**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy it was determined the facility failed to report an injury of unknown origin within two hours to state agency for one (1) of one-hundred and nineteen (119) residents, Resident #87. On 09/25/2021 during morning rounds Licensed Practical Nurse (LPN) #2 found Resident #87 with blood on the forehead and a laceration in which she was unable to determine how the resident got it. LPN #2 revealed she contacted the nurse supervisor on duty, LPN #3 and informed her resident had a cut. She then contacted the Nurse Practitioner (NP) and agreed to send resident out to the emergency room (ER). Resident #87 was treated with seven (7) sutures to the forehead and received a splint for a fractured pinky finger. The finding include: Review of the facility's Abuse Prevention Program policy dated 05/02/2017, revealed all personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin. An injury should be classified as an injury of unknown origin when the source of the injury was not observed or known by any person, and the Initial Risk Management Investigation could not determine the cause of the injury. Additionally, any alleged violation involving an injury of unknown origin must be reported to the Administrator and Director of Nursing (DON). The person who witnessed the event must immediately report to the Charge Nurse (CN) and the CN must immediately report tot eh Administrator or designee. The CN must complete an incident report and obtain a written, signed and dated statement from the person who reported the incident. Review of Resident #87's clinical record revealed the facility admitted the resident on 07/09/2019, with multiple diagnosis, which included Alzheimer's Disease, Dementia with Behavioral Disturbances, anxiety, major depressive disorder, and cognitive communication deficit. Staff report Resident historically wandered into other resident's rooms, took items and got in their beds. Review of Resident #87's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), and determined the resident was not interviewable. Resident #87 was assessed for bed mobility, transfers, walk in room, walk in corridor, locomotion on unit and off unit and to eat as supervision-oversight, encouragement and cueing with the assistance of one (1) staff member. Resident was assessed as two (2) staff physical assist to get dressed and for personal hygiene. Review of the facility Risk Management Investigation (RMI) #3221completed on 09/25/2021 at 7:15 AM, by LPN #2, revealed the location of the incident was unknown. The incident itself was documented as an injury of unknown origin. Review of discharge documents for 09/25/2021 revealed the ER doctor noted Resident #87 was seen in the emergency department and a face-to-face diagnostic evaluation was completed of the patient. The patient presented with a laceration above the left eye. The patient was found by staff with blood on his/her bed and a laceration above the eye. The patient did not know specifically what happened or how he/she got injured. The patient was a poor historian. Interview with LPN #2 on 09/30/2021 at 2:05 PM, revealed when she completed her morning rounds, she found Resident #87 in bed and noticed something on his/her head. Resident had blood on his/her face, on their pillow, on their hand and on the floor by the head area and she could not determine what happened. LPN #2 revealed she called the Nurse Practitioner (NP) and was told to use her discretion to determine if the resident needed to be sent to the ER. LPN #2 revealed the laceration to the resident's head was pretty wide open. Resident #87 was sent to the ER for the laceration and concerns about his/her pinky finger. Continued interview with LPN #2 on 09/30/2021 at 3:15 PM, revealed she was instructed by LPN #3 to complete the RMI. She further revealed she documented the incident as an injury of unknown origin not as a fall. LPN #2 revealed she had to return to the facility because she was unaware she was supposed to complete the RMI. She also revealed she did not tell LPN #3 it was a fall. LPN #2 also revealed she and a Certified Nurse Assistant (CNA) changed Resident #87's brief just before Emergency Medical Services (EMS) arrived because resident was wet. LPN #2 revealed she knew this incident was reportable because it was a head injury. Interview with LPN #3 on 10/08/2021 at 10:53 AM, revealed she reported this incident as a fall. She revealed she was contacted by LPN #2 and informed resident had fallen out of bed. She revealed based on her nineteen (19) years of experience and her knowledge about Resident #87, she determined the resident had a fall. LPN #3 revealed she was off the floor when the incident took place. When she went to assess resident, resident was in bed with his/her feet wrapped up in the sheets. She further revealed she texted the DON and told her she believed resident had an unwitnessed fall with an injury and resident was sent out to the ER. LPN #3 revealed she could not think of anything else it could be. She believed the resident fell and got up and back in bed. LPN #3 described a fall is when someone could not get up off the ground and an injury of unknown origin is when you did not know where the injury came from. However, she still believed the resident must had fallen. LPN #3 stated, I assumed it was a fall. Interview with DON on 10/08/2021 at 1:40 PM, revealed Resident #87's head wound was investigated as a fall. The DON revealed she conducted an interview on 09/27/2021 and she revealed there were two parts of a fall investigation and that investigation lead to a fall. She revealed she went up to the resident's room and found blood on resident's bed, linen and on the floor. Resident motioned to the floor and said, That was where he/she fell. However, many staff had stated resident does not speak in sentences, could only say yes and no and okay. The DON went on to say she could not speculate as to what happened to the resident. She also stated she could not say what LPN #2 did or did not see. The DON went on to explain she was unable to change the RMI report to reflect a fall instead of an injury of unknown origin. She revealed floor nurses did not do investigations. Additionally on 10/09/2021 the DON revealed she went in to the RMI and edited the part of the form which stated Resident stated, that's where I feel and pointed to the floor, scant area of dry blood noted on the floor, resident was able to get self up off floor and ambulate per self. She further revealed when edits were made to the form there was not a place for that person's name to be entered. Interview with the Administrator on 10/09/2021 at 4:30 PM, revealed an injury of unknown origin was an injury that cannot be determined how it was caused. She revealed all injuries were investigated and should be investigated when they were found. When an injury was determined to be an injury of unknown origin, it should be reported to the Office of Inspector General and all proper authorities. The incident should be reported to the supervisor and then the supervisor should report to the DON and/or Administrator. If they are not happy with supervisor's action, they should report to the Administrator. The Administrator also revealed if an injury was determined to be an injury of unknown origin it would be reported immediately, however, with five (5) nurse assessments they determined it was a fall and the resident said he/she fell. She also revealed she and the DON conducted the investigation and a timeline was completed. 3. Review of the facility's investigation revealed Licensed Practical Nurse (LPN) #11 provided a written statement on 03/30/2021 at 11:32 AM, which revealed LPN #11 admitted to yelling out F-Me after being notified by a CNA of an overflowing toilet, along with poop & water all over the floor. Interview with Registered Nurse (RN) #2, on 05/24/2021 at 2:12 PM, revealed Resident #74 was unable to get anyone to help him/her to empty the bedside commode, so Resident #74 emptied it himself/herself, which resulted in the toilet clogging up due to all of the toilet paper, etc. Further interview revealed an employee came in and said some rude things about the clogged toilet which Resident #74 overheard. Interview with Licensed Practical Nurse (LPN) #11, on 05/25/2021 at 11:51 AM, revealed that on the date of the incident, she was told that there was water on the bathroom floor. Upon entering Resident #74 bathroom, water and feces were found all over the floor. LPN #11 stated that she was completely shocked by the scene and that an expletive came out of her mouth. LPN #11 was escorted out of the building during her shift, when administration was informed of the statements made. LPN #11 stated she signed a statement of admission. Interview with Certified Nursing Assistant (CNA) #7, on 05/26/2021 at 1:49 PM, revealed Resident #74 took all of his/her paper towels off the sink and put them in the toilet and CNA #7 told LPN #11. While in the hallway CNA #7 heard LPN #11 say Shit, and Fuck I can't believe the toilet is overflowing. Then Resident #343 said something about hearing the comments as well. Interview with the Administrator, on 05/28/2021 at 10:20 AM, revealed after the allegation it was the expectation for the staff receiving that info to report it immediately. 4. Review of Resident #51's Care Plan dated 03/16/2020, indicated the resident was receiving care at the facility for restorative nursing and other services. The Care Plan stated Resident #51 wished to remain at the facility until his health improved and a safe discharge was arranged. Interventions included but were not limited to, meeting with the resident to discuss plans to return to the community with each full assessment. