Every finding on record at Ansley Cove Healthcare and Rehabilitation

Based on interview, and record review, the facility failed to refund any and all monies due to the resident's representative within 30 days of the resident's date of death /discharge from the facility for 1 of 3 residents reviewed for discharge, of a total sample of 3 residents, (#1).Findings:Resident #1 resided at the facility for approximately nine years and passed away on [DATE]. Review of the resident #1's Medicaid eligibility/benefit dated [DATE] indicated the resident's gross monthly income to be $1159.22. Per the benefit, the resident was entitled to keep $160.00 a month to meet her personal needs. Review of the billing reconciliation reflecting the account from [DATE] to [DATE], revealed the resident's husband paid the monthly patient responsibility of $314.92 from the couples joint checking account.Further review of resident #1's billing reconciliation noted the patient responsibility of $314.92 continued to be drawn from the joint checking account in [DATE], after the resident had died 13 days earlier. Review of emails from the Business Office Manager to the corporate office from [DATE], and [DATE] revealed the corporate office accounting was notified by the Business Office Manager of resident #1's death and asked to remove resident #1 from the Automated Clearing House (ACH) payment.Review of emails dated [DATE], [DATE], [DATE], [DATE], and [DATE] revealed the facility was aware the resident's husband was requesting the refund from her account. An email dated [DATE] detailed the corporate office communication to the Business Office Manager and the Administrator which reported, the family is due a much bigger refund than what was originally thought.On [DATE] at 12:50 PM, the Corporate Regional Director of Operations verified resident #1's husband was owed a refund and was not sure what caused the delay. It was acknowledged that at the time of the survey the facility owed the resident's husband a refund of $1,905.35, over four months after she had passed away.On [DATE] at 12:53 PM, the Administrator confirmed the resident's family still had not received the refund from the facility. He said the facility's Business Office Manager did not have the authority to cut refund checks and they had been waiting for the corporate office to process the refund.Review of the facility's policy entitled Refund Policy/Procedure, Subject: Death of a Resident in a Facility, revised on [DATE] indicated it was the policy of the facility to provide services related to the death of a resident in a facility in accordance with state and federal regulations. Procedure 1 indicated, the facility must, upon the death of a resident with a personal fund deposited with the facility or advanced payments, convey within 30 days of the resident's death, a final accounting of those funds to the individual or probate jurisdiction administering the resident's estate.

Based on interview and record review, the facility failed to provide care and services in accordance with the resident's care plan, the resident's choice and as per professional standards of practice for 1 of 6 residents reviewed for quality of care, out of a total sample of 15 residents, (#2). This failure contributed to the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for some time prior to discovery.On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardio-pulmonary resuscitation (CPR). The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. The facility's failure to provide care, timely assess and recognize a change in the resident's condition and failure to initiate life-saving interventions prior to the resident's death resulted in Immediate Jeopardy starting on [DATE]. Findings: Cross reference F600 and F610Review of resident #2's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses that included encephalopathy, type 2 diabetes, stroke, dysphagia (difficulty swallowing), heart failure, and dementia. Review of resident #2's Medicare 5-Day Minimum Data Set (MDS) assessment with Assessment Reference Date of [DATE] revealed a Brief Interview for Mental Status score of 3 out of 15, that indicated severe cognitive impairment. The MDS assessment noted resident #2 was totally dependent on staff for all Activities of Daily Living (ADLs), including mobility. Resident #2 was incontinent of bowel, had an indwelling urinary catheter and received all medications, nutrition and fluids via a gastrostomy tube (g-tube) due to dysphagia.Review of resident #2's physician orders revealed orders for continuous tube feeding dated [DATE], routine g-tube flushes for hydration dated [DATE], vital signs every shift dated [DATE], daily indwelling catheter care dated [DATE], anticoagulant monitoring every shift for sudden changes in condition dated [DATE], daily wound care dated [DATE], and nightly g-tube site care dated [DATE]. Review of resident #2's comprehensive care plan identified need for assistance with ADLs, initiated on [DATE]. Interventions directed staff to provide total care and reposition the resident at least every 2 hours. The care plan also reflected the resident's advanced directive status as full code, initiated on [DATE]. The goal noted to initiate CPR in the event of cardiac or respiratory arrest. Review of nursing documentation showed a progress note by Registered Nurse (RN) B dated [DATE] at 12:30 AM, which noted the resident was found unresponsive to sternal rub, CPR was initiated, 911 was called, and the resident was transferred to the hospital. Interviews and record review revealed staff failed to identify and respond to a resident #2's change in condition during the 3:00 PM to 11:00 PM shift on [DATE]. The assigned nurse reported administering medications via g-tube and observing the resident with eyes closed but she did not physically assess if the resident was responding or breathing. Staff acknowledged they observed the resident but did not physically assess her to ensure she was breathing. Documentation by the assigned Certified Nursing Assistant (CNA) noted the resident was not available for care during the entire 3 PM to 11 PM shift indicating resident #2 did not receive any ADL care during the shift.On [DATE] at 2:09 PM, Registered Nurse (RN) B stated she received report from the prior shift and no significant concerns about resident #2 were reported. She indicated Licensed Practical Nurse (LPN) E alerted her that resident #2 did not look good shortly after midnight. RN B stated she went to assess resident #2 and found her unresponsive to sternal rub with no palpable pulse and initiated code blue at approximately 12:25 AM, indicating CPR was not initiated timely. She explained staff assisted with positioning the resident and obtained the crash cart. RN B stated there was no one assigned to document the code in real time, and there were no CPR role assignments. On [DATE] at 3:05 PM, during a telephone interview, LPN E stated she entered resident #3's room around midnight while stocking supplies and checking tube feedings. LPN E indicated resident #2 appeared different from how she remembered her, with lips appearing ashen/dry. LPN E stated she immediately reported her concerns to RN B, the assigned nurse. LPN E noted she did not assess the resident but informed RN B. She recalled within 5-10 minutes RN B asked her to confirm code status, and she reported resident #2 was a full code. LPN E stated she did not participate in CPR.According to the EMS report dated [DATE], dispatch received a call from the facility at 12:33 AM and arrived on scene at 12:40 AM. Upon arrival, resident #2 was cold to the touch, pulseless, in asystole (absence of heart activity), and exhibited stiffness of the neck and face preventing intubation. Resident #2 did not respond to multiple rounds of CPR and did not regain consciousness. On [DATE] at 9:00 AM, EMS staff who responded to the facility on [DATE], said they believed resident #2 had been deceased for some time prior to initiation of CPR. Hospital records dated [DATE], revealed resident #2 arrived at the hospital at 1:14 AM via EMS with very rigid extremities, a core body temperature of 90.7 degrees Fahrenheit ( ), and recurrent rigor mortis. EMS and hospital records indicated the resident had been deceased for some time prior to being found.According to Medicine Net, after death the body will turn stiff over a few hours. In the stage of rigor mortis, the body begins to harden but is still movable from 0-8 hours and the muscles become fully stiff from 8-12 hours. The stiffness starts on the face/head, neck, chest, and continues down to abdomen and lower extremities. An article by Biology Insights notes that the body cools at an average rate of 1.5 to 2 degrees Fahrenheit per hour. (Retrieved [DATE]. https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, https://biologyinsights.com/how-long-does-a-dead-body-stay-warm-after-death/). Normal body temperature is between 97-99 degrees Fahrenheit (F). Taking the lowest body temperature of 97 degrees F, the estimated time resident #2 had been deceased was at least 3 hours minimum before she was found unresponsive. On [DATE] at 3:45 PM, LPN A said she was training with LPN E on [DATE] during the 11 PM to 7 AM shift. She confirmed resident #2's assigned Certified Nursing Assistant (CNA) C from 3-11 PM shift, was still in the facility at this time. She recalled LPN E did rounds on all residents that night including resident #2 and that at about 11:30 PM to 11:45 PM, she heard LPN E inform RN B that resident #2 was deceased . She recounted that LPN E questioned CNA C about when she last checked resident #2 and CNA C started yelling that she had not taken care of resident #2 because she thought the resident was in the hospital. She recalled LPN E said resident #2 was in rigor mortis when she was found her so it must have been a few hours since she passed. She said LPN E assisted RN B to call the Director of Nursing (DON), and placed the crash cart in resident #2's room prior to EMS arrival. LPN A revealed she observed RN B performing CPR on resident #2 even though she was already deceased .On [DATE] at 5:33 PM, during a telephone interview, CNA C stated she checked on resident #2 during the 3:00-11:00 PM shift on [DATE] and reported the resident was resting. She indicated resident #2 never talked to her and was sleeping the whole shift. CNA C said the care she provided was only emptied the catheter bag as resident #2 received tube feeding and did not have a bowel movement during her shift. CNA C stated she documented resident #2 as resident not available in error. During a follow up interview on [DATE] at 6:09 PM, CNA C stated she did not receive report from the 7:00 AM -3:00 PM shift CNA on [DATE]. She indicated she checked on resident #2 and although she was expected to reposition the resident throughout the shift, she was busy and