abuse policy, and the floor staff acted appropriately during this incident, and the management team met to discuss the incident after the investigation. During an interview on 07/12/2024 at 3:27 PM, the Administrator stated Resident #284 was sitting in their wheelchair when Resident #286 passed by them, and Resident #284 smacked Resident #286. The Administrator further stated she expected staff to follow the facility's policy and abuse should be reported to the DON or herself immediately per policy.

Based on interview, record review, and facility document and policy review, the facility failed to ensure a pharmacy recommendation was addressed by the physician in a timely manner for 1 (Resident #34) of 5 residents reviewed for unnecessary medications. In addition, once the physician responded to the pharmacy recommendation, facility staff failed to immediately implement the physician's recommendation. Findings included: A facility policy titled, Consultant Pharmacist Reports, dated 11/2021, revealed Documentation and Communication of Consultant Pharmacist Recommendations included Policy The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations, and are responded to in an appropriate and timely fashion. Procedures A. A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable form to nurses, prescribers, and the care planning team. This should include: 1) Documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated manner. The policy revealed, 3) The consultant pharmacist documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for prescriber and/or nursing review. The policy revealed, B. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review and C. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within a reasonable time period, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director. An admission Record revealed the facility admitted Resident #34 on 10/12/2019 and most recently readmitted the resident on 03/12/2024. According to the admission Record, the resident had a medical history that included a diagnosis of gastroesophageal reflux disease (GERD). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #34's care plan revealed a focus area, initiated on 10/28/2019, that indicated the resident was at risk for malnutrition/dehydration related to multiple diagnoses, including the resident's diagnosis of GERD. An intervention initiated on 11/30/2021 and revised on 02/13/2024 instructed staff to administer medications for GERD as ordered by the physician. A Note to Attending Physician/Prescriber, with a medication regimen review (MRR) date of 10/02/2023, revealed a note that indicated, [Resident #34] receives two or more medications with similar mechanism of actions which may represent duplicate therapy. The note identified the medications in question as famotidine (a medication used to treat GERD) 20 milligram (mg), to be taken every night, and pantoprazole (a medication used to treat GERD) 40 mg, to be taken every day. The note recommended the physician consider discontinuing one medication if clinically appropriate due to risk of adverse effects and to avoid polypharmacy. A Consultant Pharmacist's Medication Regimen Review, dated 11/05/2023, revealed that a consultant pharmacist sent a pharmacy recommendation for Resident #34 the previous month regarding a possible duplication of therapy. The review indicated the consultant pharmacist was unable to find a response to the recommendation and requested the facility follow up. A Note to Attending Physician/Prescriber, with a MRR date of 12/03/2023, revealed a note that indicated, [Resident #34] receives two or more medications with similar mechanism of actions which may represent duplicate therapy. The note identified the medications in question as famotidine 20 mg, to be taken every night, and pantoprazole 40 mg, to be taken every day. The note recommended the physician consider discontinuing one medication if clinically appropriate due to risk of adverse effects and to avoid polypharmacy. Resident #34's MRR records revealed the physician's first documented response to these recommendations was dated 12/08/2024, over two months from the date of the pharmacist's original recommendation. Per documentation on the 12/03/2023 Note to Attending Physician/Prescriber, the physician agreed with the recommendation on 12/08/2023 and provided a verbal order to decrease Resident #34's pantoprazole to 20 mg every day. Resident #34's Order Recap [recapitulation] Report, reflecting all orders during the timeframe from 12/01/2023 to 07/31/2024, revealed the resident's order for pantoprazole 40 mg, one tablet by mouth one time a day for GERD, was not decreased to 20 mg per the physician's verbal order until 12/14/2023, five days after the physician provided the verbal order to decrease the dose. The order to decrease the dosage was entered on 12/13/2023 with a start date of 12/14/2023. Resident #34's medication administration record (MAR), for the timeframe from 12/01/2023 to 12/31/2023, revealed documentation that indicated staff did not implement the physician's verbal order to decrease the dose of Resident #34's pantoprazole until 12/14/2023. During an interview on 07/10/2024 12:36 PM, the Director of Nursing (DON) confirmed Resident #34's pantoprazole was not decreased until 12/13/2023 and it went unaddressed from the 10/02/2023 pharmacy recommendation until the new order was entered on 12/13/2023. She indicated that her expectation was for the pharmacy recommendations to come directly to her as soon as they were completed. She stated she reviewed and sorted the recommendations, had medical records staff take them to the prescribing physician that day, then sent the staff back the next day to pick them up and the responses were given back to her, and they were addressed immediately at that time. During an interview on 07/12/2024 at 9:03 AM, the Administrator stated she was the DON and the Administrator at the time Resident #34's pharmacy recommendation was not addressed by the prescribing physician in a timely manner. She stated that she did not know why there was a delay in addressing the recommendation. She indicated that all pharmacy recommendations needed to be addressed as soon as possible, but no longer than a week. During an interview on 07/12/24 01:25 PM with R# 34's Medical Provider, he/she stated typically the facility would bring the pharmacy rec. to his/her office once a month and he/she would go over them and fax them back to the facility with a reason for not agreeing with the recommendation or any medication and/or lab orders. He/she stated he would expect medication and/or lab orders be acted on within a day or two after receiving them. He/she continued to state the resident had some other medication changes back in Nov. of 2023 due to dealing with a DVT. The Medical Provider stated he/she did not know why there was a lag in responding to the pharmacy recommendation.

Based on observation, interview, record review, and review of facility's Policy, it was determined the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (1) of twenty-three (23) sampled residents (Resident #4). Observation on 04/24/19 during the morning mealtime revealed Resident #4 was being assist by a SRNA who was standing next to and over top of the resident. The findings include: Review of the facility's Policy, titled Resident Rights, undated, revealed the resident has the right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. Review of Resident #4's clinical record revealed the facility admitted the resident on 05/01/18 with diagnoses which included Muscle Weakness, Difficulty in Walking , Aschemic Heart Disease, COPD, Chronic Pain, Heart Failure, Need for Assistance with Personal Care, Parkinsonism, Angina Pectoris, Hypomagnesemia, Unpsecified Psychosis, Anxiety Disorder, Hypercholesterloemia, Dementia, Hearing Loss, Seasonal Allergies, GERD, Dysphagia, Cognitive Communication Deficit and Prostate Neoplasm. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 01/26/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15), indicating severe cognitive impairment. Observation of the morning meal, on 04/24/19 at 8:06 AM, revealed Resident #4 was being assisted with his/her meal. Continued observation revealed SRNA #5 was standing beside the resident while she was feeding him/her. Interview with State Registered Nurse Aide (SRNA) #5, on 04/24/19 at 8:10 AM, revealed she had worked at the facility for two (2) months. Continued interview revealed she normally stands to feed Resident #4 because he/she is in a high back wheelchair. She further stated she was supposed to pull up a chair to assist feeding residents; however, it was easier for her to stand to assist Resident #4. Further interview revealed it was a dignity issue to stand and feed residents. She stated she should have been at the resident's eye level. Interview with Certified Medical Assistant #9, on 04/25/19 at 10:30 AM, revealed she had worked at the facility for six (6) years. She stated the process to assist with feeding residents was to wash her hands, set up the tray and ensure the resident was sitting upright. She further stated she would pull up a chair and sit with the resident while she assisted the resident with their meal. She stated it is a dignity issue to stand up to feed a resident. Interview with Kentucky Medication Aide (KMA), on 04/25/19 at 10:42 AM, revealed, she had worked at the facility for two years. She stated she would wash her hands prior to assist feeding a resident, she would check the tray card for accuracy and pull up a chair to sit in while feeding the resident. She stated it was never okay to stand and feed a resident because that was a dignity issue for the resident. Interview with SRNA #6, on 04/25/2019 at 10:50 AM, revealed she had worked at the facility since September 2018. Per interview she stated the process to assist a resident with their meal was to get a tray off the cart, check the meal card, wash her hands and grab a folding chair to set beside the resident. She stated it would not be okay to stand beside them and feed them. Further interview revealed staff sit beside them to be at eye level. She stated, if you stand up, it could make the resident not feel at ease, and it is also a dignity issue. Interview with Registered Nurse #1, on 04/25/2019 at 10:55 AM, revealed she was the charge nurse and had worked at the facility for about seven (7) months. Continued interview revealed when she assisted a resident with their meal, she pulled up a chair and sat next to them. She stated you always wanted to be eye-to-eye with the resident before assisting with the meal. She stated standing up is a dignity issue and would be over powering to the resident, she further stated you could not converse with them if you are standing over them. Interview with Director of Nursing (DON), on 04/25/2019 at 1:35 PM, revealed she had worked for the company for twelve (12) years in different roles; this was her first DON role. Per interview, it was her expectation for all residents to be treated with respect and dignity. She further stated when staff are assisting dependent residents with feeding it is her expectation that staff to make sure the tray is correct and matches the resident's diet. Continued interview revealed she expects staff to wash their hands and explain to the resident what they have to eat. She stated it is her expectation for the staff to sit in a chair while feeding the resident. She stated standing is not our practice and it would be a dignity issue to be standing while feeding the resident. She stated staff need to be at eye level with the residents. Interview with Administrator, on 04/25/19 at 2:15 PM, revealed she had been working at the facility for six (6) weeks. She stated it was her expectation for staff to assist residents in a dignified manner. She stated under normal circumstances it would not be appropriate to stand beside a resident, unless they are care planned for the staff to stand. She stated they should pull up a chair and sit down next to the resident to assist them with their meal. She stated sitting would be keeping with their dignity. Continued interview revealed it was her expectation staff ensure the residents' rights and treat them in a dignified manner and sit along beside them to assist with dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure the Comprehensive Care Plan was revised for three (3) of twenty two (22) sampled residents (Resident #8, Resident #49 and Resident 51). 