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #51 had a Brief Interview of Mental Status (BIMS) of eleven (11). Review of the Progress Note dated 05/06/2021, revealed that Resident #51 a\was able to voice wants and needs with clear speech. Review of investigation documents and employee statements revealed Resident #51 made a complaint of treatment to Licensed Practical Nurse (LPN) #3 on 05/04/2021 regarding the loud voice of a CNA. Interview with Resident #51, on 05/05/2021 at 1:44 PM, revealed the resident had a bad incident last night. Resident #51 stated Certified Nursing Assistant (CNA) #2, reportedly talked to Resident #51 like a child and kept yelling at him/her. Per Resident #51, CNA #2 told Resident #51 to get up and was real pushy and domineering. Resident #51 stated that he/she was not afraid of the CNA but did not want to be pushed around. Interview with Unit Manager (UM) #1, on 05/05/2021 at 3:24 PM, revealed the staff identified by Resident #51 was on the schedule last night as reported, but stated she had not received any incident reports or grievances from any residents. Interview with Unit Manager (UM) #1 on 05/07/2021 at 10:15 AM revealed the incident was under investigation. Interview with CNA #2, on 05/10/2021 at 10:22 AM, revealed she talked loudly because she was tone deaf. CNA #2 stated she was giving Resident #51 a shower and afterward Resident #51 asked for the CNA's name and the name of her Supervisor. Resident #51 informed CNA #2 that he/she was going to report her to LPN #3. Resident #51 said he/she was going to tell LPN #3 that she was yelling at him/her. Interview with Licensed Practical Nurse (LPN) #3, on 05/17/2021 at 10:17 AM, revealed Resident #51 told her that CNA #2 was talking loud to him/her in the shower room and he/she did not like it. LPN #3 did not feel that it was a reportable incident, so she did not say anything about it to the next nurse during shift report, because she forgot. LPN #3 stated that it slipped her mind. LPN #3 believed Resident #51 took offense because he/she felt like CNA #2 was yelling at him. If there was evidence of abuse or allegations, LPN #3 stated she was supposed to report to the Assistant Director of Nursing (ADON) within a two (2) hour window. Interview, on 05/18/2021 at 1:22 PM, with the Director of Nursing (DON) revealed she currently oversaw the investigation process. Staff were expected to report incidents and allegations immediately and the DON expected a thorough investigation to be completed. The DON stated resident complaints of yelling or harsh treatment by staff should be reported to the supervisor immediately. The supervisor should then report to the DON or ADON. LPN #3 should have reported the resident's complaint immediately. Any kind of distress could cause harm to the resident. The CNA should have been suspended immediately. Interview with the Administrator, on 05/28/2021 at 10:20 AM revealed if a resident informed staff he or she had issues with another resident or staff, it was the expectation for the staff receiving that info to report it immediately. LPN #3's statement that she forgot to follow up on the resident's complaint and failed to report the incident because she did not believe anything happened, was not acceptable and did not follow facility protocol. Based on interview, record review, and facility policy review it was determined the facility failed to ensure an allegation of abuse was reported for five (5) of one hundred thirteen (113) sampled residents (Residents #51, #54, #74, #92, and #146). Staff failed to report an allegation of staff to resident verbal abuse related to Resident #146. On 04/23/2021, the facility sent CNA (certified nursing assistance) #18 home related to sleeping and displayed behaviors of playing with resident items, going through resident's belongings, and laying across a sink. Staff stated the facility had them write witness statements related to the event. However, the facility had no documented evidence of staff statements and the incident was not reported to the State Survey Agency. On the night of 05/07/2021, Resident #92 reported to staff CNA #18 exhibited the behaviors above, but was allowed to complete the shift. The facility did not report the allegation of abuse/neglect until the morning of 05/08/2021, when additional resident, Resident #54, reported more behaviors from CNA #18, including the CNA showing residents her backside. Resident #51 reported to staff his/her concerns regarding treatment provided by a CNA but staff failed to report the allegation to management. Resident #74 reported to staff his/her concerns regarding language used by Licensed Practical Nurse #11 but the concern was not reported to management. The findings include: Review of the facility's policy, Abuse Prevention, updated 05/02/2017, revealed all personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin. The policy defined verbal abuse as any use of oral, written or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. The policy revealed any alleged violations involving mistreatment, abuse, neglect, misappropriation of resident property and any injuries of an unknown origin must be reported to the Administrator and Director of Nursing (DON). The policy revealed the person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse would immediately report the incident to the Administrator or to the individual in charge of the facility during the Administrator's absence. 1. Review of the clinical record revealed the facility admitted Resident #146 on 03/30/2021 with diagnoses that included Morbid (Severe) Obesity, Spinal Stenosis, and Chronic Pain Syndrome. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and determined he/she was interviewable. Observation of Resident #146, on 05/03/2021 at 5:35 PM, revealed the resident seated in bed, dressed and groomed. Interview during the observation, revealed the resident requested a muscle relaxer the evening of 04/30/2021; however, Licensed Practical Nurse (LPN) #39 stated there were none available. The resident stated later in the evening he/she asked LPN #32 for a muscle relaxer; the nurse told the resident he/she had to wait until 2:00 AM for a pain pill. The resident stated he/she explained to the nurse that he/she had already taken pain medication and needed a muscle relaxer for spasms/pain in his/her waist and legs. According to the resident, both nurses were rude, spoke to him/her like a child and caused him/her to cry. Resident #146 stated he/she dealt with the pain and cried himself/herself to sleep. Continued interview revealed Resident #146 reported the incident the next morning to the nurse who said she would report it. Resident #146 stated he/she reported the incident to Social Services Designee #2 the morning of 05/03/2021. According to the resident, the Social Services Designee stated she would look in to it. Review of the clinical record revealed a Physician's Order, dated 04/28/2021, for Cyclobenzaprine 10 mg tablet every 6 hours as needed for muscle spasms; and an order, dated 03/30/2021, for Hydrocodone-Acetaminophen tablet 7.5-325 mg every 6 hours as needed for pain. Review of the pharmacy Delivery Manifest, dated 04/27/2021 at 3:55 PM, revealed thirty (30) tablets of Cyclobenzaprine were delivered to the facility for Resident #146, and on 05/01/2021 at 4:58 AM, thirty (30) additional tablets of Cyclobenzaprine were delivered. Review of Resident #146's Medication Administration Record (MAR), dated April 2021, revealed the Cyclobenzaprine and Hydrocodone were not administered on 04/30/2021. Further review revealed the facility assessed the resident with a pain level of zero (0) out of ten (10) on the 3 PM-11 PM and 11 PM-7 AM shift; however, interview with the resident revealed he/she reported unrelieved pain to LPN #39 and #32. Review of the clinical record for Resident #149 revealed the facility admitted the resident on 04/01/2021. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #149 with a Brief Interview for Mental Status score of fifteen (15) and determined he/she was interviewable. Interview with Resident #149, on 05/10/2021 at 2:10 PM, revealed LPN #32 was disrespectful and hollered at Resident #146. According to the resident, Resident #146 was so upset he/she started crying. Interview with LPN #39 was attempted on 05/27/2021; however, the staffing agency did not provide a contact number. Interview with LPN #32, on 05/27/2021 at 4:11 PM, revealed her interactions with Resident #146 were cordial; however, she had apologized to the resident if she made (him/her) feel any kind of way. She stated she was not aware of any concerns regarding her interactions with the resident. Review of the 2nd floor Staffing Assignment Sheet, dated 05/01/2021, revealed LPN #3 was assigned to Resident #146 on the 7:00 AM - 3:00 PM shift. Interview was attempted with LPN #3, on 05/27/2021 at 3:16 PM; however, the LPN did not return the call. Interview with Social Services Designee #2, on 05/25/2021 at 2:16 PM, revealed Resident #146 reported he/she could not get a muscle relaxer when requested. She stated the resident told her that a nurse was nasty towards him/her. According to the Social Services Designee, the resident stated it did not make them feel good because he/she had muscle spasms and pain. The Social Services Designee stated she reported the allegation to the 2nd floor Unit Manager (UM) and the Assistant Director of Nursing (ADON). She revealed she did not submit a written statement regarding the allegation and was not aware of the outcome of an investigation. Interview with the 2nd Floor Unit Manager (UM), on 05/28/2021 at 9:27 AM, revealed allegations of abuse should be reported to the ADON, DON and Administrator immediately to ensure the resident's well-being. He stated the Social Services Designee mentioned Resident #146's concern a little while