did not do so. She said she mistakenly documented resident #2 was not available because she confused her with a resident who was hospitalized in the room next to resident #2. Review of the facility's Admissions and Discharges from [DATE] to [DATE], facility census, and medical record review revealed the resident CNA C said had been hospitalized was at the facility on [DATE] and there were no residents matching the last name provided by CNA C that were in the hospital. On [DATE] at 11:30 AM, during a telephone call CNA G said she was assigned to resident #2 on [DATE] during the overnight shift. She said she arrived to work late that night at 11:30 PM and went to do her rounds right away. CNA G recalled resident #2 was asleep and her urinary catheter bag was full. She said resident #2 was cold to touch when she lifted the bed cover to touch her legs but did not explain why she lifted the covers. She explained she covered resident #2 back up and walked out of the room without reporting her findings to the nurse. CNA G recalled CNA C reported not emptying resident #2's urinary catheter bag but there was no other communication. CNA G disconnected the telephone call abruptly after being asked if she participated in the code blue. CNA G telephoned back and disclosed resident #2 was already deceased when she arrived for her shift at 11:30 PM. She revealed that when she did rounds, she observed resident #2 appeared stiff and cold to the touch. She added that CNA C divulged during report that she had not provided any care to resident #2 during the 3 PM to 11 PM shift and did not provide a reason. CNA G verbalized that she felt pressured by the Nursing Home Administrator (NHA) and DON to give false witness statements, and she feared retaliation if she did not do so.Review of the Transfer Form dated [DATE] revealed the most recent documented vital signs for resident #2 included a blood pressure of 138/64 recorded on [DATE] at 12:06 AM and a pulse oximetry of 95% recorded on [DATE] at 7:04 PM. Additional vital signs including a pulse of 78, respirations of 20, and temperature of 98.0 were documented on [DATE] at 10:34 PM.On [DATE] at 4:34 PM, during a telephone interview, LPN F acknowledged she was the assigned nurse for resident #2 on the 3:00-11:00 PM shift on [DATE]. She stated she administered medications via g-tube and observed resident #2 with eyes closed. On [DATE] at 4:58 PM, LPN F verified the vital signs were not taken at 12:06 AM. She stated she took resident #2's vital signs early during the 3 PM to 11 PM shift at 4:45 PM but documented them later which resulted in documentation times not accurately reflecting when vital signs were taken. During a follow up interview on [DATE] at 3:57 PM, LPN F was presented with findings from the hospital and EMS reports. LPN F stated she observed resident #2 and noted the feeding pump running without alarms. LPN F indicated during medication administration via g-tube, she did not physically touch the resident and did not verify if the resident was breathing. She said she believed the resident's eyes were closed and did not check for any change in condition. LPN F verified she did not check if the resident received any care during her shift, she primarily ensured the head of the bed was elevated for the tube feeding. Review of the resident #2's medical record revealed LPN F documented a skilled evaluation on [DATE] at 10:35 PM, noting the resident was oriented times three (to person, time, and place), communicated verbally, had clear speech, a flat abdomen with bowel sounds present, and was taking nutrition and medications orally. The documentation also indicated skin issues had not been evaluated. This was in contradiction to the MDS assessments that noted the resident was dependent, with severe cognitive impairment and received all nutrition and hydration via gastric tube and not orally. This was also in contradiction to the family stating the resident was mostly non verbal. Review of resident #2's medical record revealed a Nurse Practitioner note dated [DATE]. The physical examination documented the resident did not open her eyes but was able to respond and verbalize her name.On [DATE] at 11:03 PM, during a telephone interview, the Medical Director stated dependent residents were to be checked every two hours. He said he expected nurses to initiate CPR for full code residents when indicated. The medical director stated he was informed of the incident the following day and shared findings from his review of the hospital records with facility leadership. On [DATE] at 2:40 PM, an interview was conducted with the Administrator (NHA) and the DON. The DON stated she received a call from RN B after resident #2 was transferred to the hospital. She indicated she instructed the nurse to collect witness statements from staff working that night. Review of the witness statements revealed statements were not collected from the CNAs working the 11:00 PM -7:00 AM shift or from LPN A. The DON did not explain why follow up did not occur to obtain the missing statements from all staff working. The DON acknowledged inconsistencies documented in resident #2's medical record. Contrary to the medical director's statement that he had shared the hospital records findings, the DON stated the medical director had not provided details from his review of hospital records. The DON mentioned the facility did not have access to the hospital records and was unaware of the physical findings documented by EMS or the hospital noting the resident had been deceased for some time. The DON presented documentation of drills conducted after the event; however, there was no documentation of the dates, response times, staff participants, or debriefing following the drills. The DON stated the facility did not have a loudspeaker system and staff would yell during emergencies but could not confirm whether this could be heard inside resident's rooms. The DON mentioned there was no debrief with staff following the event. She stated she asked LPN E why she did not further assess the resident after noticing something different, and LPN E responded the resident did not look well and she notified RN B. The DON confirmed the documentation did not include details of CPR performed or whether vital signs were attempted and stated all staff should have responded to the emergency. Review of the facility's policy and procedure titled Activities of Daily Living (ADLs) revised on [DATE] revealed an intent to based it on the resident's comprehensive assessment and consistent with the resident's needs and choices.Review of the facility's policy and procedure titled Documentation in Medical Record revised on [DATE] read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on interview, and record review, the facility failed to protect the resident's right to be free from neglect by not providing necessary care and services for a totally dependent resident and failed to assess, recognize and intervene for changes in condition for 1 of 3 residents reviewed for neglect, out of a total sample of 15 residents, (#2). This failure contributed to the resident being found unresponsive and exhibiting physical signs consistent with having been deceased for some time prior to discovery. On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardio-pulmonary resuscitation (CPR). The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. The facility's failure to provide care, timely assess and recognize a change in the resident's condition and failure to initiate life-saving interventions prior to the resident's death resulted in Immediate Jeopardy starting on [DATE].Findings:Cross reference F684 and F610Resident #2, an [AGE] year-old female, was initially admitted to the facility [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses that included encephalopathy, acute kidney failure, stroke, dysphagia (difficulty swallowing), dementia, and heart failure. The Medicare- 5 Day Minimum Data Set (MDS) assessment dated [DATE], showed resident #2 had a Brief Interview for Mental Status score of 3 out of 15, indicating severe cognitive impairment. The MDS assessment indicated resident #2 was totally dependent on staff for Activities of Daily Living (ADLs), including mobility. She was incontinent of bowel, had an indwelling urinary catheter and received all medications and nutrition by gastrostomy (g-tube) due to dysphagia. Review of resident #2's physician orders revealed orders for continuous tube feeding dated [DATE] routine g-tube flushes for hydration dated [DATE], vital signs every shift dated [DATE], daily indwelling catheter care dated [DATE], anticoagulant monitoring every shift for sudden changes in condition dated [DATE], daily wound care dated [DATE], and nightly g-tube site care dated [DATE]. Resident #2's comprehensive care plan revealed and identified need for assistance with ADLs, initiated on [DATE]. Interventions directed staff to provide total care and reposition the resident at least every 2 hours. The care plan also reflected the residents' advanced directive status as full code, initiated on [DATE]. The goal noted to initiate CPR in the event of cardiac or respiratory arrest.Review of resident #2's medical record, revealed a progress note by Registered Nurse, (RN) B dated [DATE] at 12:30 AM, which read, was notified by the nurse to look at resident as she did rounds to look at enteral feed, patient unresponsive to sternal rub. Code blue initiated and 911 called, CPR performed until police and EMS arrived. EMS arrived and transferred patient to (name of) Hospital. DON (Director of Nursing), on-call provider, and emergency contact were notified.According to the EMS report dated [DATE], dispatch received the call from the facility at 12:33 AM and arrived on scene at 12:40 AM. Upon arrival resident #2 was cold to the touch, pulseless, in asystole (absence of heart activity), and exhibited stiffness of the neck and face preventing intubation. Resident #2 did not respond to multiple rounds of CPR and did not regain consciousness. On [DATE] at 9:00 AM, interview with EMS staff who responded to the facility on [DATE], said they believed resident #2 had been deceased for some time prior to initiation of CPR.Hospital records dated [DATE], revealed resident #2 arrived at the hospital at 1:14 AM via EMS with very rigid extremities, a core body temperature of 90.7 degrees Fahrenheit ( ), and recurrent rigor mortis. According to Medicine Net, after death the body will turn stiff over a few hours. In the stage of rigor mortis, the body begins to harden but is still movable from 0-8 hours and the muscles become fully stiff from 8-12 hours. The stiffness starts on the face/head, neck, chest, and continues down to abdomen and lower extremities. An article by Biology Insights notes that the body cools at an average rate of 1.5 to 2 degrees per hour. (Retrieved [DATE]. https://www.medicinenet.com/what_are_the_stages_of_rigor_mortis/article.htm, https://biologyinsights.com/how-long-does-a-dead-body-stay-warm-after-death/). Normal body temperature is between 97-99 degrees Fahrenheit. Taking the lowest body temperature of 97 degrees F, the estimated time resident #2 had been deceased was at least 3 hours minimum before she was found unresponsive. On [DATE] at 4:34 PM, Licensed Practical Nurse (LPN) F confirmed she was the assigned nurse for resident #2 on [DATE] during the 3-11 PM shift. She said during her initial rounds, resident #2 was peacefully asleep and her vital signs were within normal limits when taken at 4:45 PM. LPN F said she administered medications to resident #2 at around 7:45-8:00 PM via g-tube and she was still sleeping. She said she saw resident #2 again at around 10:15-10:30 PM and she was still sleeping. LPN F did not assess resident #2 for responsiveness or checked if she was breathing because she said it was normal for her to sleep all day due to the medications she was taking. LPN F said she left the facility at 11:30 PM and learned resident #2 had passed when she returned for her shift the next day. A skilled nursing note in resident #2's medical record by LPN F on [DATE] at 10:35 PM, documented resident #2 was alert and oriented x 3 (person, place, time), communicated verbally with clear speech, had warm skin, and took nutrition/hydration orally. This was in contradiction to the MDS assessments and interviews that noted the resident was dependent, non-verbal with severe cognitive impairment and received all nutrition and hydration via gastric tube and not orally. Review of the Medication Administration Report from [DATE]-[DATE] for resident #2, revealed there were no medications ordered or given that would cause excessive sedation or sleepiness. Review of resident #2's Documentation Survey Report for [DATE], revealed that on [DATE] Certified Nursing Assistant (CNA) C documented at 10:59 PM that resident #2 was not available for any of ADL tasks, like bladder/bowel elimination, transfers in/out of bed, personal hygiene, or repositioning in bed. The record noted resident #2 was to be monitored for safety every hour but CNA C documented resident was not available for the entire 3-11 PM shift. The last safety check on that day was documented at 1:50 PM by the 7 AM- 3 PM CNA. On [DATE] at 5:33 PM, CNA C confirmed she was the assigned CNA for resident #2 on [DATE] during the 3-11 PM shift. She recalled she was very busy that evening because she had 12 residents assigned to her. She said resident #2 slept the whole shift except for one time when she opened her eyes slightly and smiled at her. CNA C said resident #2 did not have a bowel movement so there was no need to change her brief, but she emptied her urinary catheter bag once during the shift. She said resident #2 required repositioning every few hours but she did not do it because she was busy. CNA C verified she was at the facility past 12:00 AM completing documentation but didn't learn of resident #2's death until she returned for her shift on [DATE]. In a follow up interview with CNA C on [DATE] at 6:09 PM, she said she mistakenly documented resident #2 was not available because she confused her with a resident who was hospitalized in the room next to resident #2.Review of the facility's Admissions and Discharges from [DATE] to [DATE], review of facility census, and medical record revealed resident in the next room was not in the hospital on [DATE] or in the month of November.On [DATE] at 11:30 AM, during a telephone call CNA G said she was assigned to resident #2 on [DATE] during the overnight shift. She said she arrived to work late that night at 11:30 PM and went to do her rounds right away. CNA G recalled resident #2 was asleep and her urinary catheter bag was full. She was unable to explain why she lifted resident #2's covers to touch her legs, but she said resident #2 was cold to the touch. She covered resident #2 back up and walked out of the room without reporting her findings to the nurse. Contrary to CNA C's statement that she emptied the urinary bag, CNA G recalled CNA C reported not emptying resident #2's urinary catheter bag but there was no other communication. CNA G disconnected the telephone call abruptly after being asked if she participated in the code blue. In a later returned phone call, CNA G divulged resident #2 had already been deceased when she arrived for her shift at 11:30 PM. She revealed that when she did rounds, she observed resident #2 appeared stiff and cold to the touch. She added that CNA C disclosed during report that she had not provided any care to resident #2 during the whole shift but did not provide a reason. CNA G verbalized that she felt pressured by the Nursing Home Administrator (NHA) and Director of Nursing (DON) to give false witness statement, and she feared retaliation if she did not do so.On [DATE] at 2:09 PM, Registered Nurse (RN) B confirmed she was the assigned nurse on the 11 PM to 7 AM shift for resident #2 on [DATE]. She received report from LPN F and recalled there was nothing significant reported about resident #2. She said that just after midnight, on [DATE], she was standing at her medication cart with LPN D when LPN E came to tell her she needed to check on resident #2 because she did not look okay, her mouth was open, lips were dry, and she was unresponsive. RN B said LPN E had attempted to do a sternal rub and reposition the resident but she did not respond. RN B recalled going to see resident #2 a little after midnight and she was resting with her mouth open but there was nothing different about her. She said resident #2 was pulseless but her skin temperature was normal. At around 12:25 AM she called a code blue, placed the resident on a back board with assistance from CNA G and LPN D, initiated CPR, and had LPN D bring the crash cart to the room. She recalled police arrived first at about 12:30 AM and took over CPR followed by EMS at 12:35 AM. RN B said resident #2 remained unresponsive and was transferred to the hospital at approximately 12:45 AM. On [DATE] at 3:05 PM, LPN E confirmed she worked 11 PM-7 AM on [DATE]. She said she arrived at the facility on time and had been assigned to train LPN A. While LPN A was at the medication cart, she went to do rounds on her assigned residents and to stock the tube feeds. She recalled entering resident #2's room some time before midnight to stock tube feed supplies and noticed the resident didn't look as good as the last time she saw her. She said resident #2's eyes were closed, she was lying on her left side covered with a blanket, her lips looked ashy and dry, but she looked comfortable. LPN E reported her observations to RN B but she did not perform an assessment on the resident prior to exiting the room. LPN E went about her duties and said RN B approached her just after midnight asking about resident #2's code status because she was unresponsive. RN B called a code, but LPN E said she was not part of it because resident #2 was not her resident. She recalled CNA C was still there charting, so she asked her when she last saw resident #2 and CNA C responded it had been a few hours. On [DATE] at 3:45 PM, LPN A said she was training with LPN E on [DATE] during the 11 PM to 7 AM shift and arrived a few minutes before the start of her shift. She confirmed CNA C was still there charting and LPN F was providing report to RN B. She recalled LPN E did rounds on all residents that night including resident #2 and that at about 11:30 PM to 11:45 PM, she was at the medication cart when she heard LPN E inform RN B that resident #2 was deceased . She recounted that LPN E questioned CNA C about when she had last seen resident #2 and CNA C started yelling that she had not taken care of resident #2 because she thought the resident was in the hospital. She said LPN E stated resident #2 was in rigor mortis when she was found so it must have been a few hours since she passed. She said LPN E assisted RN B with running the code, calling the DON, and placing the crash cart in resident #2's room prior to EMS arrival. LPN A revealed she observed RN B performing CPR on resident #2 even though she was already deceased . She learned resident #2's core body temperature was 90.7 F from EMS, when they returned to pick up equipment they left behind which confirmed she had been deceased for a long time. LPN A said she was not asked to write a witness statement by the DON or NHA. On [DATE] at 11:09 AM, resident #2's granddaughter/Power of Attorney (POA) said she learned of her grandmother's passing from the hospital on [DATE] some time after 1:00 AM. The emergency room physician informed her resident #2 had no pulse on the way to the hospital, that her body was cold, and that she had most likely been deceased for some time. The granddaughter stated a family member visited with resident #2 on [DATE] and she appeared anxious, and confused. She said her grandmother was mostly non-verbal and required a lot of care because she was unable to move on her own. She believed the facility neglected to provide the care her grandmother needed and were not forthcoming about her death. On [DATE] at 2:40 PM, the NHA and DON who was also the Abuse Coordinator were interviewed. The DON recalled receiving a call from RN B at approximately 12:30 AM on [DATE] to inform her resident #2 was found unresponsive and CPR was initiated. She said she instructed RN B to collect witness statements from staff involved. The DON denied knowing resident #2 had passed when she was called and maintained she did not instruct staff to perform CPR on an already deceased resident. She said the medical director informed her and the NHA that resident #2 had passed away at the hospital because he had reviewed the hospital record. The DON and NHA denied knowing resident #2 had already passed prior to being found by staff and that she arrived at the hospital in rigor mortis with a body temperature of 90.7 F. On [DATE] at 11:03 PM, the medical director stated nurses were expected to initiate CPR for full code residents when indicated. He mentioned dependent residents were expected to be checked approximately every two hours. The medical director stated he was informed of the incident the following day and that the facility was conducting an internal investigation. He indicated he shared findings from his review of the hospital records with facility leadership. Review of the facility's policy and procedure on CPR revised [DATE] revealed staff should not perform CPR if the resident showed obvious signs of clinical death including rigor mortis. The facility's policy and procedure on Abuse, Neglect, and Exploitation revised [DATE] defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of neglect include failure to provide care needs such as comfort, safety, feeding, bathing, dressing, and turning/repositioning.