1. Resident #8 had unwitnessed fall events in his/her room, during unassisted transfers, on 12/28/18 and 04/03/19. However, there was no documented evidence the Comprehensive Care Plan (CCP) was revised to include interventions related to the Root Cause of the fall events to prevent further falls of the same nature. 2. Per record review and interviews, Resident #49 sustained a fall, on 04/23/19 at the bedside during an unassisted transfer from the wheelchair to the bed. However, there was documented evidence the CCP was revised to include an intervention status post the fall to prevent further falls of the same nature, until 04/25/19. 3. Per observation and interviews, Resident #51 was re-admitted to the facility on [DATE] after a hospitalization, with a urinary catheter. However, there was no documented evidence the Comprehensive Care Plan was revised to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). The findings include: Review of the facility's Policy, titled Care Plan, dated 08/01/13, revealed the individualized CCP would be developed to include measurable objectives and timetables to meet the medical, nursing, mental and psychological resident needs. Additionally, the CCP would identify care needs based on ongoing thorough assessment of the resident. Continued review revealed each resident's CCP would incorporate identified problem areas; incorporate risk factors; reflect treatment; aide in preventing declines in functional status; and reflect currently recognized standards of practice for problem areas and conditions. Further, when a resident was re-admitted to the facility from a hospital stay, the Care Planning/Interdisciplinary team would revise the CCP as necessary to changes in the resident's condition. Review of the facility's Policy, titled Fall Program Guide, undated revealed it was the facility's responsibility to ensure the residents care, treatment and the environment was assessed, care planned and implemented. Additional review revealed the facility Fall Protocol included documenting interventions and identified fall risk in the CCP. 1. Review of Resident #8's medical record revealed the facility admitted the resident on 05/26/18, with primary diagnosis of Repeated Falls. Secondary diagnosis included Atherosclerotic Heart Disease of Native Coronary Artery, and Benign Prostatic Hyperplasia. Review of Resident #8's Quarterly MDS Assessment, dated 01/25/19 revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15), indicating moderated cognitive impairment. Additional review revealed the facility assessed the resident to required limited assistance of one (1) staff for bed mobility, transfers, walking, and locomotion. Continued review revealed the Resident required extensive assistance of one (1) staff for dressing, toileting and personal hygiene. Per Assessment, the resident was not steady but could stabilize by themselves from sit to stand, walking, turning and surface to surface transfer; however, required assistance to stabilize on and off the toilet. Further, the resident was frequently incontinent of bladder and continent of bowel. Per review, Resident #8 had two (2) or more falls since the last assessment with injury. Continued review revealed the resident had received the following medications seven (7) days during the assessment period: insulin, antipsychotic, antidepressant and a diuretic. Further, the resident had not received therapy of Restorative programs. Further review revealed the resident used a bed and chair alarm daily. Review of the Comprehensive Care Plan, dated 06/05/18 revealed the Resident #8 was at risk for falls related to Confusion, Gait/balance problems, Psychoactive drug use, Unaware of safety needs, and wandering. The goal was for the resident not to sustain serious injury. Interventions included to anticipate and meet the needs of the resident, initiated on 06/05/18 and bed alarm, initiated on 06/20/18. Continued review revealed interventions to place the walker directly in front of the resident, initiated on 10/16/18; nonskid strips on the floor at bedside, initiated on 11/29/18; nonskid socks while in bed, initiated on 12/04/18; and nonskid strips to floor in front of recliner, initiated on 12/21/18. Additional review revealed interventions included a sensor alarm to the chair, initiated on 02/26/19; scheduled toileting, initiated on 03/19/19; therapy screen for transfer, initiated on 03/21/19; and nonskid strips on floor in front of guest chair, and initiated on 03/29/19. However, there is no documented evidence the CCP was revised after fall events on 12/28/18 and 04/03/19 with interventions to prevent falls of the same nature. Review of Nurse's Notes, dated 12/28/18 at 2:45 AM, revealed a Situation Background Assessment Request (SBAR) related to an unwitnessed fall. Additional review revealed Resident # 8's alarm was sounding and staff noted the resident sitting on the floor in front of the recliner at bedside. Further review revealed the resident stated he/she sat down on the chair and slid to the floor. Review of Resident Accident/Incident Report, dated 12/28/18 at 2:45 AM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid off the recliner to the floor during an unassisted transfer to the chair. Continued review revealed the personal alarm was in use and functioning properly and the assistive device, walker was not used because the resident walked from the bed to the chair. Further review revealed the recommended action taken was to add dycem to the recliner. However there was no documented evidence the CCP, Risk for Falls, dated 06/05/18 was revised to include the addition of dycem to prevent falls of the same nature. Review of the Fall Scene Investigation Report, dated 12/28/18, revealed Resident #8 stated he/she was going to sit in the chair and slid in the floor. Additional review revealed the walker was not in use but was in reach, and the resident was wearing nonskid socks. Further, the alarm was working correctly. Review of the Root Cause Analysis (RCA), dated 12/28/18, revealed Resident #8 got out of bed and attempted to sit in the recliner; sat on the edge of the seat and slid onto the floor. Additional review revealed the resident transferred self from bed to chair, the alarm was sounding and staff immediately responded to the resident. Continued review revealed the resident had slid to the floor from the recliner seat. Review of SRNA #9's Witness Statement, dated 12/28/1,8 revealed Resident #8 stated he/she was attempting to go to the restroom. Interview with State Registered Nursing Assistant (SRNA) #9, on 04/25/19 at 1:17 PM, revealed she did not recall when Resident #8 was last toileted prior to the fall on 12/28/18 or the placement of the walker status post fall. However, she provided care to residents per the CCP. Review of Nurse's Notes, dated 04/03/19 at 9:45 PM, revealed a Situation Background Assessment Request (SBAR) related to an unwitnessed fall. Per the SBAR, Resident # 8 was noted lying on the floor in front of his/her wheelchair at the doorway with the wheelchair behind them. The resident was wearing street clothes and shoes. Per the resident, he/she slid out of the chair and was OK. Additional review revealed the resident had no injuries and the family and physician were notified of the fall event. Further, there were no new order received by the physician. Review of Resident Accident/Incident Report, dated 04/03/19 at 9:45 PM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid out of the wheelchair. Continued review revealed the personal alarm not used at the time of the fall; however, it was functioning properly. Further review revealed the recommended action taken was to add dycem to the wheelchair. However, there was no documented evidence the CCP or Risk for Falls assessment was revised to include placement of dycem to the recliner after the 04/03/19 fall event. Review of the Fall Scene Investigation Report, dated 04/03/19, revealed the resident stated he/she slid out of the wheelchair. Additional review revealed the chair alarm was not in use and the resident was wearing shoes at the time of the fall. Further, the alarm was working correctly. Review of the RCA, dated 04/03/19, revealed Resident #8 self-transferred into the wheelchair and slid out of the wheelchair at the doorway. Additional review revealed the resident was unaware of safety and risk for falls and enjoyed sitting and watching visitors and staff. Further review revealed the intervention was to add dycem to the wheelchair to reduce risk of sliding out. However, there was no documented evidence the CCP or Risk for Falls was revised to include placement of dycem to the recliner after the 04/03/19 fall event. Review of SRNA #7's Witness Statement, dated 04/03/19, revealed after the fall, she realized the resident's chair alarm was not in the wheelchair. Interview with SRNA #7, on 4/25/19 at 9:01 AM, revealed she did not recall when she last noticed the chair alarm in Resident #8's wheelchair prior to the fall on 12/28/18 or why it was not in the wheelchair per the CCP. However, the CCP was the guide she used to know what fall precautions each resident required. Continued interview revealed she checked resident rooms at the beginning of her shift and ongoing throughout her shift to ensure all fall precautions were in place per the CCP. 2) Review of Resident #49's medical record revealed the facility admitted the resident on 03/15/19, with primary diagnosis of Dementia without Behavioral Disturbance. Secondary diagnosis included Pneumonitis, Gastrointestinal Hemorrhage, Osteoarthritis, Hypertension, Glaucoma, Polyneuropathy, Anxiety, Depressive Disorder, Hyponatremia, Anemia, Mitral Value Insufficiency, Chronic Obstructive Pulmonary Disease, Difficulty Walking, Muscle Weakness, and Metabolic Encephalopathy. Review of the admission MDS, dated [DATE], revealed Resident #49 had difficulty with visions and wore glasses. Continued review revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), indicating severe cognitive impairment. Per the MDS, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfer and toileting; walking did not occur, and required total assistance with locomotion and assistance from one (1) staff for personal hygiene. Per the MDS, the resident had impaired balance between surfaces and impaired range of motion in the both lower extremities. Further, the resident had one (1) fall in the previous month and received seven (7) days of antidepressant and antibiotic medication during the assessment period. Further review the resident received Physical, Occupational, and Speech therapy minutes during the assessment period. Review of Resident #49's Comprehensive Care Plan, dated 04/09/19, revealed the resident was at risk for falls related to impaired cognition, use of psychotropic medication, limited range of motion of the bilateral lower extremities, and unable to ambulate. The goal was for the resident not to sustain any falls. Interventions included educated the resident and provide reminders for safety; keep the room free of clutter and obstruction and for staff to provide assistance with transfer. Review of the admission Nursing Evaluation, dated 03/15/19, revealed Resident #49 required assistance of two (2) staff for mobility and transfers. Further review revealed he/she was confused and oriented to person. Review of Fall Risk Evaluation, dated 03/15/19, revealed the facility assessed Resident #49 as high risk for falls, with a total score of fourteen (14). Additional review revealed the resident had intermittent confusion, had two (2) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of Fall Risk Evaluation, dated 03/24/19, revealed the facility assessed Resident #49 as high risk for falls, with a total score of sixteen (16). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of a SBAR, dated 04/23/19 at 5:15 PM, revealed Resident #49 sustained an unwitnessed fall without injury. Per review, the Resident was sitting in the floor on their buttocks beside the bed. Additional review revealed the Resident stated they got up without assistance from the wheelchair and forgot to lock the wheels; the wheelchair rolled and the resident fell to the floor. Further review revealed a reminder was posted in the room to Ask for Assistance. However, there was no documented evidence the CCP was revised, by LPN #2, with the intervention until the morning of 04/25/19. Attempted to call LPN #2 on 04/25/19 at 1:12 PM. Message was left to return call; however, no returned call was received. Review of a Resident Accident/Incident Report, dated 04/23/19 at 5:15 PM, revealed Resident #49 was observed in the room, sitting in the floor beside the bed and wheelchair post fall event. Additionally, the resident stated they had forgot to lock the wheelchair brakes and was trying to get in the bed. Further review revealed signage was posted in the room to Ask for Assistance Review of a Fall Scene Investigation Report, dated 04/23/19 at 5:15 PM, revealed Resident #49 stated he/she was trying to self-transfer to bed from the wheelchair. Additional review revealed the resident was wearing shoes at the time of the fall. Further review revealed the wheelchair slid out from under the resident during the attempted transfer. Review of a Summary of Root Cause Analysis (RCA), dated 04/23/19, revealed Resident #49 attempted to self-transfer into the bed from the wheelchair and slid out of the wheelchair into the floor. Additional review revealed the resident had a diagnosis of Dementia, Muscle Weakness, Polyneuropathy, Metabolic Encephalopathy, and Poor Safety Awareness and forgot to lock the wheelchair resulting in the fall. The intervention was to place signage in the room to Ask for Assistance prior to attempting transfer. Review of Nurse's Notes, for April 2019, revealed no documented evidence of a fall on 04/23/19 at approximately 6:00 PM. Review of a Physician's Orders, dated 04/25/19, revealed an order for Anti-roll backs to Resident #49's wheelchair. Interview with Resident #49, on 04/24/19 at 8:11 AM, revealed the resident had sustained a fall on 04/23/19 around 6:00 PM when he/she was trying to go back to bed to rest. Per interview, Resident #49 stated he/she attempted to get in bed by themselves and forgot to lock the wheelchair and when he/she stood from the wheelchair, it rolled backwards causing them to lose their balance and fall to the floor. Additional interview revealed the resident did not have an injury with the fall. Further interview revealed the nursing staff told him/her not to get in or out of bed by themselves. 3. Review of Resident #51's medical record revealed the facility admitted the resident on 03/02/19 with a primary diagnosis of Acute on Chronic Systolic Congestive Heart Failure. Secondary admitting diagnosis included Diabetes Mellitus Type II, cognitive Communication Deficit, Enlarged Lymph Nodes, Ischemic Cardiomyopathy, Essential Hypertension, Atrial Fibrillation, and Respiratory Failure. Review of the admission Minimum Data Set (MDS) Assessment, dated 03/22/19, revealed the facility assessed Resident #51 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognitive response. Additionally, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfers, and toilet use. Continued review revealed the resident required extensive assistance of one (1) staff with personal hygiene and ambulation in the room. Further review revealed the resident had seven (7) or more episode of urinary incontinence, but had at least one (1) episode of continent voiding during the assessment period. Review of the Comprehensive Care Plan (CCP), dated 04/09/19, revealed Resident #51 had toileting elimination deficit related to impaired mobility, and frequent incontinence of bladder. The goals included remaining clean and odor free and show signs of improvement in bladder continence while on scheduled toileting. Interventions included assess toilet patterns and needs, staff assistance with toileting needs, scheduled toileting every one (1) and half-hours. However, there was no documented evidence the CCP was revised on 04/16/19 or after to include an indwelling catheter. Review of Resident #51's Nurse's Notes, dated 04/10/19 at 8:00 AM, revealed a Situation Background, Assessment/appearance, Request (SBAR) assessment related to shortness of air and hypoxia. Additional review revealed the Resident was noted with tremors and was struggling to breathe with oxygen on at four (4) liters per nasal cannula, wheezes were auscultated in the lungs, and edema was noted in bilateral lower extremities. The physician and resident representative were notified and the Resident was sent to the emergency room for further evaluation. Further, review of Physician's Order, dated 04/10/19 at 8:30 AM revealed an order to send to hospital for evaluation and treatment. Additional review of Nurse's Notes, dated 04/16/19 at 3:00 PM revealed Resident #51 returned to the facility and was taken to his/her room. However, there was no documented evidence the CCP was not developed to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the Resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). Review of the State Registered Nursing Assistant (SRNA) [NAME]/Care Plan, dated 04/16/19, revealed Resident #51 had a catheter, required a leg strap, and catheter care. However, there was no documented evidence to resident's Comprehensive Care Plan was the CCP, was revised to include the indwelling catheter indication for use, ongoing care and removal protocols. Interview with Resident #51, on 04/23/19 at 4:00 PM, revealed he/she had a recently hospitalization related to excess fluid and trouble breathing. Per interview, while at the hospital an indwelling catheter was placed to help get the fluid off. Additional interview revealed he/she cleaned the catheter when on the toilet at least daily and night shift nursing staff had communicated to the Resident, by doing so would prevent infection related to the catheter. Further interview revealed the Resident was curious to know when the catheter would be removed since he/she had been back to the facility for a week now and was feeling better. Interview with SRNA #7, on 04/25/19 at 9:01 AM, revealed she has been at the facility for two (2) month. Per interview, Resident #51 had a catheter for almost two (2) weeks now after returning from the hospital. Additionally, she knew what care to provide to each resident per the CCP. Further, it was important for the CCP to be updated and revised to ensure necessary care was provided to a catheter to ensure it was clean, there was output, and the resident was not experiencing pain associated to the catheter. Interview with Kentucky Medication Aide (KMA), on 04/25/19 at 8:58 AM revealed she had worked at the facility for six (6) years. Interview revealed she knew how to provide care to each resident per the CCP. Per interview, Resident #51 returned to the facility after a hospitalization 04/16/19 with an indwelling catheter. However, she was not aware the CCP had been revised to include the indwelling catheter. Per KMA, it was important to provide catheter care each shift to decrease the risk for infection and or trauma to the Resident. It was also important to see the catheter each shift and documented the output and let the nurses know any changes to ensure a resident received care for their catheter; care that only a nurse could provide, like flushes or changing it, if the catheter was blocked. Further, she was not aware why the Resident had the catheter but knew the Resident was curious about when it was due to be changed or removed because she had never had a catheter before. Continued interview with KMA revealed the CCP should be revised after each fall to ensure resident remain safe and do not get hurt. Additionally, the revision of the CCP was the responsibility of the nurses including the MDS and DON. Further, she was not aware that Resident #8's CCP did not include dycem to the wheelchair seat and recliner seat. Per interview, she was not aware of any intervention implemented related to Resident #49's recent fall from the wheelchair. Interview with LPN #3, on 04/24/19 10:58 AM, revealed the she was responsible to review and revise the CCP with newly identified problem areas on re-admission. Per interview, it was the responsibility of the nurse to ensure the CCP identified all resident needs based on a thorough assessment of the resident. Additional interview revealed the nurse re-admitting Resident #51 on 04/16/19 failed to revise the CCP to include the indicated use of the urinary catheter, ongoing care, and interventions to decrease the risk for infection and trauma. Further, it was important for the CCP to be revised and to include all resident care needs to ensure resident were provided quality care to meet their needs. Continued interview with LPN #3 revealed the licensed nurse was responsible to complete a thorough assessment of the resident and events prior to a fall event. Per interview, it was the responsibility of the nurse to ensure the CCP was revised to include an intervention based on a RCA of the fall event, at the time of the fall to prevent further falls of the same nature. Additionally, the CCP for Resident #8 should have been revised on 12/28/18 and 04/03/19 to include the placement of dycem to the recliner and wheelchair seats. Further, the CCP should have been revised for Resident #49, on 04/23/19 to include the sign placed in the Resident's room to Call for Assistance. Continued interview revealed it was important that the direct care staff complete a thorough assessment of all fall events to determine the true RCA and to implement an intervention that was sufficient and effective. Interview with Minimum Data Set (MDS) Coordinator, on 04/25/19 at 10:00 AM, revealed she gathered information to revise the CCP per record review to include hospital discharge summaries, physician orders, diagnosis, and nursing assessments. Additionally, she would talk with the nursing staff and the residents, and attending Monday through Friday IDT clinical meetings to review the twenty-four (24) hour reports. Continued interview revealed she was unaware Resident #51 re-admitted to the facility on [DATE] with an indwelling catheter. Per the MDS coordinator, nursing staff did not communicate the information to her and the assessments and discharge summary did not note the indwelling catheter. Per interview, the CCP should have been revised to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the Resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). Continued interview revealed it was important for the CCP to be revised with catheter care to ensure staff are providing the appropriate catheter care to reduce the risk for infection and trauma. Further, to complete ongoing assessment to determine when the catheter could be removed as necessary. Further interview revealed in addition to the Monday through Friday Clinical meeting, the facility had a Falls Committee meeting, after the morning meeting. Per interview, during this meeting, the IDT reviewed immediate interventions direct care nurses had implemented status post falls to determine if they were the most appropriate or if an additional intervention was necessary. The attendees at the meeting included: the activities director, unit managers, DON, MDS, Social Services, SRNA off the floor, and the Administrator. Additional interview revealed a thorough review of the fall paper work was completed for each fall including the Incident Report, Witness Statement, Fall Scene investigation, the SBAR, Nurses Notes, etc. Continued interview revealed the RCA was determined after review and any revisions were made to the CCP at that time to prevent another fall of the same nature. Per interview, the interventions were made based on the RCA and the individual resident's strengths and weaknesses, and should be effective and sufficient to prevent falls. Further, the SRNA care plan as well as the CCP should have been updated immediately status post falls for Resident #8 and Resident #49. However, she was not aware Resident #49 had sustained a fall on 04/23/19 during an unassisted transfer from the wheelchair to the bed. Per the MDS Coordinator, CCPs and SRNA [NAME] revisions should be legible writing with initials of the staff making the revision and dated with the current date to ensure the IDT are aware of the Resident care needs to keep them safe. Interview with the Director of Nursing (DON), on 04/25/19 at 2:30 PM, revealed she had been at the facility as the DON since 10/01/18. Per interview, it was the responsibility of the assigned direct care nurse to revise the CCP based on a face-to-face assessment for each resident on admission and re-admission to the facility. Continued interview revealed the direct care nurse assigned to Resident #51, on 04/16/19 failed to revise the CCP to include the use of an indwelling catheter. Additionally, the CCP should have been revised to include the indicated use for, ongoing care, assessment, criteria for discontinuation of the urinary catheter, ongoing monitoring for changes in the resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). Further, it was important for the CCP to be revised with changes in a resident's status because it was a guide used by the interdisciplinary team to ensure individualized quality care was provided to the resident to