back; however, he forgot to address it. Interview with the ADON, on 05/27/2021 at 9:50 AM, revealed staff were responsible for reporting an allegation of abuse immediately to their supervisor, ADON, Director of Nursing (DON), or Administrator to initiate an investigation and ensure resident safety. She revealed the Social Services Designee notified her of Resident #146's allegation on 05/25/2021 (25 days after the alleged incident) and she immediately went to speak with the resident. The ADON stated she questioned the resident regarding his/her stay and staff treatment; however, she did not interview specific to the allegation. She revealed the facility did not investigate the incident because the resident did not mention concerns with staff or indicate abuse occurred. Interview with Resident #146, on 05/27/2021 at 10:54 AM revealed the facility had not interviewed or followed-up with him/her regarding the incident. Interview with the DON, 05/28/2021 at 3:22 PM, revealed she was not aware of Resident #146's concerns with treatment by nursing staff. She revealed the ADON was responsible for notifying her and the Administrator for anything of concern and investigating the issue. The DON revealed the ADON interviewed Resident #146; however, the resident did not have any complaints. The DON revealed she was not aware of any issues with timely reporting of abuse allegations. Interview with the Administrator, on 05/28/2021 at 4:13 PM, revealed the facility investigated all issues that were concerning and could be considered reportable. She stated all issues were first reported to the ADON. The Administrator revealed the ADON initiated the investigation and reported the findings to her. The Administrator revealed the facility had not identified issues with reporting of abuse. 2. Review of the facility's policy, Resident Rights, undated, revealed residents had the right to be free from verbal, sexual, physical or mental abuse. In addition, the facility implemented procedures to protect residents from abuse, neglect or mistreatment. In the event of an alleged violation, the facility is required to report to the appropriate officials and promptly and thoroughly investigated. Through interview, State Survey Agency (SSA) revealed Certified Nurse Assistant (CNA) #18 was sent home on [DATE] due to sleeping and related behaviors in front of residents. However, the facility had no report or documentation related to incident. Record review of time punches on 04/23/2021 revealed CNA #18 clocked in at 7:15 PM and clocked out 9:00 PM. Interview with CNA #18 on 05/27/2021 at 12:42 AM, revealed a Certified Medication Technician (CMT), unknown name, accused her of being on drugs about a month prior to SSA interview. The CMT reported CNA #18 was asleep at the sink and acting weird. Interview with CMT #1, on 05/27/2021 at 10:18 AM, revealed she was familiar with CNA #18. She stated CNA #18 wasn't there and indicated she should not have been working with the residents. She stated she observed CNA #18 acted as if she did not know what she was doing and was not acting how she should. CMT #1 explained she reported the behavior to LPN #10. CMT #1 indicated CNA #18 left early that day and she had not seen her since. CMT #1 additionally stated she was asked to write a statement and gave it to HS #1. Interview with LPN #10, on 05/26/2021 at 1:22 PM, revealed on 04/23/2021 CMT #1 reported weird behavior from CNA #18. LPN #10 explained, she approached CNA #18 and asked if she was okay. CNA #18 replied there was something in her eye and she had to take out her contact. LPN #10 also described CMT #1 had reported CNA #18 was looking for something on the floor and said she dropped an earring. LPN #10 then observed CNA #18 entered room [ROOM NUMBER], took linen and filled up the inside of sink to make it flush with counter, and laid her head down in the sink. LPN #10 told CNA #18, You can't be here and asked her what was wrong? CNA #18 said, Please don't send me home, I'm just tired and exhausted and haven't ate. Upon observation, LPN #10 stated she called HS #1 and she came to the 6th floor and walked her down. Additionally, LPN #10 stated CNA #18's shift started at 7:00 PM and she was sent home within hour or so. LPN #10 stated she wrote statement for the incident on 04/23/2021. Interview with HS #1, on 05/27/2021 at 3:34 PM, revealed on 04/23/2021 CMT #1 and an unnamed nurse on the sixth (6th ) floor called HS #1 to report CNA #18 falling asleep, unknown time, in resident room and not acting quite right. HS #1 stated she went upstairs and interviewed CNA #18. CNA #18 reported she was just tired. HS #1 stated CNA #18 appeared tired upon observation. HS #1 called Assistant Director of Nursing (ADON) to inform her of observations. ADON advised let her go home due to resident safety. HS #1 additionally stated when staff is sleeping on the job, they are no good to the residents and accidents can easily happen. HS #1 said she did not evaluate or interview the residents at the time. However, indicated now in hindsight she should have talked to a few residents. Further stating, CNA #18 could have injured or potentially dropped a resident. HS #1 stated she asked staff to write statements related to their observations on 04/23/2021. HS #1 stated she placed the statements in the ADON box, mailbox behind the reception desk. Interview with the DON and Administrator, on 05/26/2021 at 2:35 PM, revealed the facility had no witness statements from any staff related to CNA #18 being sent home on [DATE]. Both staff indicated CNA #18 had no write-up in personnel file. Interview with DON, on 05/28/2021 at 8:49 AM, revealed she was not familiar with CNA #18 behaviors on 04/23/2021; nor was she aware the facility sent CNA #18 home early. However, she stated it should have been reported. The DON indicated witness statements should be obtained from management staff, house supervisor, DON, ADON, and Human Resources (HR). The DON stated if staff was sent home early, she was notified by phone or text. DON stated the House supervisor had the authority to send staff home if resident care was comprised. Further stating HS #1 should have called her make aware of CNA #18's behaviors. She indicated CNA #18 clocked out at 9:00 PM on 04/23/2021. Interview with the Administrator, on 05/28/2021 at 11:57 AM, revealed she was aware CNA #18 was reported asleep the evening of 04/23/2021 and HS #1 made the decision to send CNA #18 home to get rest. She additionally stated HS #1 made rounds to ensure there was no negative impact on resident. Administrator stated if staff was found sleeping on job they would typically be sent home because its against policy. The SSA investigated an additional allegation related to CNA #18 that occurred on 05/07/2021. Observation and interview with Resident #54, on 05/08/2021 at 8:22 AM, revealed facility staff interviewed Resident #54 after he/she asked to speak with a supervisor during morning rounds. He/she described a CNA he/she had seen once before, unknown name, as thin, white, had brown hair in a bun, tall, and not typically on the floor. Facility identified the CNA to be CNA #18. Resident #54 stated her roommate, Resident #58, needed to be changed and CNA #18 was rude. CNA #18 started going through Resident #58's bag and played with his/her dolls. Resident #54 explained, CNA #18 set the dolls on the bed like she (CNA #18) was a little kid and was not playing with Resident #58. CNA #18 looked like she was on drugs and could barely keep her eyes open. Resident #54 recalled CNA #18 said, That's what happens when you go deep in thought. Resident #54 additionally explained CNA #18 started showing Resident #58 her tattoos on her bottom, belly, back, and legs. Resident #54 explained Resident #58 could not express herself verbally and this upset CNA #18. Resident #54 stated CNA #18 started cussing at Resident #58 and he/she started crying. Resident #54 reported no nurse came back into the room after evening medication pass on 05/07/2021. Record review and interview with Resident #92 on 05/26/2021 at 9:20 AM, revealed he/she was admitted to the facility on [DATE]. His/her quarterly MDS dated [DATE] revealed the facility assessed Resident #92 with a BIMS of 15, indicating he/she was cognitively intact. Resident #92 stated CNA #18 appeared higher than a [NAME]. Resident #92 stated he/she was walking down the odd side of the hall when CNA #18 came out of room [ROOM NUMBER] and was unsteady like she was drunk. Resident #92 reported the situation to the nurse, unknown name, on the floor. Record review and interview with Resident #67, on 05/25/2021 at 2:43 PM, revealed he/she was admitted to the facility on [DATE]. His/her annual MDS dated [DATE] revealed the facility assessed Resident #67 with a BIMS score of fourteen (14), indicating he/she was cognitively intact. Resident #67 remembered CNA #18, he/she stated it was strange she kept nodding off, and leaning over the bed. He/she further stated, I had to wake her up a couple times. Record review and interview with Resident #96, on 05/26/2021 at 10:50 AM, revealed he/she was admitted to the facility on [DATE]. The facility assessed Resident #96 on 03/18/2021 with a BIMS score of fifteen (15), indicating he/she was cognitively intact. Resident #96 stated CNA #18 was acting like she was drunk. Resident #96 reported CNA #18 was going one room to another collecting garbage bags, she was swaying like she was on drugs. She came in to collect garbage and almost fell over. Record review revealed the facility admitted Resident #54 on 04/25/2019. The facility assessed Resident #54 on 02/25/2021 with a Brief Interview for Mental Status (BIMS) fifteen (15), indicating he/she was cognitively intact. Interview with LPN #15, on 05/26/2021 at 8:56 AM, revealed on the night of 05/07/2021, she