Based on record review, and interview, the facility failed to investigate allegation of neglect to ensure staff recognized change in resident condition and provided timely interventions for 1 out of 15 residents reviewed for advanced directives, (#2). On [DATE] after midnight, resident #2 was found unresponsive and staff initiated CPR. The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. The facility Administration's failure to consider the hospital report findings indicating the resident had been deceased for some time and failure to conduct a complete and accurate investigation resulted in Immediate Jeopardy starting on [DATE].Findings: Resident #2 was originally admitted to the facility on [DATE]. The resident was hospitalized and readmitted to the facility on [DATE] and her diagnosis included encephalopathy, type 2 diabetes, stroke, heart failure and dementia. Medical record review revealed a Minimum Data Set assessment dated [DATE] in which resident #2 scored 3 out of 15 on the Brief Interview for Mental Status that indicated severe cognitive impairment. The MDS assessment also noted, resident #2 was dependent on staff for all Activates of Daily Living care to include mobility and incontinence care. Due to swallowing difficulties, the resident received all medications and nutrition through gastric tube. The resident had a stage 4 pressure wound to the coccyx. The resident's care plan indicated that staff needed to reposition the resident, every 2 hours at a minimum, to off load the pressure to promote wound healing. Review of staff schedules revealed Certified Nursing Assistant, (CNA) C, was assigned to resident #2 on [DATE], on the 3 PM to 11 PM shift. During an interview on [DATE] at 5:33 PM, CNA C verified she was resident #2's direct caregiver on [DATE], on the 3 PM to 11 PM shift. She said she was overwhelmed because there were only 3 aides, herself included, during the shift and she had 12 residents assigned to her. CNA C said she did not see the off going CNA from the 7AM to 3 PM shift and therefore did not receive a report status on the resident #2's condition on her assignment. She indicated during her initial resident round, resident #2 was sleeping. She added she checked on resident #2, three times during the evening of [DATE]. Contrary to CNA C's statement, review of the medical record revealed CNA C documented resident #2 was not available for any care during the 3 PM to 11 PM shift on [DATE]. CNA C added, she found out resident #2 died, when she came to work the next day. On [DATE] at 2:09 PM, Registered Nurse, (RN) B said her assignment included resident #2, on the 11 PM to 7 AM shift. RN B received an unremarkable report from the off-going nurse from the 3 PM-11 PM shift, Licensed Practical Nurse (LPN) F. RN B explained there were 4 nurses on the 11 PM-7 AM shift, that included herself, LPN E and 2 newly hired nurses, that were in training, LPN A and LPN D. She said just after midnight, LPN E told her to check on resident #2 because resident #2 did not look okay. She said LPN E had attempted a sternal rub but the resident did not respond. RN B was not able to recall the exact time but explained sometime shortly after midnight she went to see resident #2 and the resident did not have a pulse. She recalled around 12:35 AM she called a code blue and placed the resident on a back board with the assistance of a CNA, name not recalled and training nurse, LPN D. She said she conducted the code blue without any assistance from the nurses. She indicated she called EMS and the Director of Nursing, (DON), while doing chest compressions on resident #2 but she did not do any rescue breaths. On [DATE] at 3:49 PM, 4 days later, RN B made changes to her first interview and said, LPN E did not perform a sternal rub on resident #2 and that she did rescue breaths with an Ambu bag during the code blue. On [DATE] at 3:45 PM, LPN A indicated she was a newly hired nurse and was being trained by LPN E on [DATE], on the 11 PM-7 AM shift. LPN A stated CNA C, the 3 PM to 11 PM, aide that was assigned to resident #2 was still at the facility when she arrived. She said she was on the medication cart and LPN E rounded on all the residents including resident #2, who was not on their assignment. Shortly thereafter, between 11:30 PM and 11:45 PM, LPN A said she overheard LPN E speaking to RN B and the other nurse that was training, LPN D. LPN E asked them if they had checked resident #2 because she was already deceased when she conducted her initial rounds. CNA C, who was still at the facility, was asked when she last checked on the resident during the 3 PM to 11 PM shift. She recalled CNA C screamed and yelled that she had not taken care of resident #2 because she thought resident #2 was in the hospital. LPN A recalled LPN E saying resident #2 was already in rigor mortis. LPN A said RN B and LPN E were on the phone with the Director of Nursing (DON), but she was not able to hear what the DON instructed them to do. LPN A explained based on the two nurses' actions, she assumed the DON instructed them to call EMS and place the crash cart in the resident's room so it would seem CPR was in progress. She stated a police officer arrived before EMS and LPN A escorted him to resident #2's room. LPN A saw RN B performing CPR on resident #2 while LPN E removed the tube feeding. LPN A said she was not asked to provide a witness statement that night. On [DATE] at 11:03 PM, the Medical Director said the expectation was that residents be checked every 2 hours and CPR initiated when indicated. He recalled he was informed of the incident involving resident #2 and code blue, the next day. He indicated he reviewed the hospital record and shared his findings with the Administrator and DON. On [DATE] at 2:40 PM, and [DATE] at 1:43 PM, meetings were held with the Administrator and DON to clarify the inconsistent and varied verbal accounts of events during resident #2's code blue and the findings of the facility's investigation. The DON said she was aware CNA C had documented, resident #2 was not available on the 3 PM to 11 PM shift on the evening of [DATE]. She indicated CNA C's witness statement demonstrated the CNA had provided care to resident #2 but did not explain why CNA C documented the resident was not in the facility. Contrary to the Medical Director's statement, the Administrator and DON said the Medical Director reviewed resident 2's hospital record but had not shared his findings with them. It was pointed out that the hospital record noted resident had signs of rigor mortis when EMS transferred her to the hospital. The Administrator and DON could not provide an explanation for how the facility's investigation demonstrated resident #2 received quality care and timely CPR when the hospital's findings noted the resident had been deceased for some time and was in rigor mortis. The DON indicated there were many conditions/diagnoses that would rapidly increase the onset of rigor mortis but could not name a condition or diagnoses resident #2 had that would cause rapid rigor mortis. There was no evidence to support the facility was concerned with any potential neglectful actions prior to or during the code blue. The facility did not submit an Immediate or Five Day report to the State Agency until approximately 27 days later. The Administrator confirmed he sent an email to the State Agency's local field office and the email read, .to give you a heads up we had a very disgruntled employee.Employee indicated that they would be contacting AHCA (Agency for Health Care Administration)/Department of Labor on the facility.they would get the facility Shut Down. The email indicated that it was LPN A that was considered as the disgruntled employee. When pointed out the email did not indicate any allegations of neglect, the Administrator said the facility received a text, from LPN A, alleging CNA C, the 3 PM to 11 PM aide, had neglected resident #2, prior to the code blue. The Administrator indicated he was aware of this text and it's content on [DATE], that is why he sent the email to the AHCA local Field Office. The Administrator could not reasonably explain why he waited until [DATE] to submit the Immediate report when he was aware of an allegation of neglect on [DATE]. The Administrator and DON said they did not include any witness statement or interview from the EMS responders for the facility's investigation. The DON said since the code blue she had reinterviewed the staff who had given statements. However, neither the Administrator nor DON could explain why they did not seek out a statement from LPN A, the staff person who alleged neglect. On [DATE] at 12:22 PM, CNA G indicated she was assigned to resident #2 on [DATE] during the 11 PM to 7 AM shift. She said she was unable to talk and ended the call. During a retuned call, CNA G stated resident #2 was already deceased when she arrived to work at 11:30 PM on [DATE]. She said the resident was stiff and cold to the touch. She explained CNA C, who worked from 3 PM to 11 PM, told her she did not provide care for resident #2 during the entire shift, but did not provide a reason. She reported the Administrator and DON pressured her to give false witness statements, which she did because she feared retaliation if she did not do so.