meet their needs. Continued interview revealed the DON did not have a current process in place to audit care plans and ensure revisions were made as necessary. Further interview with the DON revealed status post falls, the nurse should assess the resident and fall scene immediately documenting findings in the medical record. Additionally, the nurse should do their due diligence to determine the root cause of the fall and implement an appropriate intervention related to the resident's individualized needs and the RCA, to prevent further falls of the same nature. Per interview, the CCP should have been revised immediately after the falls for Resident #8 on 12/28/19 and 04/03/19 for dycem to the recliner and wheelchair seats and for Resident #49 on 04/23/19 for the sign placed in the Resident's room. Further, the facility's fall follow up process should have been maintained and Resident #49's interventions should have been revised on the CCP before the evening of 04/24/19. After review of the SBAR, it was determined the best intervention for Resident #49 was anti roll back brakes to the wheelchair to prevent further falls if the Resident were to attempt to self-transfer to bed again; which was revised on 04/25/19. Per interview, she updated the CCP for Resident #49 on 04/24/19 after 5:00 PM. Continued interview revealed she backdated the intervention of Signage in the resident's room for 04/23/19 because the SBAR stated LPN #2 placed the sign in the room then. However, the CCP should have been revised at the time of the fall or during the Clinical meeting the morning of 04/24/19. Further interview revealed the Clinical meeting on 04/24/19 did not occur because surveyors were in the building. She expected the facility policy and protocols to be upheld related to fall management to ensure all resident's safety. Interview with the Administrator, on 04/25/19 at 3:00 PM, revealed she expected the direct care nursing staff to revise the CCP after re-admission assessments of residents to ensure any changes in a resident's status were identified and necessary care was provided. Per interview, she expected nursing leadership (DON and MDS) to audit the CCP to ensure necessary revisions are made after a re-admission. Additionally, she expected the CCP to include the indicated use of indwelling catheters, ongoing catheter care, and criteria for discontinuation of the catheter for all Resident's with catheters. Further, the CCP was the guide used by all staff to ensure a resident received necessary quality care to meet their needs and ensure their safety. Further interview with the Administrator revealed she expected the direct care nursing staff to maintain the facility's Care Plan policy. Per interview, it was the responsibility of the direct care nurse to revise the CCP immediately with an intervention to reduce the risk of further falls and at the latest within twenty-four (24) hours. Per interview, she expected the IDT to ensure the facility policy and protocols were followed after each resident fall through review of the fall event documentation. Additionally, she expected interventions to be based on the RCA and the residents needs and be effective in maintaining the resident's safety and meeting their needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for three (3) of twenty-two (22) sampled residents; Resident #8, Resident #49 and Resident #53. 1. Resident #8 was assessed by the facility to be at High Risk for falls and to require the limited assist of one (1) staff for transfers and ambulation, and extensive assist of two (2) for toileting. However, record review revealed on [DATE], the resident self-transferred from the bed to the recliner while alone in the bedroom without supervision. Resident #8 sustained a fall when sliding from the recliner seat to the floor. Additionally, per SRNA #7's Witness Statement, on [DATE], the resident stated he/she was trying to go to the restroom. Further record review revealed on [DATE], the resident self-transferred into the wheelchair while alone in the bedroom without supervision. Resident #8 sustained a fall when sliding from the wheelchair seat to the floor. Continued review revealed SRNA #9's Witness Statement, on [DATE] revealed the wheelchair sounding alarm was not in the resident's wheelchair at the time of the fall. The facility failed to complete thorough investigation, as there was no documented evidence the Root Cause Analysis (RCA) of the falls addressed the causative factors related to why the Resident slid out of the chair. 2. Resident #49 was assessed by the facility to be at High Risk for fall and to require extensive assistance of tow (2) for transfers. However, interviews and record review revealed on [DATE], the resident self-transferred from the wheelchair to the bed while alone in the bedroom without supervision. Resident #49 sustained a fall, when the wheelchair rolled away, to the floor. Continued review revealed SRNA #10's Witness Statement, on [DATE] revealed the resident was assisted to and from the toileting and left in his/her room in the wheelchair prior to the fall. There was no documented evidence of a facility assessment related to the fall event in the medical record on [DATE] or [DATE]. Further, the facility failed to complete a thorough investigation, as there was no documented evidence the CCP was revised with an intervention related to the RCA until [DATE]. 3. Observation of Resident #53, on [DATE] at 4:10 PM, revealed an over the counter medication bottle, opened on the bedside table. Continued observation revealed the bottle was labeled Cayenne four hundred (400) milligram (mg). Interview with Resident #53 revealed his/her daughter brought the medication to the facility on [DATE] and it was supposed to help with his/her legs. Continued interview with the resident revealed he/she does not self-administer his/her own medications. The findings include: Review of the facility's Policy, titled Fall Program Guide, undated revealed it was the facility's responsibility to ensure the resident care, treatment and the environment was assessed, care planned and implemented. Additional review revealed the facility Fall Protocol included determinations of deficient practice to reduce falls and fall risk. Continued review revealed deficient practice was identified through record review and interviews of each fall, including what Fall Risk Factors (FRFs) were not identified as a problem; which FRF were known by staff and not communicated through documentation; were interventions and identified fall risk documented in the Comprehensive Care Plan (CCP); and were interventions taken sufficient. Further, review revealed an assessment of the resident would be performed at the time of the incident, by a licensed nurse to attempt to determine causative factors of the incident. 1. Review of Resident #8's medical record revealed the facility admitted the resident on [DATE], with primary diagnosis of Repeated Falls. Secondary diagnosis included Atherosclerotic Heart Disease of Native Coronary Artery, and Benign Prostatic Hyperplasia. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated [DATE] revealed the facility assessed Resident #8 to have a Brief Interview of Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severe cognitive impairment. Additional review revealed the facility assessed the resident to require limited assistance of one (1) staff for bed mobility, transfers, walking, and locomotion. Continued review revealed the Resident required extensive assistance of one (1) staff for dressing, toileting and personal hygiene. Per Assessment, the Resident was not steady but could stabilize by themselves from sit to stand, walking, turning and surface to surface transfers; however, required assistance to stabilize on and off the toilet. Further, the resident was frequently incontinent of bladder and continent of bowel. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #8 to have a BIMS score of nine (9) out of fifteen (15), indicating the resident had moderate cognitive impairment. Continued review revealed the facility assessed the resident to require one (1) person physical assistance for bed mobility, transfers, walking in the room or corridor, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. Further review revealed the facility assessed the resident to have had two (2) or more falls without injury since admission or the last assessment. Per the MDS the resident had received the following medications seven (7) days during the assessment period: insulin, antipsychotic, antidepressant and diuretic. Review of Resident #8's Quarterly MDS Assessment, dated [DATE] revealed the facility assessed the resident to have a BIMS score of nine (9) out of fifteen (15), indicating moderated cognitive impairment. Additional review revealed the facility assessed the resident to required limited assistance of one (1) staff for bed mobility, transfers, walking, and locomotion. Continued review revealed the Resident required extensive assistance of one (1) staff for dressing, toileting and personal hygiene. Per Assessment, the resident was not steady but could stabilize by themselves from sit to stand, walking, turning and surface to surface transfer; however, required assistance to stabilize on and off the toilet. Further, the resident was frequently incontinent of bladder and continent of bowel. Per review, Resident #8 had two (2) or more falls since the last assessment with injury. Continued review revealed the resident had received the following medications seven (7) days during the assessment period: insulin, antipsychotic, antidepressant and a diuretic. Further, the resident had not received therapy of Restorative programs. Further review revealed the resident used a bed and chair alarm daily. Review of a Physician's Orders for Resident #8, dated [DATE], revealed an order for a chair alarm, bed alarm and code alert bracelet. Review of a Fall Risk Evaluation, dated [DATE], revealed the facility assessed the resident as high risk for falls, with a total Score of twenty-two (22). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, had gait/balance problems and received medication that caused lethargy or confusion. Per the evaluation, a total score of ten (10) or above represented High Risk for falls and should be considered for potential falls. Review of Resident #8's Comprehensive Care Plan, dated [DATE] revealed the resident was at risk for falls related to Confusion, Gait/balance problems, psychoactive drug use, Unaware of safety needs, and wandering. The goal was for the resident not to sustain serious injury. Interventions included to anticipate and meet the needs of the Resident, initiated on [DATE] and to have a bed alarm, initiated on [DATE]. Continued review revealed interventions to place the resident's walker directly in front of the resident, initiated on [DATE]; nonskid strips on the floor at bedside, initiated on [DATE]; nonskid socks while in bed, initiated on [DATE]; and nonskid strips to the floor in front of the recliner, initiated on [DATE]. Additional review revealed interventions included sensor alarm to chair, initiated on [DATE]; scheduled toileting, initiated on [DATE]; therapy screen for transfer, initiated on [DATE]; and nonskid strips on the floor in front of the guest chair, initiated on [DATE]. Review of a Nurse's Notes, dated [DATE] at 2:45 AM, revealed a Situation Background Assessment Request (SBAR) for Resident #8 related to an unwitnessed fall. Per the SBAR, Resident # 8's alarm was sounding and staff noted the resident sitting on the floor in front of the recliner at bedside. The resident stated he/she sat down on the chair and slid to the floor. Additional review revealed the resident had no injuries and the family and physician were notified of the fall event. Further, there were no new order received by the physician. Review of Resident Accident/Incident Report, dated [DATE] at 2:45 AM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid off the recliner to the floor during an unassisted transfer to the chair. Continued review revealed the personal alarm was in use and functioning properly and the assistive device walker was not used because the resident walked from the bed to the chair. Further, the recommended action taken was to add dycem to the recliner. However, there was no documented evidence the CCP, Risk for Falls, dated [DATE] was revised to include placement of dycem to the recliner after the [DATE] fall event. Review of the Fall Scene Investigation Report, dated [DATE], revealed Resident #8 stated he/she was going to sit in the chair and slid in the floor. Additional review revealed the walker was not in use but was in reach, and the resident was wearing nonskid socks. Further, the alarm was working correctly. Review of SRNA #9's Witness Statement, dated [DATE], revealed Resident #8 stated he/she was attempting to go to the restroom. Interview with SRNA #9, on [DATE] at 1:17 PM, revealed she did not recall when Resident #8 was last toileted prior to the fall on [DATE] or the placement of the walker status post fall. Review of the Root Cause Analysis (RCA), dated [DATE], revealed Resident #8 got out of bed and attempted to sit in the recliner; sat on the edge of the seat and slid onto the floor. Additional review revealed the resident transferred self from bed to chair, the alarm was sounding and staff immediately responded to the resident. Continued review revealed the resident had slid to the floor from the recliner seat; however, there was no documented evidence the RCA addressed the Resident's toileting needs. Review of Fall Risk Evaluation, dated [DATE], revealed the facility assessed Resident #8 as high risk for falls, with a total score of twenty-two (22). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, had gait/balance problems and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of Nurse's Notes, dated [DATE] at 9:45 PM, revealed a Situation Background Assessment Request (SBAR) related to an unwitnessed fall. Per the SBAR, Resident # 8 was noted lying on the floor in front of his/her wheelchair at the doorway with the wheelchair behind them. The resident was wearing street clothes and shoes. Per the resident, he/she slid out of the chair and was OK. Additional review revealed the resident had no injuries and the family and physician were notified of the fall event. Further, there were no new order received by the physician. Review of Resident Accident/Incident Report, dated [DATE] at 9:45 PM, revealed Resident #8 had an unwitnessed fall in his/her room. Additional review revealed the resident slid out of the wheelchair. Continued review revealed the personal alarm was not in use at the time of the fall; however, it was functioning properly. Further, the recommended action taken was to add dycem to the wheelchair; however there was no documented evidence the CCP or the Risk for Falls assessment was revised to include placement of the dycem to the recliner after the [DATE] fall event. Review of the Fall Scene Investigation Report, dated [DATE], revealed the resident stated he/she slid out of the wheelchair. Additional review revealed the chair alarm was not in use and the resident was wearing shoes at the time of the fall. Further, the alarm was working correctly. Review of SRNA #7's Witness Statement, dated [DATE], revealed after Resident #8 fell, she realized the Resident's chair alarm was not in the wheelchair. Interview with SRNA #7, on [DATE] at 9:01 AM, revealed she did not recall when she last noticed the chair alarm in the Resident's wheelchair prior to the fall on [DATE] or why it was not in the wheelchair per the CCP. Review of the RCA, dated [DATE], revealed Resident #8 self-transferred into the wheelchair and slid out of the wheelchair at the doorway. Additional review revealed the resident was unaware of safety and risk for falls and enjoyed sitting and watching visitors and staff. Further, the intervention was to add dycem to the wheelchair to reduce risk of sliding out. However, there was no documented evidence the RCA addressed the wheelchair alarm not being in place at the time of the fall. Interview with Resident #8, on [DATE] at [DATE] at 1:00 PM, revealed he/she had sustained falls in the recent past mostly related to trying to go to the restroom. Additional interview revealed the resident choose not to wait for assistance with transfers and going to the restroom at times because he/she did not want to wait for help. Further interview revealed the resident was not concerned or bothered by the alarming devices on his/her bed and chair. 2) Review of Resident #49's medical record revealed the facility admitted the resident on [DATE], with primary diagnosis of Dementia without Behavioral Disturbance. Secondary diagnosis included Pneumonitis, Gastrointestinal Hemorrhage, Osteoarthritis, Hypertension, Glaucoma, Polyneuropathy, Anxiety, Depressive Disorder, Hyponatremia, Anemia, Mitral Value Insufficiency, Chronic Obstructive Pulmonary Disease, Difficulty Walking, Muscle Weakness, and Metabolic Encephalopathy. Review of the admission MDS, dated [DATE], revealed Resident #49 had difficulty with visions and wore glasses. Continued review revealed the facility assessed the resident to have a BIMS score of five (5) out of fifteen (15), indicating severe cognitive impairment. Per the MDS, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfer and toileting; walking did not occur, and required total assistance with locomotion and assistance from one (1) staff for personal hygiene. Per the MDS, the resident had impaired balance between surfaces and impaired range of motion in the both lower extremities. Further, the resident had one (1) fall in the previous month and received seven (7) days of antidepressant and antibiotic medication during the assessment period. Further review the resident received Physical, Occupational, and Speech therapy minutes during the assessment period. Review of Resident #49's Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for falls related to impaired cognition, use of psychotropic medication, limited range of motion of the bilateral lower extremities, and unable to ambulate. The goal was for the resident not to sustain any falls. Interventions included educated the resident and provide reminders for safety; keep the room free of clutter and obstruction and for staff to provide assistance with transfer. Review of Fall Risk Evaluation, dated [DATE], revealed the facility assessed Resident #49 as high risk for falls, with a total score of fourteen (14). Additional review revealed the resident had intermittent confusion, had two (2) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of the admission Nursing Evaluation, dated [DATE], revealed Resident #49 required assistance of two (2) staff for mobility and transfers. Further review revealed he/she was confused and oriented to person. Review of Fall Risk Evaluation, dated [DATE], revealed the facility assessed Resident #49 as high risk for falls, with a total score of sixteen (16). Additional review revealed the resident had intermittent confusion, had three (3) or more falls in the last three (3) months, was ambulatory and incontinent, was chair bound and received medication that caused lethargy or confusion. Per the evaluation, a total score ten (10) or above represented high risk for falls and should be considered for potential falls. Review of a SBAR, dated [DATE] at 5:15 PM, revealed Resident #49 sustained an unwitnessed fall without injury. Per review, the Resident was sitting in the floor on their buttocks beside the bed. Additional review revealed the Resident stated they got up without assistance from the wheelchair and forgot to lock the wheels; the wheelchair rolled and the resident fell to the floor. Further review revealed a reminder was posted in the room to Ask for Assistance. Review of a Resident Accident/Incident Report, dated [DATE] at 5:15 PM, revealed Resident #49 was observed in the room, sitting in the floor beside the bed and wheelchair post fall event. Additionally, the resident stated they had forgot to lock the wheelchair brakes and was trying to get in the bed. Further review revealed signage was posted in the room to Ask for Assistance Review of a Fall Scene Investigation Report, dated [DATE] at 5:15 PM, revealed Resident #49 stated he/she was trying to self-transfer to bed from the wheelchair. Additional review revealed the resident was wearing shoes at the time of the fall. Further review revealed the wheelchair slid out from under the resident during the attempted transfer. Review of a Summary of Root Cause Analysis (RCA), dated [DATE], revealed Resident #49 attempted to self-transfer into the bed from the wheelchair and slid out of the wheelchair into the floor. Additional review revealed the resident had a diagnosis of Dementia, Muscle Weakness, Polyneuropathy, Metabolic Encephalopathy, and Poor Safety Awareness and forgot to lock the wheelchair resulting in the fall. However, the intervention was to place signage in the room to Ask for Assistance prior to attempting transfer. Review of Nurse's Notes, for [DATE], revealed no documented evidence of a fall on [DATE] at approximately 6:00 PM. Review of a Physician's Orders, dated [DATE], revealed an order for Anti-roll backs to Resident #49's wheelchair. Interview with Resident #49, on [DATE] at 8:11 AM, revealed the resident had sustained a fall on [DATE] around 6:00 PM when he/she was trying to go back to bed to rest. Per interview, Resident #49 stated he/she attempted to get in bed by themselves and forgot to lock the wheelchair and when he/she stood from the wheelchair, it rolled backwards causing them to lose their balance and fall to the floor. Additional interview revealed the resident did not have an injury with the fall. Further interview revealed the nursing staff told him/her not to get in or out of bed by themselves. Interview with SRNA # 6, on [DATE] at 9:07 AM, revealed she was aware Resident #49 had fallen the evening of [DATE] around 6:00 PM however; she was unaware of any fall precautions implemented after the fall. Continued interview revealed the nurses revised the CCP after each fall with interventions to prevent future falls. Further interview revealed Resident #49 had a new sign in his/her room at the foot of the bed by the bathroom that reminded the resident to call for assistance. Per interview, today was the first day she had seen this sign. Further interview revealed the sign was not a sufficient intervention to prevent future falls from transferring back to bed, because it was across the room from his/her bed and he/she would have their back to the sign, and the Resident had poor eyesight. Interview with SRNA #8, on [DATE] at 9:07 AM, revealed she was aware Resident #49 had fallen on [DATE] around 6:00 PM. Continued interview revealed she was not aware of any fall precautions implemented after the fall to prevent additional falls. Per interview, there was a new sign in the resident's room that advised him/her to call for assistance; however, the resident's vision was poor and the sign was placed across the room. Interview with Kentucky Medication Aide (KMA), on [DATE] at 8:58 AM, revealed she had worked at the facility for six (6) years. Continued interview revealed she assisted the nurse after falls by taking the resident's vital signs and giving her statement related to what the resident was doing before the fall. Further interview revealed she was not aware Resident #49's CCP had been revised to include signage in the resident's room or that the CCP for Resident #8 did not include dycem to the wheelchair and recliner. Further, it was important to complete a thorough investigation of falls and revise the care plan with a purposeful intervention to decrease the resident's risk for more falls and injury. Interview with LPN #3, on [DATE] at 10:58 AM, revealed the nurse was responsible for completing a thorough assessment of the resident and events prior to the fall and documented the assessment in the medical record, per the facility policy and protocols. Per interview, it was the responsibility of the nurse to determine an immediate intervention based on what the resident was trying to do at the time of the fall event, to prevent another occurrence/fall of the same nature. Additionally, the RCA should be determined by talking to the staff, the resident involved in the event and reviewing the resident record. Further interview revealed the interventions should be effective and reasonable. The interventions should assist the resident in meeting their needs and remain safe. Interview with Minimum Data Set (MDS) Coordinator, on [DATE] at 10:00 AM, revealed it was important direct care nurses documented thorough fall investigations at the time of a fall because she utilized that information to completed assessments and to revise the CCP to meet the resident's needs. She stated the CCP was used by the IDT as a guide to provide care to each resident. Additionally, documented post fall assessments were reviewed in the IDT clinical meetings and the Falls Committee meeting, after the morning meeting, to ensure the RCA had been identified and revision to the CCP were made as necessary. Per interview, the fall follow