was the nurse for both sides of the unit after 10:30 PM. She recalled complaints from staff and residents related to CNA #18. Resident #92 asked, Is that girl high? LPN #15 explained she reported the concerns related to CNA #18 to House Supervisor #1 around 8:00 PM or 9:00 PM. House Supervisor #1 and UM #1 came to the floor, talked to her, and said she was okay. LPN #15 stated CNA #18 seemed tired. Interview with LPN #14, on 05/25/2021 at 2:30 PM, revealed the morning of 05/08/2021, CNA #18 told LPN #14 she was tired. LPN #14 stated when she started her rounds residents complained of care. Resident #54 and Resident #67 complained about care or stated the CNA was nodding off. SSA attempted to call UM #1 for interview on 05/26/2021 at 2:54 PM, no answer. Review of the facility obtained statement from UM #1 on 05/08/2021 revealed she went to the sixth (6th) floor to meet HS #1 and assess CNA #18, untimed. She observed CNA #18 to be tired. However, no staff on the floor reported anything unsafe. They decided it was okay for CNA #18 to stay in the facility. Interview with House Supervisor (HS) #1, on 05/26/2021 at 3:09 PM and 05/27/2021 at 3:34 PM, revealed on 05/07/2021, LPN #15 called her to the sixth (6th ) floor at 8:20 PM and reported a problem with CNA #18 appearing under the influence and sleepy. HS #1 interviewed LPN #15 who stated she was going off what residents reported to her. Further interview with CNA #18, on 05/27/2021 at 12:42

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to provide adequate supervision for one (1) out of one-hundred and nineteen (119) residents sampled, Resident #87. Observation on 09/29/2021 at 4:00 PM, revealed Resident #87 wandering the Seventh (7th) Floor without supervision. Resident #87 was entered room [ROOM NUMBER], walked about ten (10) steps in, turned around and walked out. Resident #87 walked into room [ROOM NUMBER], went to the empty bed near the window, got in bed, under the covers and then got back up. Resident #87 went across the hall and entered the shower room and remained in there for three (3) minutes. Resident #87 came out of the shower room and went back to room [ROOM NUMBER] and got back in the same empty bed, under the covers and laid his/her head on the pillow as if to go to sleep. Continued observation on 09/29/2021 at 4:22 PM, further revealed Resident #87 continued to wander unsupervised on the Seventh (7th) floor. Resident had been at the common area near the nurse's station and headed back down the hall toward the activity center at the end of the hall. Resident stopped at room [ROOM NUMBER] in which another resident stood in the door and told the resident go on, get away from here. At that point Certified Nursing Assistant (CNA) # 1 intervened and sent Resident #87 on down the hall. Resident started to enter room [ROOM NUMBER] again, except CNA #1 stopped the resident and told resident Let's go to your room. CNA #1 took Resident #87 to the other side of the hall to room [ROOM NUMBER]. The findings include: Review of the facility policy for Wandering Resident, undated, revealed the facility was to ensure residents who wander, had the freedom and opportunity to wander in safe, designated areas of the building and grounds with appropriate dress and appropriate supervision. Staff were to redirect the resident if the resident invaded the privacy and/or personal space of others, or was disruptive to activities or events. The wandering behavior was to be care planned with appropriate interventions put in place. Any decreased or increased behavior was to be reported to the physician. Review of Resident #87's clinical record revealed the facility admitted the resident on 07/09/2019, with multiple diagnosis, which included Alzheimer's Disease, Dementia with Behavioral Disturbances, anxiety, major depressive disorder, and cognitive communication deficit. Staff report Resident historically wandered into other resident's rooms, took items and got in their beds. Review of Resident #87's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), and determined the resident was not interviewable. Resident #87 was assessed for bed mobility, transfers, walk in room, walk in corridor, locomotion on unit and off unit and to eat as supervision-oversight, encouragement and cueing with the assistance of one (1) staff member. Resident was assessed as two (2) staff physical assist to get dressed and for personal hygiene. Review of Resident #87's Comprehensive Care Plan last reviewed on 09/01/2021, revealed resident was care planned for wandering on 07/10/2019. Resident wandered into other resident's rooms and took their personal items. Resident also had a history of using other resident's bathrooms and attempted to undress other residents. Also, resident had a history of getting in other resident's beds (female, male and empty beds). Interventions put in place were to allow resident to make own decisions about treatment to provide a sense of control (Initiated 07/10/2019, no revisions). To check on resident frequently and meet resident's needs in a timely manner (Initiated 04/02/2021, no revisions). To provide an explanation of all care activities when they took place (Initiated 07/10/2019, no revisions). If resident resists Activities of Daily Living, leave and return in five (5) to ten (10) minutes and try again (Initiated 07/10/2019, no revisions). Continued review of Resident #87's care plan revealed additional interventions for wandering concerns were to offer the resident education and redirection as to possible outcomes of not complying with treatment or care as needed (Initiated 07/10/2019, no revision). Allow the resident to have choices during care provision (Initiated 07/10/2019, no revision). Redirect the resident as needed (Initiated 12/27/2019, no revision). Resident to be referred to psych services as needed for behaviors and medication management (Initiated 11/10/2020, no revision). Interview with CNA #1 on 09/29/2021 at 4:00 PM, revealed she expressed she had told management on several accounts she did not feel this facility was the best fit for Resident #87. She revealed resident entered other resident's rooms all the time and the only thing that staff could do was redirect resident, over and over. She also revealed Resident #87 would get in bed with other resident's and they did not know any better so the residents did not care. Observation on 09/30/2021 at 3:00 PM, Resident #87 up in hallway, entered room [ROOM NUMBER], Licensed Practical Nurse (LPN) #2 ran to the room to get the resident, called resident's name two (2) times without any acknowledgement. LPN #2 took resident by the hand and led resident back to his/her room and reminded Resident #87 their room was 716. Observation on 10/01/2021 at 9:13 AM, Resident #87 in bed with the same clothes as the day prior. Asked resident how he/she was doing and resident just mumbled back. Resident followed surveyor out of the room. Resident had a blanket in his/her hands, no socks on their feet. Resident went into room [ROOM NUMBER] and stood next to the sink. Resident exited that room and went to room [ROOM NUMBER] at which time Registered Nurse (RN) #13 engaged resident and redirected resident to his/her room to find resident nonslip socks. Observation on 10/04/2021 at 10:31 AM, Resident #87 ambulated out of room [ROOM NUMBER] and entered room [ROOM NUMBER] to the window, staff passed area but unaware Resident #87 was in that room. Resident #87 drank from a can in room [ROOM NUMBER]'s table and exited room, staff redirected resident to the television. Registered Nurse (RN) #13 informed Resident #87 drank from a can in room [ROOM NUMBER]. Interview with CNA #58 on 10/03/2021 at 2:53 PM, revealed she physically witnessed Resident #87 in bed with male and female residents, all the time. She revealed she always informed the nurse on duty but everybody on the floor knew resident got into bed with other residents. Interview with Certified Medication Technician (CMT) on 10/03/2021 at 9:26 AM, revealed she had found Resident #87 in bed with both male and female residents and Resident #87 would be asleep. She described this resident as a team project, in that they have to keep up with resident at all times. CMT revealed she had reported it immediately to her supervisor every time she witnessed it, but it was nothing new. Interview with Social Service Designee #1 on 10/01/2021 at 11:35 AM, revealed Resident #87 would go in any opened door and lay down in the bed. She described resident as unable to sit down and very unfamiliar of his/her surroundings. Interview with Social Service Designee #2 on 10/04/2021 at 8:58 AM, revealed Resident #87 was not easily redirected and was strong willed. She was familiar with resident's behaviors and aware resident went into other rooms and got into other beds. She revealed she does not work on the Seventh (7th) floor. Interview with LPN #40 on 10/02/2021 at 4:35 PM, revealed on 07/19/2021 she felt she had to keep Resident #87 by her side on 1:1 because resident continued to go into men's room and attempted to get in their bed. She revealed she was concerned for Resident #87's safety. She revealed she reported it to the weekend supervisor LPN #46. She revealed staff talked about more supervision for resident but revealed they did not discuss it with the Director of Nursing (DON) but it was documented in progress notes. Review of Resident #87's Progress Notes for 07/19/2021 at 7:42 AM, completed by LPN #40, revealed resident was up all night, in other resident's rooms, in bed with men. Redirected several times, 1:1 with resident and unable to give care to other residents. Concerned for resident in bed with men on floor and wandering into their rooms. This progress noted was checked to show up on the shift report and the twenty-four (24) hour