Based on interview and record review, the facility failed to conduct a Quality Assurance and Performance Improvement (QAPI) meeting when allegations of neglect and concerns were identified related to the death of resident #2.Findings:Cross Reference F600, F684, F610, and F895On [DATE] just after midnight, resident #2 was found unresponsive and staff initiated cardiopulmonary resuscitation (CPR). The resident was transferred to the hospital by Emergency Medical Services (EMS). The EMS and hospital records noted resident #2 was very rigid with stiff extremities and core body temperature of 90.7 degrees Fahrenheit. The records indicated the resident displayed signs and symptoms of rigor mortis indicating the resident had been deceased for some time, before staff had identified the resident to be unresponsive and initiated CPR. On [DATE] at 2:41 PM, the Nursing Home Administrator (NHA) stated he was responsible for the monthly QAPI meetings with the Director of Nursing and the Medical Director. He said that all incidents such as neglect, falls and abuse were brought forth to the meetings. He noted the QAPI program was intended to look at any systemic breakdowns and trends.The NHA spoke about the incident when resident #2 was found unresponsive on [DATE]. He stated that witness statements were collected related to the CPR event and they were used to conduct an internal investigation. He explained the investigation was intended to ensure staff provided timely and effective CPR. The Administrator did not address any timelines of the event or conclusive times the resident was last cared for. He explained the investigation was not brought to QAPI because there were no concerns with staff performance during the code blue event where CPR was performed.Review of witness statements, hospital records, and staff interviews related to resident #2 being found deceased revealed inconsistencies with timelines, CPR recordings, documentation and false witness statements On [DATE] at 11:05 AM, the Medical Director confirmed he attended monthly QAPI meetings. He stated he reviewed resident #2's hospital record, which noted resident #2 had arrived at the hospital with stiff extremities, hyperthermia, and exhibited signs of rigor mortis. The Medical Director said he provided this information to the NHA and DON but did not participate in any QAPI meetings related to the incident nor inquired why the incident was not brought to QAPI.On [DATE] at 1:43 PM, the DON said she was aware resident #2's assigned Certified Nursing Assistant (CNA) had documented, resident #2 was not in the facility during the 3 PM to 11 PM shift on the evening of [DATE]. She did not explain why the CNA documented the resident was not in the facility. Interviews with other staff disclosed the CNA told them she did not provide care to resident #2 as she thought the resident was in the hospital. The Administrator and DON could not provide an explanation for how the facility's investigation demonstrated resident #2 received quality care and timely CPR when the hospital's findings noted the resident had been deceased for some time and was in rigor mortis. The Administrator did not explain how resident #2 was left unattended, died and was in rigor mortis without staff noticing. The Administrator said the facility received a text, alleging the 3 PM to 11 PM CNA had neglected resident #2 by not providing any care to her during the entire shift. The Administrator indicated he was aware of this text and the allegation of neglect on [DATE]. Although the NHA was aware of the neglect allegation, there was no QAPI meeting held to ensure identified concerns were addressed.

Based on interview and record review, the facility failed to ensure all staff adhered to ethical practices and professional standards by providing inconsistent and misleading statements related to a resident's death in the facility, failed to provide high-level personnel oversight to ensure adherence to ethical standards, and failed to develop effective lines of communication to encourage immediate reporting of violations without fear of retaliation. These failures contributed to the inadequate investigation of resident #2's death. Findings:Cross Reference F600, F684, F610According to the facility's Compliance and Ethics Program policy revised [DATE], the facility is committed to compliance and has designated, implemented, and enforced a compliance and ethics program for promoting quality of care and preventing and detecting criminal, civil and administrative violations. The program's compliance guidelines included compliance activities such as monitoring, auditing, reporting systems, and data integrity. The facility would review the program annually with staff to improve performance in deterring, reducing and detecting violations and promote quality of care.Review of resident #2's medical record, revealed a progress note by Registered Nurse (RN) B dated [DATE] at 12:30 AM which read, was notified by the nurse to look at resident as she was unresponsive to sternal rub. Code blue initiated and 911 called, cardiopulmonary (CPR) performed until police and Emergency Medical Services (EMS) arrived. EMS arrived and transferred resident to (name of hospital). DON (Director of Nursing), on-call provider, and emergency contact were notified.According to the EMS report and hospital records dated [DATE], resident #2 had rigid extremities and hyperthermia consistent with prolonged time of death which indicated she had been deceased for some time prior to staff initiating CPR. The record indicated that facility staff told EMS resident #2 was last observed well by staff at 11:00 PM on [DATE].A discrepancy existed between the time staff reported to EMS resident #2 was last observed well and the time staff provided their witness statements and interviews. The 3-11 PM nurse reported she last saw resident #2 between 10:15 PM and 10:30 PM, however she did not assess resident #2 and the last set of vital signs were taken at 4:45 PM according to Licensed Practical Nurse (LPN) F's witness statement. Based on these findings it was unknown whether resident #2 was well or even observed at 11:00 PM.On [DATE] at 4:34 PM, LPN F, the 3 PM to 11 PM nurse, reported when she arrived for her shift, she did rounds and noted resident #2 was asleep. She obtained vital signs, which she stated were within normal limits, but documented them at 10:35 PM. LPN F confirmed she last saw resident #2 between 10:15 PM and 10:30 PM asleep and in no distress, however LPN F did not assess her to determine if she was even breathing. LPN F documented in the resident's chart at 10:35 PM that resident was alert and oriented X3, communicated verbally, and had warm skin. This documentation was inconsistent with LPN F's statement that she did not do an assessment on resident #2.On [DATE] at 5:33 PM, Certified Nursing Assistant (CNA) C was assigned to resident #2 from 3-11 PM. She said she checked on resident #2 three times during her shift, and she was asleep except when she emptied her urinary catheter bag and the resident opened her eyes slightly and smiled. CNA C's statement contradicted what she documented at 10:59 PM on [DATE] which noted the resident was unavailable for all care tasks throughout the shift including incontinence care. CNA C alleged she confused resident #2 with a resident next door who had been hospitalized for a few days, however the facility's Admissions and Discharges from [DATE] to [DATE], revealed the resident in the next room was at the facility and not in the hospital on [DATE].On [DATE] at 11:30 AM, and during a follow up interview, CNA G stated she arrived for her shift late at 11:30 PM on [DATE] and learned resident #2 was deceased . She said the resident was cold to the touch and her urinary catheter bag was full. CNA G said that during report CNA C revealed she had not provided care for resident #2 the whole shift as she thought the resident was in the hospital. She explained the Administrator and the DON told her to provide false witness statements or she would lose her job. On [DATE] at 2:09 PM, RN B was the assigned nurse for resident #2 from 11 PM to 7 AM on [DATE]. She stated LPN E assisted with rounds that night and stocked the tube feed supplies for resident #2. RN B said LPN E found resident unresponsive at around 12:00 AM. RN B said LPN E attempted a sternal rub on resident #2 to arouse her, however in a follow up interview she retracted her statement alleging LPN E never touched the resident. She maintained that other staff members did not assist with CPR but was unable to explain how she was able to dial 911 and call the DON while performing chest compressions. RN B noted CPR started at 12:25 AM, EMS report showed the call came in at 12:33 AM, the DON reported she received a call from RN B at 12:30 AM, and RN B documented in the resident's chart at 12:30 AM. Based on the timeline of events, it would have been implausible for RN B to complete these tasks on her own while attempting CPR.On [DATE] at 3:05 PM, LPN E confirmed she assisted RN B with rounds and stocking tube feed supplies during the 11 PM- 7 AM shift. She denied any involvement during the code blue on resident #2. She explained she stocked tube feeds for resident #2 at around midnight and noticed the resident had ashy lips and dry mouth, which could have indicated a lack of oxygen, but she did not intervene. LPN E said she reported her findings to RN B and continued with her other duties. Review of LPN