up should have been documented in the medical record. Continued interview revealed it was important for the CCP to be revised immediately with an intervention related to the RCA status post fall to ensure staff are providing the appropriate care to reduce the risk for falls and injury. Further interview revealed a thorough review of the fall paper work was completed for each fall including the Incident Report, Witness Statement, Fall Scene investigation, the SBAR, Nurses Notes, etc. She stated, the RCA was determined after review and any revisions were made to the CCP at that time to prevent another fall of the same nature. Per interview, the interventions were made based on the RCA and the individual resident's strengths and weaknesses, and should be effective and sufficient to prevent falls. Further interview revealed the CCP should have been updated immediately after Resident #8 and Resident #49's fall. However, she was not aware Resident #49 had sustained a fall on [DATE] during an unassisted transfer from the wheelchair to the bed because nursing staff did not communicate the information to her and the assessments was not in the medical record. Interview with the Director of Nursing (DON), on [DATE] at 2:30 PM, revealed after a fall, the nurse should assess the resident and fall scene immediately and document the findings in the medical record. Per interview, the nurse should do their do diligence to determine the root cause of the fall and implement an appropriate intervention related to the resident's individualized needs and the RCA, to prevent further falls of the same nature. Continued interview revealed the CCP should have been revised immediately after the falls for Resident #8 on [DATE] and [DATE] for dycem to the recliner and wheelchair seats and for Resident #49 on [DATE] for the sign placed in the Resident's room. Further, the facility's fall follow up protocol should have been maintained and Resident #49's interventions should have been in place before the evening of [DATE]. She stated, after review of the SBAR, it was determined the best intervention for Resident #49 was anti roll back brakes to the wheelchair to prevent further falls if the resident were to attempt to self-transfer to the bed again; which was revised on [DATE]. She expected the facility policy and protocols to be upheld related to fall management to ensure all resident's safety Interview with the Administrator, on [DATE] at 3:00 PM, revealed she expected the direct care nursing staff to maintain the facility's Fall Management Policy and Protocols. Per interview, it was the responsibility of the direct care nurse to documented a thorough post fall assessment in the medical record and implement an immediate intervention to reduce the risk of further falls, at the latest within twenty-four (24) hours. Per interview, she expected the IDT to ensure the facility policy and protocols were followed after each resident fall through review of the fall event documentation. Additionally, she expected interventions to be based on the RCA and the residents needs and be effective in maintaining the residents safety and meeting their needs. Further, the RCA should be determined based on statements and assessments of the fall event and the resident's needs. Review of the facility's Policy, titled Storage of Medications, undated, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Continued review revealed medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 3. Review of Resident #53 medical record revealed the facility admitted the resident on [DATE] with diagnoses including Type 2 Diabetes, Hypercholesterolemia, HTN, Hypomagnesmia, Heart Failure, Heart Disease, Peripheral Vascular Disease, Cerebral Infarction, Arthroplasty, Contracture of Muscle, Left Hand, Anemia, Deficiency of other Vitamins, Hypokalemia, Preglaucoma, Angina Pectoris, Atrialfibrilation, GERD, Disease of the Intestine, Muscle Weakness, Calculus of the Kidney, Bilateral Above the Knee Amputation (AKA), Pace Maker and Atherosclerotic Heart Disease. Review of Resident #53's admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating cognitively intact. Continued review revealed the facility assessed the resident to have vision impairment, sees large print, but not regular print in newspapers or books and does not wear corrective lens. Review of Resident #53's Evaluation of Resident's Ability to Safely Self-Administer Medication, dated [DATE], revealed the resident lacked upper body strength to safely self-administer medications. Continued review of the document revealed the resident does not know when his/her medications are due. Review of Resident #53's Monthly Physician's Orders, dated [DATE], revealed there was no order for Cayenne four hundred (400) mg. Observation of Resident #53, on [DATE] at 4:10 PM, revealed an over the counter medication bottle opened on the bedside table. Continued observation revealed the medication was labeled Cayenne four hundred (400) mg. Interview with Resident #53, on [DATE] at 4:10 PM, revealed his/her daughter brought the medication in. Continued interview revealed the medication was supposed to help his/her legs. Further interview with the resident revealed he/she does not self-administer his/her own medications Interview with Certified Medical Assistant (CMA) #9, on [DATE] at 10:30 AM, revealed, she had been employed by the facility for six (6) years. Per interview, Resident #53 does not administer his/her own medications. She stated the residents do not self-administer their own medications. Per interview, she is not aware of any resident that would be able to safely self-administer medication. She stated if she observed medications in a room, she would remove the medications and notified the charge nurse immediately. Continued interview revealed all medications should be stored in the medication cart and it must be locked. Further interview revealed the facility does have residents that wander and it could have been harmful to them. Per interview Resident #53 could have taken too much of the medication and that would have endangered his/her safety. Interview with Kentucky Medication Aide (KMA) #10, on [DATE] at 10:42 AM, revealed she had been working at the facility for two (2) years. Continued interview revealed she was not aware of any resident in the facility that had been safely assessed to self-administer their own medications. She stated Resident #53 is not safe to self-administer his/her own medications. She stated all medications must be locked in medication room in medication carts. Further interview revealed they have residents that wander in and out of rooms, one could have taken that medication, and it would not have been safe. Per Interview, she stated if she found a medication in a resident's room, she would remove the medication and notify the nurse in charge. She further stated it would be hazardous for Resident #53 and all other residents because they could have choked, got sick and possibly died. Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 4:15 PM, revealed, she was assigned to Resident #53. Continued interview revealed Resident #53 should not have any medications in the room. Per interview, nursing staff administer all medications to Resident #53. She stated she removed the medication from the resident's bedside table and explained to the resident why the medication cannot be on the bedside table. She further stated she explained to the resident that she would need to get an order from the physician for the medication and would lock it up in the med cart until she obtained the order. Further interview revealed it could have been dangerous if another resident wandered in the room and got the medication. Per interview, Resident #53 could have taken more than the appropriate dose and there could be side effects of the medication or it could interact with a medication the resident was prescribed. Additional interview revealed the facility performs an assessment quarterly on residents to assess for self-administration of medications; however, to her knowledge, there were no residents able to self-administer medications. She further stated all medications should be stored in a locked drawer or medication cart. She stated the safety of the residents comes first and the facility's Policy should be followed. Interview with Director of Nursing (DON), on [DATE] at 1:35 PM, revealed she had been working for the company for twelve (12) years and had been DON since 10/2018. She stated it was her expectation for all medications to be locked up for the safety[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure that resident who enters the facility with an indwelling catheter or subsequently receives one was assessed for removal of the catheter as soon as possible and received appropriate treatment and services to prevent urinary tract infections and to restore continence, for one (1) of three (3) sampled residents observed for indwelling urinary catheter care out of twenty-two (22) sampled residents (Resident #51). Observation and interview with Resident #51, on 04/23/19 revealed the resident had an indwelling urinary catheter placed during a recent hospital stay related to excess fluid. However, review of the medical record review revealed no documented evidence of timely and appropriate assessments related to the indication for use of an indwelling catheter or documentation of clinical indications for the use of a catheter. In addition, the medical record did not include criteria for the discontinuation of the catheter when the indication for use was no longer present. Per record review, there was no documented evidence related to ongoing care and catheter removal protocols. Further, there was no documented evidence of the Resident's response of the use of the catheter and ongoing monitoring for changes in condition related to potential Catheter Associated Urinary Tract Infections (CAUTI's). The findings include: Interview with the Registered Nurse (RN) Consultant, on 04/25/19 at 4:27 PM, revealed the facility did not have an indwelling urinary catheter policy that addressed catheter care and services based on professional standards of practice. Review of Resident #51's medical record revealed the facility admitted the resident on 03/02/19 with a primary diagnosis of Acute on Chronic Systolic Congestive Heart Failure. Secondary admitting diagnosis included Diabetes Mellitus Type II, cognitive Communication Deficit, Enlarged Lymph Nodes, Ischemic Cardiomyopathy, Essential Hypertension, Atrial Fibrillation, and Respiratory Failure. Review of the admission Minimum Data Set (MDS) Assessment, dated 03/22/19, revealed the facility assessed Resident #51 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognitive response. Additionally, the facility assessed the resident to require extensive assistance of two (2) staff with bed mobility, transfers, and toilet use. Continued review revealed the resident required extensive assistance of one (1) staff with personal hygiene and ambulation in the room. Further review revealed the resident had seven (7) or more episode of urinary incontinence, but had at least one (1) episode of continent voiding during the assessment period. Review of Resident #51's Baseline Care Plan, dated 03/02/19, revealed the resident had bladder incontinence. The goal was to establish an individualized bladder routine. Interventions included perineal care per policy; keep call light in reach and the use of adult briefs. Further review revealed the resident had Activities of Daily Living (ADL) Functional/Rehab Potential. The goal was to achieve/maintain maximum functional mobility. Interventions included therapy referrals; assist with toileting, transfers, and hygiene. Review of the State Registered Nursing Assistant (SRNA) [NAME]/Care Plan, dated March 2019 and revised 03/20/19, revealed Resident #51 required assistance for transfers and toileting needs. Additional review revealed the resident had incontinent bladder episodes and was on a one (1) and half-hour schedule toileting plan. Review of the Comprehensive Care Plan (CCP), dated 04/09/19, revealed Resident #51 had toileting elimination deficit related to impaired mobility, and frequent incontinence of bladder. The goals included remaining clean and odor free and show signs of improvement in bladder continence while on scheduled toileting. Interventions included to assess the toilet patterns and needs, staff assistance with toileting needs and to schedule toileting every one (1) and half-hours. Review of Resident #51's Nurse's Notes, dated 04/10/19 at 8:00 AM, revealed a Situation