report. Interview with LPN #5 on 10/02/2021 at 5:30 PM, revealed one day staff looked for Resident #87 and found him/her in bed with Resident #402. The two residents were lying in bed together. LPN #5 revealed she did not report this information to the supervisor because the resident was easily redirected. LPN #5 explained it was common knowledge on the Seventh (7th) floor that Resident #87 got into bed with male and female residents. Interview with LPN #46 on 10/03/2021 at 2:30 PM, revealed she was aware Resident #87 got into bed with other residents, both male and female. She revealed that if staff could not locate the resident, they would look in all of the rooms until they found him/her; most likely, the resident would be in somebody else's bed. LPN #46 also revealed to give resident better supervision through night staff would keep resident at their side. LPN #46 believed she would have reported it to the Assistant Director of Nursing (ADON) or the DON. LPN #46 revealed if resident was not at her side she would check on the resident every time she walked up or down the hall. Interview with LPN #27 on 10/04/2021 at 1:20 PM, revealed she had witnessed Resident #87 in other resident's rooms. She revealed the resident is unaware of what he/she does. LPN #27 revealed she tried hard to keep Resident #87 engaged in activities, would try to get resident to color or to fold clothes, anything to keep resident busy. LPN #27 also revealed she did not believe this facility was the best fit for Resident #87 and resident would do better in a truly secured unit. Interview with Unit Manager (UM) # 1 on 10/07/2021 at 3:45 PM, revealed resident was very demented and well in progression of Dementia. She revealed Resident #87 constantly wandered, and would wander into other resident's rooms. UM #1 also revealed she continuously had to intervene or resident would get in other resident's beds. Interview with Weekend Supervisor LPN #3 on 10/09/2021 at 10:53 AM, revealed Resident #87 would wander the unit and take other resident's items, would take stuff off of the medication carts, anything resident got their hands on. LPN #3 revealed resident would go in other resident's rooms and fall asleep in an empty bed. LPN #3 further revealed staff constantly had to have their eyes on Resident #87. Interview with RN #11 on 10/03/2021 at 3:14 PM, revealed he had been at the facility for four (4) months. He was informed at orientation that Resident #87 got into bed with other residents. He also revealed he has witnessed resident go into other resident rooms, male rooms but he has not seen resident in male beds. He revealed resident should be care planned for this behavior. Interview with Social Service Director (SSD) on 10/01/2021 at 11:23 AM, revealed Resident #87's care plan should have reflected redirection and that it took several staff to follow resident because he/she constantly walked around the unit. However, she also revealed she was not the one responsible to update the care plan. She further revealed the Director of Nursing (DON) was the one responsible to review the twenty-four (24) hour progress notes and the information about this resident should have been discussed in the Interdisciplinary Team Meeting (IDT). Interview with Nurse Practitioner (NP) #2 from psychological services on 10/01/2021 at 2:44 PM, revealed she had observed Resident #87 in bed with a female resident and also in another room in an unoccupied bed. She revealed staff was not aware of where resident was. NP #2 got resident up out of the bed and went and located staff to assist with resident. Interview with Psychologist who provided psychological services for facility, on 10/04/2021 at 1:30 PM, revealed Resident #87 wandered throughout the Seventh (7th) floor and he/she would wander any place the door was open. Resident would wander into other resident's rooms, would take other resident's personal items and even use other resident's bathrooms. He revealed resident historically got in bed with other residents and it had been reported Resident #87 got in bed with male residents. Agency psychologist revealed if staff were not aware of where resident was and what he/she was doing, resident could end up harmed or exploited by another resident. He further revealed he did not believe this facility was the best location for Resident #87, however the facility was unable to place resident at any other facility. Interview with DON on 10/8/2021 at 1:40 PM, revealed she was informed recently about Resident #87's getting in bed with other residents. The DON explained she was unaware of the psychologist recommendation for resident to have more in depth contact with staff as she does not review psycho notes, Social Services does that . The DON revealed it was the responsibility of Social Services to update resident's care plan. Interview with the Administrator on 10/09/2021 at 4:00 PM, revealed she was aware that Resident #87 got into bed with other residents occasionally and was easily redirected. She revealed it was not reported to her that resident had been found asleep in other resident's beds. However, she revealed resident would try to lay in people's beds, but the correct questions were asked and appropriately answered, were residents fully dressed, were all briefs intact and was anybody scared. The Administrator revealed she was unaware of resident's past behaviors of going in resident's rooms, undressing, using the bathroom in resident's sinks, she explained those behaviors had not happened since she had been the administrator. The Administrator revealed psych notes were to be reviewed by the Social Services Director and if there were any concerns, they would be discussed in the morning meeting. Continued interview with the Administrator on 10/09/2021 at 4:00 PM, further revealed she would not speculate about what could happen to a resident who wandered into other rooms and revealed staff had not reported any concerns. She revealed she was unaware of the psychologist recommendation for resident to have more intentional contact with staff and stated, she would have to review the notes but the facility considered all recommendations. 3. Review of facility policy titled, Smoking Policy, not dated, revealed the facility allowed smoking for residents, staff and visitors in designated areas. Smoking activity must be fifteen (15) feet from any doorway, window or vent system. The facility kept all residents' smoking materials. All staff members received education on the smoking policy and smoking assessments during general orientation. The policy further stated residents were to be assessed for smoking upon admission and educated on smoking practices, and in addition assessed quarterly, annually, or after an unsafe smoking episode, or a change of condition. The Social Service Designee (SSD) conducted the smoking assessment. The care plan and Certified Nursing Assistant (CNA) assignment sheet were reflective of the resident's needs as far as safe smoking. The admitting nurse may complete the smoking assessment if SSD was not available. Review of the facility's policy titled, Standard Supervision and Monitoring not dated revealed, the facility recognized supervision and guidance to the resident was an essential part of nursing care in which standard approaches were successful in meeting the resident's physical and psychological needs. Review of facility's document titled. 3rd floor smoking privileges and restrictions, dated 05/23/2017, revealed the designated smoking area as the third (3rd) floor patio. Residents were assessed to wear a smoking apron and must have it on prior to lighting a cigarette. Continued review of the document revealed no assigned seating in the smoking area, cigarettes and trash placed in appropriate containers, and residents may not wait in line for the smoking patio to open. The policy continued to state no verbal or physical altercations to occur among residents while on the patio. Review of the position description titled Smoking Monitor not dated, revealed the purpose of the smoking monitor was to provide each resident with a safe smoking environment, and monitor residents during smoking hours. In addition, the smoking monitor ensured supervision of residents at all times while on the smoking patio. Record review for Resident #109, revealed the facility admitted the resident on 04/19/2017 with diagnoses that included Hemiplegia and hemiparesis following Cerebral Infarction, Contractures, Chronic Obstructive Pulmonary Disease, Atherosclerotic heart disease, Falls, Peripheral Vascular Disease, Low vision Right Eye Category 1, Blindness Left Eye Category 3. Review of the Minimum Data Set (MDS) revealed the facility assessed the resident with a BIMs score of ten (10) and determined the resident with mild cognitive impairment. Review of Resident #109's Care Plan initiated 05/15/2018 and updated 04/12/2021, revealed Resident #109 was to wear a smoking apron, provided with a copy of the smoking policy, could smoke in a designated area, and undergo a smoking assessment quarterly and as needed. Review of the Smoking Policy and care/safety of smoking residents, revealed Resident #109's signature present. Interview on 05/06/2021 10:15 AM, with Resident #109, revealed the smoking times were 9:00 AM, 1:00 PM, 3:00 PM and 6:00 PM. Resident#109 continued to explain the staff covered him/her with a smoking apron and kept an eye on residents. Resident #109 reported he/she had to wear a smoking apron because of burning a hole in his/ her clothing a while ago. Interview on 05/15/2021 at 8:30 AM, with Resident #109, revealed staff assisted him/her to and from the smoking porch. However, when returning from the porch the smoking monitor positioned his/her wheel chair in front of the elevators and nurses' station. Resident #109 stated