E's witness statement dated [DATE] revealed she entered resident #2's room at approximately 12:20 AM.On [DATE] at 3:45 PM, LPN A verified she worked the 11 PM to 7 AM shift on [DATE]. She stated some time between 11:30 PM and 11:45 PM, she heard LPN E tell RN B resident #2 was deceased . LPN A mentioned LPN E stated the resident was in rigor mortis when she found her and she added that LPN E assisted with the code blue by calling the DON, and placing the crash cart in resident #2's room prior to EMS arrival. This contradicted LPN E's statement that she did not assist with CPR. LPN A said the DON was contacted by LPN E and RN B prior to CPR initiation. She was unable to hear the conversation but based on LPN E and RN B's actions she believed the DON instructed them to place the crash cart in resident #2's room prior to EMS arrival to give the impression CPR was in progress. LPN A stated she was not asked to provide a witness statement.Review of LPN E's witness statement dated [DATE], revealed she rounded on resident #2 at approximately 12:20 AM and the resident did not look well. She then reported her findings to the assigned nurse, RN B and went to the nurses' station. RN B returned to the nurses' station to ask LPN E the code status for resident #2 prior to starting CPR. LPN E added that RN B immediately called a code blue after learning the resident was a full code. LPN E's witness statement conflicted with RN B's statement, which stated that after she determined resident #2 had no pulse, she immediately started CPR. LPN E's statement suggested CPR was delayed since RN B left the resident's room to verify the code status.On [DATE] at 2:40 PM, the DON denied the allegation that she instructed staff to give impression of doing CPR when EMS arrived. She confirmed she received a call from RN B to inform her resident #2 had been found unresponsive and CPR was initiated. The DON said she instructed staff to collect witness statements from the staff involved. She explained the witness statements were used to ensure staff had followed appropriate procedure during the code. She confirmed that witness statements were not part of their CPR process in the past. She maintained that staff provided timely and appropriate CPR to resident #2 and that she was not aware the resident had been deceased when staff found her.On [DATE] at 2:40 PM, the Administrator said LPN A refused to write a statement because she was upset about not getting paid but there was no documentation to show her refusal. He stated he was not aware resident #2 had been deceased prior to CPR because the medical director had not shared that information after review of resident #2's hospital record.On [DATE] at 11:03 AM, the medical director explained the nurse practitioner saw resident #2 on [DATE] and hospice was discussed. The medical director stated he was informed of the incident the following day and the facility was conducting an internal investigation. Contrary to the Administrator's statement the medical director stated he shared findings from his review of the hospital records with facility leadership. Review of resident #2's medical record revealed she was seen by the nurse practitioner on [DATE] but there were no recommendations made related to hospice care.On [DATE] at 1:20 PM, the staffing coordinator confirmed LPN A had texted her on [DATE] related to not receiving her paycheck. She said LPN A made allegations of neglect for resident #2 related to CPR event. The Staffing Coordinator stated she forwarded the message to the Administrator and Human Resources (HR) manager.On [DATE] at 1:55 PM, the HR manager confirmed she received the text message from staffing coordinator but did not report the allegations of neglect because she was not clinical.On [DATE] at 3:08 PM, the Administrator confirmed he received the text message with LPN A's allegations of neglect and acknowledged he did not report the allegations.On [DATE] an email was sent to the State Agency (SA) field office from the Administrator that noted, just wanted to give a heads up we had a very disgruntled employee that the facility terminated today. The employee indicated that they would be contacting the SA to get the facility shut down. The employee in question was listed as LPN A.On [DATE] at 1:52 PM, the compliance officer who handled the hotline when employees called with concerns stated it was the expectation that all staff conducted themselves in an ethical manner and avoided falsifying documentation or providing false information related to residents. She defined ethical behavior as having good moral character.

Based on observation, interview and record review, the facility neglected to identify and implement appropriate fall prevention interventions for a resident with a high risk for falls who also received a combination of high-risk medications, resulting in the resident experiencing a fall with injury.This failure resulted in actual harm to 1 of 4 residents reviewed for Quality of Care, (#1).Findings:Review of the medical record revealed resident #1, a [AGE] year-old female was admitted to the facility from an acute care hospital on 7/28/25 with diagnoses including generalized muscle weakness, difficulty in walking, lack of coordination, and cognitive communication deficit.Review of the most recent Modified Minimum Data Set (MDS) Comprehensive Significant Change Assessment with an Assessment Reference Date (ARD) of 9/05/25 revealed during the look back period, resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The Functional Abilities and Goals assessment showed the resident did not use mobility devices such as a wheelchair or walker and required moderate staff assistance to complete Activities of Daily Living (ADLs) and mobility functions. Walking was not assessed due to medical condition/safety concerns. The resident was incontinent with bladder and bowel functions, had a history of falls since admission/entry or re-entry/prior assessment, and she received high-risk antidepressant, opioid (narcotic pain), and antiplatelet (blood clot prevention) medications. The Modified MDS Comprehensive admission Assessment with an ARD of 8/04/25 noted resident #1 scored 8 out of 15 on the BIMS, had at least 1 fall in the last month prior to admission/entry/re-entry, and at least 1 fall in the last 2-6 months prior to admission/entry/re-entry. Both assessments indicated a Care Area was triggered for an identified problem of Confusion/disorientation/forgetfulness, risk of high-risk medication adverse effects including sedation manifested by short-term memory loss, decline in cognitive abilities, drowsiness, and increased risk for Falls with noted positive Care Plan Decisions. On 10/14/25 at 10:45 AM, resident #1 was observed lying in bed in her room with her eyes closed. Observation of the resident's forehead revealed two healing bruises measuring approximately 2 centimeters (CM) in length by 0.5 CM in width. The Hospice provider's Crisis Care Licensed Practical Nurse (LPN) was sitting at the resident's bedside. The nurse said the bruises were from a recent fall, and the resident's status changed to Crisis Care on 10/12/25 during the night shift. On 10/15/25 at 10:52 AM, resident #1 was observed in her room lying in bed. She was awake and somewhat restlessly changing positions. The Crisis Care LPN was sitting at her bedside.The nurse's Clinical admission assessment dated [DATE] noted resident #1 did not have a history of falls in the last month or six months prior to admission/entry/re-entry with one fall prevention intervention to keep the call light within reach. No Safety Education/Notification concerns were identified, and no Care Planning Focus Safety Concerns were indicated.The Care Plan Report's Focuses included: (7/29/25) ADL self-performance deficit related to generalized weakness/medications/effects of medications with an intervention of 1-2 person assistance due to fluctuations of weakness, fatigue, and weight bearing status. On 8/06/25, a Focus was added for an actual fall related to unsteady gait with an intervention for 72 hour neuro-checks, and on 10/03/25, wheelchair to be locked when in use per family request. On 9/16/25 after a second fall, a Focus was added for risk of falls related to impaired balance, impaired cognition, and unsteady gait (walking). Interventions were added for a floor mat while the resident was in bed, neuro checks for 72 hours and keep bed in lowest position while in bed. On 10/06/25, interventions were added to anticipate and meet resident's needs, non-skid footwear when out of bed, ensure the call light is within reach, and encourage the resident to use it for assistance as needed. On 10/06/25, a Focus was added for risk of abnormal bleeding related to use of anticoagulant (blood thinner) medication.There was no fall prevention Care Plan Focus from 7/28/25 to 9/16/25, over six weeks. The Order Summary Report showed resident #1 required monitoring for side effects of opioid medications including sleepiness, dizziness, and confusion. Physician's ordered medications included: (8/05/25) Trazodone (anti-depressant) 25 Milligrams (MG) at bedtime for depression/insomnia, (8/22/25) Oxycodone (opiate pain) 10 MG every six hours for pain, (9/10/25) Methadone (opiate pain) 15 MG twice daily for pain, and (9/17/25) Ativan (anti-anxiety) 0.5 MG twice daily, increased (9/24/25) to 0.5 MG every two hours as needed for agitation and anxiety.MDS Care Area Assessments (CAAs) for Falls with positive Care