Background, Assessment/appearance, Request (SBAR) assessment, related to shortness of air and hypoxia. Additional review revealed the resident was noted with tremors and was struggling to breathe with oxygen on at four (4) liters per a nasal cannula, wheezes were auscultated in the lungs, and edema was noted in bilateral lower extremities. The physician and resident representative were notified and the resident was sent to the emergency room for further evaluation. Review of Physician's Order, dated 04/10/19 at 8:30 AM, revealed an order to send Resident #51 to the hospital for evaluation and treatment. Continued review of the medical record revealed Resident #51 was re-admitted to the facility on [DATE] with diagnosis to include Iron Deficiency, Vitamin B12 Deficiency Anemia, Hypomagnesium, Low back pain, and Constipation. However, there was no documented evidence of a diagnosis related to use of an indwelling catheter. Review of Resident #51's Nurse's Notes, dated 04/16/19 at 3:00 PM, revealed Resident #51 returned to the facility and was taken to his/her room. However, there was no documented evidence of a re-admission assessment including assessment of the indwelling catheter. Review of the State Registered Nursing Assistant (SRNA) [NAME]/Care Plan, dated 04/16/19, revealed Resident #51 had a catheter, required a leg strap, and catheter care. However, there was no documented evidence the CCP was revised to include the indwelling catheter indication for use, ongoing care and removal protocols. Further review of Resident #51's Physician Orders, dated 04/16/19, revealed no documented evidence of re-admission orders related to the indication for use of an indwelling catheter or ongoing care and catheter removal protocols. Review of Resident #51's Treatment Administration Record (TAR), dated 04/16/19, revealed no documented evidence of orders related to an indwelling catheter or ongoing care. Review of the Provider's New Admit History and Physical, dated 04/18/19, revealed Resident #51 returned from the hospital on [DATE] with a diagnosis of Congestive Heart Failure (CHF) Exacerbation and Respiratory Failure. Further review revealed no documented evidence of review of the Genitourinary (GU) system or urinary catheter. Review of Resident #51's Physician Orders and Notes, dated 04/01/19 through 04/24/19 revealed no documented evidence of orders related to the indication for use of an indwelling catheter or ongoing care and catheter removal protocols. Review of the Nurse's Notes and Assessments, dated 04/19/19 through 04/24/19 revealed no documented evidence of an assessment of Resident #51's indwelling catheter. Interview with Resident #51, on 04/23/19 at 4:00 PM, revealed he/she had a recently hospitalization related to excess fluid and trouble breathing. Per interview, while at the hospital an indwelling catheter was placed to help get the fluid off. Additional interview revealed he/she cleaned the catheter when on the toilet at least daily and night shift nursing staff had communicated to the resident, by doing so would prevent infection related to the catheter. Further interview revealed the resident was curious to know when the catheter would be removed since he/she had been back to the facility for a week now and was feeling better. Interview with LPN #3, assigned to Resident #51's hallway, on 04/24/19 10:58 AM, revealed the LPN #3 was responsible to complete and document an assessment of a resident returning to the facility on re-admission. Per interview, it was the responsibility of the nurse to ensure an assessment was thorough and the assessment findings were communicated to the physician. Additional interview revealed the re-admitting nurse was responsible to obtain necessary orders from the physician. Continued interview revealed the nurse re-admitting Resident #51, on 04/16/19, failed to document an assessment including the indwelling catheter and failed to obtain an order from the physician related to the indicated use for the indwelling catheter, ongoing care and removal criteria. Further, it was her expectation that residents receive care in accordance to professional standards for urinary catheters to decrease their risk for CAUTI's and trauma related to catheters. Interview with Kentucky Medication Aide (KMA), assigned to Resident #51 on 04/25/19 at 8:58 AM, revealed she had worked at the facility for six (6) years. Per interview, Resident #51 returned to the facility after a hospitalization on 04/16/19 with an indwelling catheter. However, the KMA had not provide catheter care to the Resident since returning to the facility, because it was not on the TAR; it was the responsibility of the SRNAs to provide catheter care every shift. Per KMA, it was important to provide catheter care each shift to decrease the risk for infection and or trauma to the Resident. It was also important to see the catheter each shift and documented the output and let the nurses know any changes to ensure a resident received care for their catheter; care that only a nurse could provide, like flushes or changing it, if the catheter was blocked. Further, she was not aware why the Resident #51 had the catheter but knew the resident was curious about when it was due to be changed or removed because he/she had never had a catheter before. Interview with SRNA #7, assigned to Resident #51, on 04/25/19 at 9:01 AM, revealed she has been at the facility for two (2) month. Per interview, Resident #51 had a catheter for almost two (2) weeks now after returning from the hospital. Additionally, she provided catheter care each shift and emptied urine from the catheter bag as necessary. Further, it was important to provide care to a catheter to ensure it was clean, there was output, and the resident was not experiencing pain associated to the catheter. Interview with SRNA #9, assigned to Resident #51's hallway, on 04/25/19 at 9:07 AM, revealed she had worked in the facility for a few months. Per interview, Resident #51 had a catheter after returning from the hospital recently. Additional interview revealed she had provided catheter care each shift and emptied the catheter bag every two (2) hours. Further, it was important to provide necessary care to the residents with catheters to reduce their risk for infections. Interview with SRNA #8, assigned to Resident #51's hallway, on 04/25/19 at 9:07 AM revealed she had worked in the facility for a couple months. Per interview, Resident #51 had a catheter after returning from the hospital. Additional interview revealed she had provided urinary catheter care each shift and emptied the catheter bag every two (2) hours. Further interview revealed it was important to provide necessary care to the residents with catheters to reduce the risk for infections. Interview with the Director of Nursing (DON), on 04/25/19 at 2:30 PM, revealed she had been at the facility as the DON since 10/01/18. Per interview, it was the responsibility of the assigned direct care nurse to complete a face-to-face assessment for each resident on admission and on re-admission to the facility, and to communicate the assessment findings to the physician to ensure necessary orders for care and treatment are obtained for the resident. Additionally, the direct care nurse was responsible to documented a Nursing Evaluation Assessment and chart a Nurse's Note related to the admission or re-admission. Continued interview revealed the direct care nurse assigned to Resident #51, on 04/16/19, failed to complete a thorough assessment of the resident to include the newly placed urinary catheter. Per the DON, the nurse should have assessed the catheter (type and size, signs and symptoms of infection) and obtained orders from the physician related to the indicated use for the catheter, criteria for discontinuation and ongoing care. Per the DON, the nurse should have documented the assessment and placed orders related to the catheter on the Treatment Administration Record (TAR). Per interview, it was the DON's expectation nursing staff maintain standards of practice related to indwelling urinary catheters to ensure the catheter was necessary, and the facility provided care to decrease the risk for infection and trauma, resident safety, quality of care and to ensure resident needs are met. Further interview revealed the facility had a Quality Assurance Performance Improvement (QAPI) plan related to re-admissions; to ensure assessments are thorough and completed and that necessary physician orders are in place after a re-admission; however, the Interdisciplinary Team (IDT) missed the failures of Resident #51's re-admission on [DATE]. Interview with the Administrator, on 04/25/19 at 3:00 PM, revealed she expected the nursing staff to complete re-admission assessments timely and thoroughly. Additional interview revealed she expected Physician orders to be obtained related to any changes in a resident's status since re-admission. Per interview, she expected the nursing assessment findings to be documented and communicated to the physician and necessary orders to be implemented. Continued interview revealed she expected documented evidence for the indicated use of indwelling catheters, ongoing catheter care, and criteria for discontinuation of the catheter for all residents with catheters. Further interview revealed the licensed nurse failed to ensure Resident #51 had a thorough re-admission assessment to include an assessment of the indwelling catheter and related physician's orders. Per interview, it was important to maintain standards or practice related the urinary catheters to ensure necessary quality care was provided to each resident to meet their needs and ensure their safety.

Based on observation, interview, and review of the facility's Policy, it was determined the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Observations, on 04/23/19, revealed dust accumulation on a fan used in the dish room and the ceiling above the production area. In addition, the dish machine temperatures were missing and not documented throughout the month of April 2019. The findings include: Review of the facility's Policy, titled Water Temperatures for Dish Washing Machines, undated, revealed facility should maintain adequate dishwashing machine temperatures to effectively wash and sanitize eating utensils and dishware. Continued review revealed the results of the temperatures must be recorded daily at each meal and the Dietary Manager would keep a written record of the results in the kitchen. Review of the facility form titled Dish Machine Log dated April revealed the dish machine temperatures not recorded. The following dates not documented for Breakfast, Lunch, and Dinner on 04/03/19, Breakfast and Lunch for 04/06/19. Breakfast, Lunch and Supper for 04/07/19, 04/10/19, Breakfast, and Lunch for 04/12/19, Breakfast, Lunch for 04/15/19, Supper for 04/17/19, 04/18/19, and Breakfast and Lunch for 04/20/19, 04/21/19. Observation of the kitchen area, on 04/24/19 at 8:10 AM, revealed a fan near dish room. Continued observation revealed there was dust on the blades of the fan. Further observation revealed the fan was on and the air was directed into the dish room. Observation of the kitchen area, on 04/25/19 at 1:23 PM, revealed the fan was on and directed into the dish room. Continued observation revealed there was dust on the ceiling over the production area. Interview with Dietary Aide #4, on 04/25/19 at 1:02 PM, revealed the temperatures for the dish machine should be documented in the morning and at lunch to make sure the dishes are cleaned. Interview with Diet Aide #1, on 04/25/19 at 1:06 PM, revealed the temperature on the dish machines should be documented three (3) times a day with each meal. Per interview, this is done to make sure the dishes get clean. Interview with Dietary Aide #2, on 04/25/19 at 1:16 PM, revealed the dish machine temperatures were recorded every day to know the dish machine was working correctly so the dishes would be sanitized. Continued interview revealed should notify the manager for the dust on the fan and ceiling. Per interview, dust could get into the food. Interview with Dietary Aide #3, on 04/25/19 at 1:19 PM, revealed the dish machine temperatures should be checked three (3) times a day. Continued interview revealed the temperatures were documented daily to ensure the dish machine was running correctly and sanitizing the dishes for the safety of the residents. Per interview, the dust on the fan and the ceiling can get on the dishes and into the food and contaminate the food. Interview with [NAME] #1, on 04/25/19 at 1:08 PM, revealed the temperatures for the dish machine should be