he/she must find his/her way back to the room by feeling along the hall way, sometimes staff took the resident back to his/her room. Observation, on 05/12/2021 at 9:30 AM, revealed Resident #109 on the smoking patio wearing a smoking apron, however, the apron was not fully covering the resident's legs. Further observation revealed the Smoking Monitor was seated at the card table inside the building. Observation revealed Resident#109 on the porch out of direct view of the monitor with his/her back facing the window. Observation, on 05/12/2021 at 9:37 AM, revealed a Restorative Assistant (RA) wheeled Resident #109 from the smoking porch to the third (3rd) floor elevators, leaving the smoking porch unattended for approximately thirty (30) seconds. Interview, on 05/14/2021 at 1:27 PM, with Smoking Assistant (SA), revealed groups come in and cigarettes were distributed. Residents can have three (3) cigarettes during the smoke break. Further interview revealed there were three (3) smoke breaks a day. The Scheduler informed the SA, which residents needed special precautions like a smoking apron. SA continued, Resident #109 was blind and she positioned Resident #109 to face toward her and placed a smoking apron on the resident. The SA continued to explain, Resident #109's aid or nurse returned him/her to their room. However, sometimes she had to leave the porch to take Resident#109 back to the nurse's station and it might take around thirty (30) seconds. The SA explained that the purpose of having a smoking aid was to make sure everybody was safe and six (6) feet apart. Observation on 05/14/2021 at 1:27 PM, revealed an SA seated at card table while residents were on the smoking patio out of direct view of the SA. Interview, on 05/14/2021 at 2:25 PM, with the Scheduler revealed nursing informed her if a resident had special needs related to smoking. The Scheduler continued stating the role of the SA was to pass out cigarettes, and in addition, the SA was trained on the smoking apron, fire blanket and observation. Furthermore, the SA needed to stand outside on the patio with the residents and not leave the area while residents were smoking. Observation, on 05/15/2021 at 9:00 AM, revealed the smoking patio was open, with four (4) residents waiting to enter the smoking patio and nine (9) residents on the deck with two (2) smoke attendants. Resident #109 was on the smoking patio with his/her back to window and wearing a smoking apron. Observation, on 05/16/2021 at 10:00 AM, revealed one (1) resident on the smoking patio outside under the awning, lightly raining. Observation revaled a resident in the corner, wearing a smoking apron. The Ssmoking attendant was observed on the porch on the other side of the table texting on a phone. Continued observation revealed a resident was out of her line of vision. Interview, on 05/16/2021 at 10:00 AM, with CNA #33 revealed she usually stood at the door to observe residents but, she was texting a co-worker. Interview, on 05/18/2021 at 9:57 AM, with the Social Service Designee (SSD), revealed the role of the attendant was to ensure safety and assist the residents with smoking. Furthermore, the attendant should be observing all residents on the patio at all times for safety, social distancing, and smoking practices. SSD #2 stated a resident smoking should be positioned on the patio in a way that they that could be seen. The nurse obtained the resident contract and provided education for smoking during the admission process. SSD #2 stated she had not reviewed the smoking policy nor received any training related to residents that smoked in the facility. SSD #2 stated she was not aware of training for the smoking attendants. SSDv#2 stated if the smoking policy was not followed it could affect the resident's safety and if the attendant was distracted it could be a problem for resident safety. Interview on 05/19/2021 at 9:14 AM, with Registered Nurse (RN) #5, revealed she had not been oriented to the smoking apron or smoking safety for residents. However, if she identified burns on a resident she assessed the patient, interviewed them, and informed the nurse manager. RN #5 stated that smoking monitor was assigned to the smoking patio to make sure everyone was safe, socially distanted, and distributed cigarettes. Interview, on 05/18/2021 at 3:49 PM, with the Director of Nursing (DON) revealed she was not aware of the process around smoking and supervision on the smoking patio. Furthermore, the DON stated she had not received orientation to the facility's smoking procedure. The DON stated a smoking monitor attended to the residents on the smoking patio to ensure safety while residents smoking. She stated residents not monitored on the smoking patio were at risk for injury. Interview on 05/20/2021at 9:51 AM, Administrator (ADM) revealed all smokers were supervised in the designated smoking area on third floor patio. Further interview with ADM revealed a smoke attendant provided assistance, lit the residents' cigarettes, and ensured residents wore a smoking apron if indicated. The ADM stated the smoking attendant should not be on the phone while observing smoking residents and the smoking monitor needed to have the ability to lay eyes on the resident frequently. 2. Review of the clinical record revealed the facility admitted Resident #32 on 02/22/2019. Diagnoses included Dementia without Behavioral Disturbances, Anxiety Disorder, Hypertension, and Overactive Bladder. The facility assessed the resident on 02/18/2021, with a Brief Interview Mental Status (BIMS) of fifteen (15) and determined the resident was interviewable. Review of the facility's care plan for risk of falls, initiated 03/07/2019, revealed the resident had a history of falls in the facility and included interventions for gripper tape to the right side of the bed, ensure call light was in reach and encourage to use it for assistance, anticipate and meet resident needs, and complete the Fall Risk, per the facility's protocol. Additionally, the care plan identified that Resident #32 had Activities of Daily Living (ADL) self care deficits and included interventions to supervise transfers and the resident ambulated independently. Review of the facility's incident report, dated 02/25/2021, revealed Resident #32 was discovered on the floor next to his/her bed. The resident thought he/she lost his/her balance when he/she reached for the items from the nightstand. The facility educated the resident on the importance and safety to utilize the call light for assistance. The report was incomplete, missing information related to the resident's mental status, any predisposing physiological factors. Predisposing Environmental Factors were marked as None. However the report did not reveal the distance from the bed to the nightstand, or the items the resident reached for. The facility's Root Cause Analysis (RCA) of the fall, dated 02/25/2021, revealed the Nursing Progress Note of the fall with the same information as the report. The RCA did not reveal what led to the resident's inability to reach the items on the nightstand, which led to the fall. The care plan for Resident #32 revealed no new interventions implemented for the resident's fall risk after the fall occurred on 02/25/2021. Review of the facility's incident report for Resident #32, dated 04/20/2021, revealed the resident laid on the floor at the third floor smoking patio. The resident stated he/she fell when he/she turned to sit on the concrete bench in the smoking area. The report was incomplete, with Other (Describe) marked as Predisposing Situation Factors, however no other descriptive information was documented. The facility's RCA, dated 04/21/2021, revealed the Nursing Progress Note of the fall documented the fall was witnessed. The Note further revealed Resident #32 stumbled on the smoke patio ramp. The RCA did not document the type of footwear the resident wore, or what may have led the resident to stumble. Review of Resident #32's care plan revealed the facility revised the care plan, on 04/21/2021, with interventions to encourage proper positioning when attempting to sit down and ask for assistance when sitting down. Review of an incident report, dated 04/23/2021, revealed Resident #32 laid on the floor on his/her side at the foot of the bed and his/her pants around the ankles. The resident stated he/she stood up to put on his/her pants and fell. The report noted the resident was clean and dry, and continent of bladder and bowel. The report was incomplete, with information missing related to Predisposing Environmental Factors. There was no information about the resident's footwear or the immediate environment around the resident, such as clutter, wet floor, furniture, or uneven walking surface. The facility's RCA revealed the Nursing Progress Note, dated 04/23/2021, documented the nurse educated the resident. The care plan, revised 04/23/2021, revealed an added intervention included to encourage to use the call light for transfer/ambulation assist. Continued review of Resident #32's care plan revealed an intervention to encourage to use the call light for transfer/ambulation assistance was added, dated 04/23/2021. Review of the facility's incident report, dated 04/29/2021, revealed staff found Resident #32 on the bedroom floor entangled in bed sheets. The resident stated he/she tried to get up. The facility staff educated the resident about wearing nonskid footwear and gave the resident his/her call light. The report was incomplete, with no information marked for Predisposing Situation Factors. The facility's RCA revealed the Nursing Progress Note, dated 04/29/2021, documented the resident was entangled in his/her sheets when staff found the resident on the floor and the resident said he/she tried to get up. The RCA did not indicate if the