Plan Decisions in both Modified Comprehensive Assessments with ARDs of 8/04/25 (Admission) and 9/05/25 (Significant Change) had triggering conditions associated with resident #1's history of falls and the use of high-risk medications. Both assessments were modified during the survey to correct omissions of the resident's fall history and actual fall in the facility. There were no Focuses in the Comprehensive Care Plan for fall risks associated with high-risk opiate, anti-anxiety, or anti-depressant medications.The Physical Therapy (PT) Evaluation & Plan of Treatment completed 7/29/25 noted resident #1 required high complexity inpatient skilled therapy services 5 times weekly. The Fall Risk Assessment noted the resident was a fall risk with a history of greater than 10 falls in the previous 6 months. The reason for therapy noted the resident had balance and safety awareness deficits. The note read, Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for falls, further decline in function and decreased participation with functional tasks.The Occupational Therapy (OT) Evaluation & Plan of Treatment completed 7/29/25 noted resident #1 required skilled inpatient services with precautions that read, Fall risk.The Speech Language Pathologist (SLP) Evaluation and Plan of Treatment documented resident #1 required skilled therapy services with a diagnosis of Cognitive Communication Deficit. Included goals read, Patient will increase cognitive skills to Mild to improve ability to decrease risk for falls, increase ability to participate in ADLs and return to prior level of living. Precautions read, fall risk, confusion.In an interview on 10/15/25 at 11:05 AM, the Therapy Director recalled resident #1 received skilled therapy services during July-August 2025 after admission to the facility. She checked the medical records and explained the resident had significant memory deficits, inattention, and poor safety awareness with scores that were, very poor with severe cognitive decline at the time skilled therapy services ended on 8/30/25. She explained there were daily clinical discussions and weekly meetings where the resident's fall risk levels, plans of care, and interventions were discussed amongst the IDT. She said it was known that resident #1 was a fall risk.The Fall Risk Evaluation completed upon admission on [DATE] was marked negative for any history of falls in the previous 3 months and noted that resident #1 was able to walk however, a Gait/balance risk assessment was not done and marked, not able to perform function. The evaluation was scored at 9 (moderate/low) risk because of the questioned responses. A score of 10 or higher indicated a high risk. The Risk for Falls section was not marked for a care Focus nor indicated prevention interventions were needed.A Post Fall Evaluation completed 8/06/25 noted resident #1 fell in her room while attempting go to the bathroom alone. No Pre or Post-Fall Risk Scores were entered, and no new fall prevention interventions were marked.A handwritten Hospice Plan of Care Revision/Physician Orders note dated 8/08/25 noted symptoms of weakness and agitation. Interventions included, Monitor/assess safe environment, prevent falls, and anticipate needs.A nurses Progress Note completed by Licensed Practical Nurse (LPN) B on 9/16/25 noted resident #1 fell and was observed lying on the ground in her room. Staff determined the resident attempted to use the bathroom unassisted. The call bell was observed resting on the bed. Resident #1's medical record included two handwritten Neurological Assessment Flow Sheets (neuro-checks) for unwitnessed falls that occurred on 9/16/25 and 10/03/25. There were no records to indicate nurses completed neuro-checks for the resident's first unwitnessed fall at the facility on 8/06/25.On 10/14/25 at 2:27 PM, LPN B said she knew resident #1 and she was frequently included in her assignments during the 7:00 AM to 3:00 PM shift. The nurse recalled on 9/16/25, resident #1 had a second fall in her room. She said she was aware the resident previously fell but she wasn't the nurse then. The nurse explained she was completing medication pass when a Certified Nursing Assistant (CNA) alerted her that resident #1 fell. She said it was common for residents that were known as a fall risk to be placed near the nurses station, but it was difficult for staff to constantly supervise them, especially during medication pass and when CNAs were tasked with assisting them back to bed after dinner. She recalled a fall mat was placed after that fall and explained she took it upon herself to try and check on the resident every hour during her shifts. The nurse explained, after resident #1 was admitted to the facility, she became increasingly confused. She recalled that CNA F told her that on 10/03/25 during the 3:00 PM to 11:00 PM shift, the resident was among other residents placed in wheelchairs at the nurses station after dinner while they waited for assistance back to bed. The nurse recalled CNA F described that during the shift it got busier, no one was watching resident #1, and she fell.In an interview on 10/15/25 at 2:02 PM, CNA F said she knew resident #1 and she was often included in her assignments during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts. She explained it was common practice to have residents sit in their wheelchairs near the nurses station after dinner while they waited for CNAs to assist them back to bed for the night. She said she was aware resident #1 was confused, frequently tried to get out of bed, and she often found her in bed with her leg dangling over the side. She said staff knew it was important to keep an eye on her. She said the resident often verbalized, get me out of here. The CNA recalled on 10/03/25 after dinner, resident #1 was very agitated sitting in the wheelchair near the nurses station, and she threw a blanket onto the floor several times. She said at about 7:45 PM, she noticed the wheelchair was unlocked and observed the resident leaning forward in the chair. She explained she asked the resident to sit back, locked the wheelchair, and told her she would return in a few minutes to assist her to bed because she had to help another CNA with another resident. She recalled a few minutes later while she was in another resident's room, she heard resident #4's daughter yelling out for help because someone fell, so she left and headed down the hallway towards the nurses station where she saw resident #1 on the floor. The CNA said she did not recall seeing any Tasks or Safety directives in the electronic documentation program that CNAs used about watching for a fall. She conveyed that CNAs relied on reports to/from each other and nurses about increased awareness for residents with high fall risks. The Kardex for Certified Nursing Assistants (CNAs) dated as of 10/14/25 noted SAFETY with, encourage resident to use call light for assistance, place floor mats on floor when resident is in bed, and wheelchair to be locked when in use per family request.An Interdisciplinary (IDT) progress note completed by the former Director of Nursing (DON) dated 9/16/25 noted that resident #1 lost her balance and fell in her room after attempting to walk to the bathroom independently. Fall prevention interventions included: bed in lowest position, floor mats when available, encourage to use call bell when in need of help, continue non-slip socks, and neuro-checks.A Fall Risk Evaluation backdated on 10/05/25 with an effective date of 9/16/25 completed by the former DON indicated resident #1 was disoriented x 3 (person, place, time) at all times, chairbound, there was no Change in Condition in the previous 14 days, no assistive devices (wheelchair) were used, a Gait/balance assessment was not done, and the Fall Risk was again scored at 9 (moderate/low risk).A handwritten Hospice Plan of Care Revision/Physician Orders note dated 9/18/25 noted resident #1 had increased symptoms of anxiety and new anti-anxiety medication was ordered. Included interventions were monitoring for falls and anxiety.A nurses Skilled Evaluation progress note dated 9/21/25 noted resident was alert with forgetfulness and special safety care included having the call light within reach and a low bed. Functional notes indicated resident #1 was non-weight bearing when walking, had poor standing balance, and she was bedfast all or most of the time. A note dated 9/22/25 indicated there were no Safety concerns.A nurses progress note completed by LPN E dated 9/23/25 indicated resident #1 was confused, attempting to get out of bed unassisted, and the Hospice nurse was notified who later evaluated the resident.Two unsuccessful attempts were made to contact LPN E on 10/15/25 at 10:24 AM and 10/16/25 at 2:01 PM.A handwritten Hospice Plan of Care Revision/Physician Orders note dated 9/24/25 noted resident #1 had increased agitation. Included interventions were monitor/assess agitation, and the Ativan medication was increased to 0.5 MG sublingually (under the tongue) every 2 hours as needed.An Order Note dated 9/24/25 included a warning for possible drug interactions with active medication orders for Methadone, Oxycodone, and Ativan coadministration with moderate to severe severity because of increased central nervous system depression.A Nurses note dated 9/27/25 showed the Hospice provider was called due to family concerns and an overall decline in resident #1's ADL functioning.A nurses Skilled Evaluation note dated 10/02/25 read for Special