recorded for breakfast, lunch and supper to ensure the dish machine is washing and sanitizing the dishes correctly. Continued interview revealed maintenance was responsible for cleaning the dust from the ceiling. Further interview revealed dietary staff should check the fan and ceiling for dust and report this to maintenance because the dust could fall into the food and onto the dishes. Interview with the Certified Dietary Manager (CDM), on 04/25/19 at 1:23 PM, revealed recording of the dish machine temperature was required to be completed and documented three (3) times a day at meal times to ensure the dish machine cleans and sanitize the dishes correctly to ensure resident safety. Continued interview revealed the fan and ceiling should be cleaned appropriately and without dust. Per interview, dust will contaminate the dishes and food. Interview with Director of Nursing (DON), on 04/25/19 at 1:49 PM, revealed the dish machine temperatures should be recorded daily, per the facility's policy, to provide sanitization of dishware, infection control, and to ensure the equipment is operating properly. Continued interview revealed the fan and ceiling should be clean and dusted to prevent cross contamination of dishes, utensils and food for the safety of the residents. Interview with Administrator, on 04/25/19 at 3:09 PM, revealed the dish machine temperatures should be recorded daily to ensure the dish machine was holding the proper temperatures to sanitize and provide clean plates and dishware for resident safety. Continued interview revealed the fan and ceiling should be cleaned regularly to remove dust for sanitary conditions for the health and safety of the residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide quality of care for one (1) of eighteen (18) sampled residents (Resident #44) who required treatment for a surgical wound. Observations during wound care on 03/22/18 revealed staff failed to ensure wound care was provided in a manner to prevent contamination of the supplies. The findings include: Review of the facility Wound Care policy (no date) revealed care must be taken to prevent contamination of the supplies during wound care. Review of the medical record revealed the facility readmitted Resident #44 on 03/16/18 after being hospitalized due to requiring an Above the Knee Amputation (AKA) of the left lower extremity secondary to Osteomyelitis, Gangrene, and Peripheral Vascular Disease. The resident returned to the facility with orders for wound care to be provided by facility staff daily. On 03/22/18 at 10:10 AM, Licensed Practical Nurse (LPN) #3 was observed to provide wound care to Resident #44's surgical wound on the left leg while the resident was sitting in a shower chair in the shower room. LPN #3 washed her hands and put on gloves and cleaned the surgical wound with a gauze pad and normal saline (NS). LPN #3 then patted the area dry with a clean gauze. The LPN was then observed to place an ABD pad (type of bandage) over the wound with her right hand and with her left hand begin to wrap the wound; however, the LPN dropped the roll of Kerlix onto the bathroom floor. LPN #3 then removed the ABD pad from the incision site and placed it on Resident #44's left thigh and left the shower room to obtain another roll of gauze. A CNA was left in attendance with the resident. While the nurse was gone, the CNA assisted the resident to put on a shirt. While dressing the resident, the ABD pad was observed to move from the resident's thigh up to lay against the shirt and then back to the thigh again. After the LPN came back into the shower room, she washed her hands and put on clean gloves. LPN #3 then picked up the same ABD pad and placed it over the resident's incision site on the left leg and then wrapped it with gauze. LPN #3 stated in interview on 03/23/18 at 3:50 PM that she was unsure about using the ABD pad, but thought since the ABD pad was only in contact with the resident's skin it would be acceptable. LPN #3 stated she should have obtained a new ABD pad, especially since she was applying it to a new surgical site. Interview conducted with the Director of Nursing (DON) on 03/22/18 at 4:03 PM revealed the nurse should have obtained a new ABD pad when doing a dressing change to maintain aseptic technique. The DON stated she and the Unit Managers, and the Infection Control nurse were responsible to observe/monitor the nurses when performing wound care. The DON stated no concerns had been identified.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure the necessary treatment and services to promote healing and prevent infection were provided for one (1) of eighteen (18) sampled residents that had a wound. Observation of wound care for Resident #31 on 03/21/18 revealed staff failed to perform proper hand hygiene during wound care. The findings include: Review of the facility policy, Wound Care Procedures for Major Wounds, undated, revealed after having cleaned a wound and discarding soiled gauze, staff should remove gloves and discard them, and then apply clean gloves prior to applying a clean dressing to the wound. Review of the clinical record revealed the facility admitted Resident #31 on 02/23/11 with diagnoses of Multiple Sclerosis, Hypertension, Neurogenic Bladder, Anxiety Disorder, Depression, and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set (MDS) quarterly assessment, dated 01/26/18, revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident had moderate cognitive impairment. The MDS further revealed the resident had one (1) Stage 3 pressure ulcer and one (1) unstageable pressure area, a Suspected Deep Tissue Injury (SDTI). Observation of Resident #31 on 03/20/18 at 11:15 AM revealed the resident was lying on a pressure relief scoop mattress. The resident stated he had a bedsore to his back and granted permission at that time for the surveyor to observe wound care. Further observation revealed the resident to have a dressing to the left foot and the left foot was floated off the bed with a heel support wedge. Observation of wound care on 03/21/18 at 9:51 AM revealed Licensed Practical Nurse (LPN) #1 performed a dressing change to the Stage 3 wound on Resident #31's coccyx without any concerns. LPN #1 then began to do wound care to the wound to the left lateral foot. Observations revealed that LPN #1 did not remove her gloves after cleansing the wound and before applying a clean dressing. Interview with LPN #1 on 03/21/18 at 10:41 AM revealed that she was not sure whether she should have changed her gloves after cleaning the wound. Interview with the Infection Control nurse on 03/22/18 at 3:53 PM revealed glove changes were to be done after removing soiled dressings and after cleaning the wound. Further interview revealed that she did not do any monitoring of staff performing wound care to ensure the infection control process was maintained. Interview with the Director of Nursing (DON) on 03/22/18 at 3:59 PM revealed staff were monitored by himself, the Unit Coordinators, and the Infection Control Nurse to ensure proper infection control process during wound care. He further stated that not changing gloves after cleaning the wound was a break in the infection control process.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure incontinence care was provided in a manner to prevent urinary tract infections for one (1) of eighteen (18) sampled residents (Resident #45). Facility staff failed to properly clean Resident #45 when providing incontinence care on 03/20/18. The findings include: A review of the facility Perineal Care Validation Tool (no date) revealed steps for providing perineal care for a female resident. The steps identified to first wash the buttocks and anal area prior to providing perineal care. The tool then directed staff to cleanse each side of the outer labia majora, wiping from the front to the back using a clean area of the washcloth for each side. The next step was to separate the labia, exposing the inner labia, and wiping with a clean area of the cloth from front to back. On 03/20/18 at 3:30 PM Certified Nurse Aide (CNA #1) and CNA #2 were observed to provide perineal care/incontinence care for Resident #45. Both CNAs washed their hands and put on gloves prior to beginning and then CNA #1 removed the resident's brief that was soiled with urine and feces and both CNAs assisted the resident to roll onto his/her left side. CNA #1 then cleansed the resident's buttocks/anal area from front to back using three (3) separate disposable wipes. The CNA proceeded to place a clean brief under Resident #45, assisted the resident to roll onto his/her back, and applied the clean brief without cleansing the resident's perineal area. Interview with CNA #1 on 03/20/18 at 3:45 PM revealed she had been trained to clean a resident from front to back and make sure all areas/folds were clean when providing perineal/incontinence care. CNA #1 stated that she felt like she cleaned all of the resident folds, but stated that she did not clean the resident the way she was trained to do. Interview with the Director of Nursing (DON) on 03/23/18 at 3:45 PM revealed staff had been trained to follow procedure as trained in nurse aide classes to clean the perineal area as well as the buttocks when providing perineal/incontinence care. The DON further stated the licensed nurses and CNA preceptors were responsible to monitor the nurse aides to ensure the care was provided correctly and no problems had been reported to her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure drugs and biologicals were appropriately labeled and stored for one (1) of five (5) medication carts and for one (1) of two (2) medication rooms in the facility. Observations of a South Hall medication cart revealed a vial of insulin that was expired and available for use and an unopened/undated insulin vial that should have been refrigerated. Also observed in the cart was a personal container of prepared oatmeal. Observations of the South Hall medication room refrigerator revealed a vial labeled Vancomycin 1 Gram (g) and dated [DATE] that was available for use. The findings include: Review of the facility policy, Medication Storage in the Facility, undated, revealed outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, and disposed of according to procedures for medication disposal. Review of the package insert for Humulin R insulin, dated 2015, revealed not-in-use (unopened) Humulin R bottles should be stored in a refrigerator. Review of the Physician's Desk Reference (PDR), www.PDR.net, undated, revealed that reconstituted vials of Vancomycin may be stored in the refrigerator for up to fourteen (14) days. Review of the facility audit form, Medication Room/Nursing Station Inspection Report, undated, revealed that expired and discontinued drugs were to be removed from the refrigerator and expired meds were to be removed from the medication carts and stored properly. Observation of a South Hall medication room on [DATE] at 1:29 PM revealed the medication refrigerator contained a vial labeled Vancomycin 1 g that was reconstituted and dated [DATE]. The label on the vial stated that the Vancomycin was only stable for fourteen (14) days after it was reconstituted. Observation of a South Hall medication cart on [DATE] at 1:29 PM revealed a vial of Novolin insulin dated [DATE], that was greater than two (2) weeks beyond the expiration date of [DATE]. Observation of the cart further revealed an unopened/undated bottle of Humulin R insulin that was stored in the cart and not in the refrigerator. Further observation revealed a container of prepared oatmeal in a drawer where bottles of liquid medication were stored. Interview with LPN #2 on [DATE] at 1:29 PM revealed whichever nurse was administering the medication was responsible to check the expiration date of the medication. She further stated the Novolin insulin on the cart dated [DATE] was expired and should have been discarded. LPN #2 stated the oatmeal was hers and she had forgotten it on the cart. LPN #2 further stated that the unopened insulin should be in the refrigerator until ready to be used. Phone interview with the facility pharmacist on [DATE] at 2:09 PM revealed that unopened insulin should be kept in the refrigerator, and not stored in the cart. Interview with the Director of Nursing (DON) on [DATE] at 4:02 PM revealed the pharmacy consultant performs the audits on medication carts at least monthly. He also stated the nurses should be checking carts for expired and improperly stored drugs as they are assigned to the carts. He further stated the facility needs to ensure that drugs are stored properly.