resident had on any footwear or the type of footwear, or if the call light was in or out of reach at the time of the fall. The care plan, revised 04/30/2021, revealed an added intervention of safety awareness education as needed. On 04/30/2021, further review of the care plan revealed an intervention added for safety awareness education as needed for Resident #32. Observation of Resident #32, on 05/04/2021 at 3:42 PM, revealed the resident in bed, wore eyeglasses, a rollator near the bed, and non-skid strips on the floor on the side of the bed. Observation, on 05/17/2021 at 1:58 AM, revealed Resident #32 ambulated with his/her rollator to the nurse's station. The resident then left the rollator and drug a chair from the nurse's station over to another resident in the common area at the nurse's station, sat down, then moved his/her rollator in front of him/her. Interview with Resident #32, on 05/04/2021 at 3:42 PM, revealed he/she fell out of bed a few nights ago, and was dizzy for a few minutes. The resident revealed he/she got a new rollator, which replaced a wobbly walker from physical therapy. Interview with Certified Nurse Aide (CNA) #26, on 05/14/2021 at 10:00 AM, revealed when she came in to work a couple of weeks ago, Resident #32 fell and had already gotten up off the floor. She stated the resident does pretty good to walk. The aide stated the resident was sometimes mixed up. The CNA stated the resident told her he/she fell and the aide reported to the nurse. The aide further stated the resident did not use the call light a lot of times, as he/she liked to do for himself/herself. On 05/14/2021 at 10:14 AM, interview with Licensed Practical Nurse (LPN) #27 revealed Resident #32 was a little confused at times. She stated the resident was independent walking with episodes of falls. The nurse further stated the resident was noncompliant with using the rollator, and needed reminding to get his/her walker, or staff would bring the walker to the resident. The LPN revealed when a resident fell, the computer system had a risk management incident report that should be completed, and went to the Director of Nursing (DON), and was reviewed with the care plan in the morning meeting. Interview, on 05/14/2021 at 1:38 PM, with LPN #33, revealed she did not recall Resident #32's fall. However, she recalled the resident did not use any assistive devices. She stated the resident would ask for help and did not have any issues with noncompliance by the resident. Interview with LPN #23, on 05/14/2021 at 3:13 PM, revealed she was the nurse on duty when Resident #32 fell at the smoking patio. She stated the resident did not usually go to the smoking patio, but decided to go on that day for fresh air. The nurse revealed the staff at the smoke patio told the resident to sit on the bench and the resident tripped over his/her own feet and fell. LPN #23 stated the resident walked independently at the time and did not have a rolling walker. The nurse stated the fall documentation needed to be completed, as the purpose was to communicate from one (1) shift to the next. She stated leadership updated the care plans when they completed their risk management changes in the computer. On 05/14/2021 at 3:25 PM, interview with Unit Manager (UM) #6 revealed she was the nurse assigned to work with Resident #32 when the resident fell on [DATE]. She stated the fall occurred early in the morning with CNA #26. She stated they found the resident sitting on the floor in his/her room, with his/her feet intertwined in the sheets. The LPN revealed the resident said he/she tried to get up to go to the bathroom. The nurse stated Resident #32 was independent with walking and transfers, and did not use an assistive device at the time of the fall. Interview with the MDS Director, on 05/17/2021 at 3:05 PM, revealed she was familiar with Resident #32 but could not recall the resident's falls. She stated when a resid[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to provide pain management for one (1) of one hundred thirteen (113) sampled residents (Resident #146). Interview with Resident #146 revealed he/she experienced pain and notified staff. Resident #146 stated the pain was so bad he/she cried himself/herself to sleep. However, staff did not administer the resident's ordered pain medication. The findings include: Review of the facility's policy, Management of Pain, undated, revealed as part of a comprehensive approach to pain assessment and management, pain would be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. The policy defined pain as whatever the experiencing person said it was, existing whenever the experiencing person said it did. Further review revealed staff assessed and managed pain in a timely fashion, especially if it was of recent onset. Staff notified the physician of the resident's complaint of pain when not relieved by the medication as ordered by the physician. The policy stated thorough communication with the physician ensured an appropriate pain management plan. Further review of the policy revealed pain monitoring was documented on the back of the Medication Administration Record (MAR)/pain flow sheet which included the effectiveness of the pain medication. Effectiveness was measured one to two (1-2) hours after administration. Review of the clinical record revealed the facility admitted Resident #146 on 03/30/2021 with diagnoses that included Morbid (Severe) Obesity, Spinal Stenosis, and Chronic Pain Syndrome. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) and determined he/she was interviewable. Observation of Resident #146, on 05/03/2021 at 5:35 PM, revealed the resident seated in bed dressed and groomed. Interview, during the observation, revealed the resident requested a muscle relaxer the evening of 04/30/2021; however, Licensed Practical Nurse (LPN) #39 stated none was available. The resident stated later in the evening he/she asked LPN #32 for a muscle relaxer; the nurse told the resident he/she had to wait until 2:00 AM for a pain pill. The resident stated he/she explained to the nurse that he/she had already taken pain medication and needed a muscle relaxer for spasms/pain in his/her waist and legs. According to the resident, both nurses were rude, spoke to him/her like a child and caused him/her to cry. Resident #146 stated he/she dealt with the pain and cried himself/herself to sleep. Continued interview revealed Resident #146 reported the incident the next morning to the nurse who said she would report it. Review of the clinical record revealed a Physician's Order, dated 04/28/2021, for Cyclobenzaprine ten (10) milligrams (mg) tablet every six (6) hours as needed for muscle spasms; and an order, dated 03/30/2021, for Hydrocodone-Acetaminophen tablet 7.5-325 mg every six (6) hours as needed for pain. Review of the pharmacy Delivery Manifest, dated 04/27/2021 at 3:55 PM, revealed thirty (30) tablets of Cyclobenzaprine were delivered to the facility for Resident #146. Further review of the pharmacy Delivery Manifest, dated 05/01/2021 at 4:58 AM, revealed thirty (30) additional tablets of Cyclobenzaprine were delivered. Review of Resident #146's Medication Administration Record (MAR), dated April 2021, revealed the Cyclobenzaprine and Hydrocodone were not administered on 04/30/2021. Further review revealed the facility assessed the resident with a pain level of zero (0) out of ten (10) on the 3 PM-11 PM and 11 PM-7 AM shift; however, interview with the resident revealed he/she reported unrelieved pain to LPN #39 and LPN #32. Interview with Certified Nursing Assistant (CNA/Aide) #48, on 05/10/2021 at 10:01 AM, revealed Resident #146 usually got out of bed right before lunch, stayed up for two (2) or three (3) hours, then went back to bed because of back spasms. The Aide stated he noticed Resident #146 was still up in the wheelchair when he went on break around 8:00 PM. CNA #48 stated the resident had been up in the wheelchair for about twelve (12) hours. He stated the resident was crying and stated he/she needed a muscle relaxer for pain. The CNA stated he reported the resident's pain to LPN #39. Interview with LPN #39 was attempted on 05/27/2021; however, the staffing agency did not provide a contact number. Interview with LPN #32, on 05/27/2021 at 4:11 PM, revealed she administered the resident's muscle relaxer and pain medication in a timely manner; however, she did not document the administration on the MAR. The nurse stated she did not know why she did not document the medication administration. In addition, the LPN stated she was responsible for assessing the resident's pain level, documenting in the MAR, and following up every thirty (30) minutes to determine if the medication was effective. She stated she initially assessed Resident #146 with a pain level of zero (0) out of ten (10) because the resident was not hurting a lot. The LPN stated she reassessed the resident for effectiveness of the medication; however, she did not document the findings. The LPN stated she did not notify the physician about Resident #146's pain because she felt like it was not debilitating. LPN #32 stated she could not recall if the resident cried. Review of the 2nd floor Staffing Assignment Sheet, dated 05/01/2021, revealed LPN #39 was assigned to Resident #146 on 7:00 AM - 3:00 PM shift. Interview was attempted with LPN #39, on 05/27/2021 at 3:16 PM; however, the LPN did not return the call. Interview with the 2nd floor UM, on 05/28/2021 on 9:27 AM, revealed residents should be assessed every shift for pain and medicated accordingly. He stated the physician should be notified and alternative interventions for pain management should be used if medications were not effective. The UM stated interventions for pain management would include repositioning, backrub, or adjusting pain medications. He revealed pain assessment and medication administration should be documented in the MAR to ensure interventions were therapeutic and effective. Interview with the DON, 05/28/2021 at 3:22 PM, revealed she was not aware of issues with management or monitoring of residents' pain. The DON stated it was the nurse's responsibility to assess for pain, administer pain medications, and follow-up to determine the effectiveness of the pain treatment, including documentation of these steps. She stated the facility expected that residents would have an acceptable level of pain. Interview with the Administrator, on 05/28/2021 at 4:13 PM, revealed she was not aware of issues regarding residents and pain management. She stated she could not imagine being in pain and not having those issues addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy it was determined the facility failed to implement the care plan for one (1) of thirty-five (35) sampled residents. The care plan for Resident #97 revealed the resident was to be transferred with a maxi-lift and the assistance of two (2) persons. The findings included: Review of the facility policy, Baseline Care Plan Assessment/Comprehensive Care Plans, undated, revealed the facility Interdisciplinary team would discuss and develop quantifiable objectives along with appropriate interventions in an effort to achieve the highest level of functioning and the greatest degree of comfort/safety and overall well-being attainable for the resident. Observation of Resident #97, on 12/03/19 at 9:04 AM, revealed the resident lying in bed with the head of the bed up about ninety (90) degrees. The resident responded the surveyor. Further observation revealed the resident's right leg was flexed at the knee and the lower part of the leg was on a pillow, outwardly rotated. The resident stated he/she had broken her leg, but did not know how. When asked if he/she fell, the resident stated yeah. Observed right leg flexed at knee lying on a pillow, edema noted in foot, color pink. Review of the medical record revealed the facility admitted Resident #97 to the facility on [DATE] with diagnoses including Hemiplegia affecting Right Dominant Side, Aphasia following Cerebral Infarction, Vascular Dementia with Behavioral Disturbance and Right Distal Tibial and Fibular Fractures. Review of the Minimum Data Set (MDS), quarterly assessment, dated 07/11/19, revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) exam score of ninety-nine (99), which indicated the resident was not able to complete to the interview due to being seldom/never understood. The MDS also revealed the resident required extensive assistance of two (2) persons for the task of transfer. Review of the care plan for Resident #97, dated 04/06/18 revealed the resident had deficits in activities of daily living (ADL) tasks and required the use of a Maxi-lift for all transfers. Review of the nurse aide care plan, dated as of 12/03/19, revealed Resident #97 required a Maxi-lift for transfers. Review of the 5th floor certified nurse aide (CNA) guide, undated, revealed Resident #97 required a Maxi-lift with assist of two (2) persons. Review of Nursing Progress noted, dated 08/27/19 at 6:13 PM, authored by Licensed Practical Nurse (LPN) #6, revealed resident was guarding the right leg and was observed to have pain upon movement. The note also stated the right leg was swollen from midway the calf through the right foot. The note further stated the resident was unable to to verbalize what was causing the pain and swelling. The LPN also documented the physician was contacted and received an order for x-ray and venous Doppler study of the right leg. Review of the radiology interpretation of the right lower extremity x-ray, performed on 08/27/19, revealed nondisplaced fractures of the distal tibia and fibula. Review of the incident investigation involving Resident #97, initiated on 08/28/19, revealed a statement signed by a Certified Nurse Assistnat (CNA) #17, stating she provided Resident #97 with a shower on 08/27/19. Further review of the statement revealed she was providing the shower without assistance of other staff and used the standup lift and transferred the resident into the wheelchair from the shower chair by herself. The statement then reveaked the resident slid out of the wheelchair onto the floor. Interview with CNA #17 was attempted, on 12/06/19 at 10:50 AM. Interview with CNA #1, on 12/03/19 at 2:47 PM, revealed she assisted CNA #17 to transfer Resident #97 into the wheel chair, from the floor, in the shower room on 08/27/19. Interview with CNA's #12 and #13, on 12/06/19 at 9:06 AM and 9:11AM, revealed the level of assistance required by a resident is listed on the care plan provided to them at the beginning of the shift. Both CNA's referred to the care plans as the pocket sheets which detailed how a resident should be transferred, including any special equipment and how many persons are needed. Interview with Unit Manager #4, on 12/06/19 at 9:18 AM, revealed pocket sheets are given to all the staff at the start of the shift. She further stated if a staff member is not familiar with the residents she prefers to walk them around to the residents. She also stated CNA #17 admitted Resident #97 fell in the shower on 08/27/19 and that she was transferring the resident by herself when it occurred. She stated the aide was immediately removed from the floor upon discovering this information. Interview with the Director of Nursing, on 12/06/19 at 2:48 PM, revealed the careplan is on the nurse aide [NAME]. She further stated the pocket sheets are readily available and are a quick reference for the staff. She added every time there is a change the pocket sheets were updated. She stated CNA #17 was not following the care plan.

Based on observation, interview, record review and policy review it was determined the facility faciled to ensure resident's were afforded care and services for a safe environment for one (1) of thirty-five (35) sampled residents, Resident #97. Review of an investigation of an incident involving Resident #97, dated 08/28/19, revealed a written statement by CNA #17, that she transferred the resident using a Standup Lift without assistance. She also revealed she reported to the nurse the resident was throwing a fit, but did not report the resident suffered a fall. The findings include: Review of the facility policy, Accident/Incident Reporting Policy, undated, revealed any accident/incident will be reported immediately to the nurse or appropriate person designated to be in charge. Observation of Resident #97, on 12/04/19 at 10:06 AM, revealed the resident lying in bed with a pillow propped behind the back and the resident tilted to the right side. Further observation revealed half side rails were up bilaterally and the bed was in a low position. The resident wore a hospital gown and stated the right leg was not hurting at that time. Review of the medical record revealed the facility admitted Resident #97 on 08/18/15 with diagnoses including Hemiplegia affecting Right Dominant Side, Aphasia following Cerebral Infarction, Vascular Dementia with Behavioral Disturbance and Right Distal Tibial and Fibular Fractures. Review of the Minimum Data Set (MDS), quarterly assessment dated , 07/11/19, revealed the facility assessed the resident with a Brief Interview Mental Status (BIMS) score of ninety-nine (99), and determined the resident was not able to complete the interview, as the resident was seldom/never understood. The MDS also revealed the resident required extensive assistance of two (2) persons for the tasks of transfer. Review of the care plan for Resident #97, dated 04/06/18 revealed the resident had deficits in activities of daily living (ADL) tasks and required the use of a Maxi-lift for all transfers. Review of the nurse aide care plan, dated 12/03/19, revealed Resident #97 required a Maxi-lift for transfers. Review of the 5th floor certified nurse aide (CNA) guide, undated, revealed Resident #97 required a Maxi-lift with assist of two (2) persons. Review of Nursing Progress noted, dated 08/27/19 at 6:13 PM, authored by Licensed Practical Nurse (LPN) #6, revealed resident was guarding the right leg and was observed to have pain upon movement. The note also stated the right leg was swollen from midway the calf through the right foot. The note further stated the resident was unable to verbalize what was causing the pain and swelling. The LPN also documented the physician was contacted and received an order for x-ray and venous Doppler study of the right leg. Review of the radiology interpretation of the right lower extremity x-ray, performed on 08/27/19, revealed non-displaced fractures of the distal tibia and fibula. Review of the investigation of the incident involving Resident #97, dated 08/28/19, revealed a written statement by CNA #17, that stated she transferred the resident using a Standup Lift by herself. She stated she did this because the resident was trying to have bowel movement. She revealed the resident then slid out of the wheelchair. She also revealed she reported to the nurse the resident was throwing a fit, but did not report the resident suffered a fall. Interview with CNA #17 was attempted, on 12/06/19 at 10:50 AM. The CNA answered and stated she would the call to the surveyor back but never returned the call. Interview with Unit Manager #4, on 12/06/19 at 9:18 AM, revealed CNA #17 admitted Resident #97 had fallen in the shower on 08/27/19 and that she was transferring the resident by herself when it occurred. She stated the aide was immediately removed from the floor upon discovering this information. Interview with the Director of Nursing, on12/06/19 at 2:48 PM, revealed SRNA #17 was not following the care plan and should have reported the fall immediately.