Care/Safety, Call light is within reach.A nurse Progress Note completed by LPN A on 10/03/25 noted resident #1 received Methadone pain medication at 6:00 PM. LPN A's Late Entry Incident Note dated 10/03/25 at 8:20 PM noted resident #1 was in a wheelchair in front of the nurses station during medication pass. While the nurse was in a resident room administering medications, the note read, [resident name] fell out her wheelchair and hit her head on the floor. A progress note completed by LPN A on 10/03/25 indicated resident #1 sustained a laceration to her forehead and 911 was activated for emergency transportation to the hospital and read, resident sent to hospital due to unwitnessed fall.Major risk factors that increase fall risk include: one or more previous falls, medications, and troubles with movement and/or cognition. Opiate, Benzodiazepine (anti-anxiety), and anti-depressant medications are associated with fall risk can cause confusion, fatigue, blood chemistry abnormalities, heart rate/rhythm changes, blood pressure drops upon standing after sitting/lying down, sedation, and balance problems. Many medicines have side effects that may increase the risk of falls. Taking more than one of these medicines increases the risk even more. (retrieved from mayoclinic.org on 10/20/25)The hospital records dated 10/04/25 noted resident #1 required emergency department services after an unwitnessed fall. The note stated the resident fell out of her wheelchair and was found with a forehead laceration with blood on her hands and clothes. She was diagnosed with blunt head trauma and a laceration that required sutures.A Fall Risk Evaluation completed by the former DON was backdated on 10/05/25 with an effective date of 10/03/25 and noted a Gait/balance assessment was not completed (not able to perform). Resident #1's fall risk was again scored as 9 (moderate/low). The actioned clinical suggestions read, Rubber-soled shoes or nonskid slippers worn for ambulation.The Fall Risk Evaluation Graph showed Fall Risk Scores of 9 (moderate/low risk) on 7/28/25, 8/06/25, 9/16/25, and 10/03/25. The scores did not change even after resident #1 had three unwitnessed falls at the facility.Two unsuccessful attempts were made to interview the former DON by telephone on 10/15/25 at 1:25 PM and 10/16/25 at 9:07 AM.In an interview on 10/15/25 at 11:21 AM, the MDS Coordinator explained falls, care plan interventions, and revisions were discussed in clinical meetings every morning, and in weekly Interdisciplinary Team (IDT) review meetings. She recalled resident #1's falls were previously discussed in those meetings, and interventions were reviewed. She said fall interventions were mostly entered into the Care Plan by both the DON and the MDS Coordinator. She explained the Care Area Assessment (CAA) of the MDS triggered fall risk factors and care plan decisions. On 10/16/25 at 9:17 AM, she checked resident #1's medical record and found there was incorrect fall history coding in resident #1's MDS's. She checked the Comprehensive Care Plan and confirmed that a Fall prevention care plan was not entered timely, and the fall history prior to admission was missing. She relayed that the previous MDS Coordinator did not thoroughly check all the medical records and had missed it. She said on 8/05/25, an intervention was entered that read, encourage to use the call light. She checked the BIMS score and confirmed the resident scored 8 out of 15 which indicated cognitive impairment. She conveyed the intervention was not a safe, reliable choice for resident #1 because she would not always remember to use the call light, and she had a second fall after that.On 10/15/25 at 1:51 PM, via the telephone, resident #1's daughter recalled she received a phone call from LPN A on 10/03/25 who informed her that her mom fell from her wheelchair. She explained LPN A said no one was watching the resident because the CNAs were inside other rooms putting resident's down, and the other nurse was in a resident room administering medications. She said staff knew her mom was a fall risk and fell multiple times at home and two other times in the facility. She said she visited often and expressed her concerns to staff about leaving her in a wheelchair alone because she leaned forward, moved forward, and often bent over from the side effects of heavily sedating medications. She said it was common practice after dinner for staff to leave residents in wheelchairs near the nurses station. She said she was very concerned that there was not enough staff supervision for fall prevention safety, and she asked for more supervision before the last fall. She said all they did was put a floor mat in her room and my mom couldn't remember to use a call light. She recalled sending an email to the former DON about her concerns around 9/27/25 because she had visited around 5:00 PM and found the room door was closed, the room was dark, and her mom was restless and halfway off the bed. She said after the last fall, her mother rapidly declined, required oxygen, and 24/7, 1-1 Hospice Crisis Care.On 10/15/25 at 2:23 PM, via the telephone resident #4's daughter recalled on 10/03/25 around 8:00 PM, she had visited her mother when a resident fell out of a wheelchair near the nurses station. She explained no staff were around and it was common practice that residents were left unsupervised in wheelchairs near the nurses station after dinner. She said her mother recently left the facility and also had falls when she was there. She said her mom took blood thinners and she was concerned that she would have a bad fall because staff left residents unsupervised in wheelchairs, all the time. She recalled when resident #1 fell, she observed that a nurse responded to her on the floor and she heard her yell out, where is everybody? She stated, That's why my mom isn't there anymore; I told them multiple times she was not supervised, and she was going to fall.According to the Agency for Healthcare Research and Quality (AHRQ), a history of a fall is the single best predictor of future falls, and 30-40% of those residents who fall will do so again. Fall Management programs and prompt staff response with proper plan of care development, interventions, and investigation of fall circumstances are crucial fall prevention steps. The AHRQ resource read, Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input. (retrieved on 10/21/25 from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html).On 10/14/25 at 3:26 PM, Registered Nurse (RN) G said she worked the 3:00 to 11:00 PM shift and she knew resident #1 well. She recalled resident #1 was restless and needed more than average supervision and stated, you are supposed to do 30 minute or one hour checks.On 10/15/25 at 11:49 AM, via the telephone, RN D said she worked 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts, and resident #1 was frequently included in her assignments. The RN recalled prior to the last fall, the resident experienced increased restlessness and frequently dangled her feet off the bed. She did not recall seeing any individualized fall prevention interventions or orders in the electronic medical record. The RN stated, I was very concerned about her fall risk; the safety and wellness stuff was like nursing.On 10/15/25 at 2:30 PM, Physical Therapy Assistant (PTA) I recalled she knew resident #1 well who was frequently assigned to her for previous therapy services. She said without staff assistance, the resident would likely fall, precautions were part of the plan of care, and nursing was responsible for implementing therapy recommendations.On 10/14/25 at 3:45 PM, the Unit Manager explained she knew resident #1, and the resident was frequently agitated. The RN recalled resident #1 had increased agitation and attempted to climb out of bed. She said residents with a history of falls should be checked at least every 30 minutes. She stated, the former DON was involved with this one; I know they work together with MDS and if they need me to do anything, they let me know.On 10/15/25 at 9:54 AM, the Hospice Case Manager RN recalled resident #1 had a recent fall after she came forward while sitting in a wheelchair near the nurses station. The nurse explained the resident was on a combination of narcotic medications that caused increased drowsiness. She said after the last fall, the resident's condition declined further, and she was placed on Crisis Care with expected imminent death.On 10/15/25 at 11:35 AM, the DON was interviewed and said she had been in the position for about one week. She recalled on 10/03/25, she worked during the 3:00 PM to 11:00 PM shift but was not resident #1's assigned nurse. She recalled after she exited another resident's room, she proceeded down the hallway towards the nurses station, and in the distance she saw something on the floor. She explained as she got closer, she realized it was a resident, and she immediately responded rendering aid, and she did not see anyone else around. She said after dinner, it was a typical practice to place residents with known fall risks in their wheelchairs near the nurses station while they waited for CNAs to assist them back to bed. The DON explained she was not aware of a specific Falls Program. She said as part of her new role, she recently checked resident #1's records and found individualized care plan interventions were missing, and some Fall Risk Evaluations completed by the previous DON were backdated. On 10/16/25 at 9:57 AM, the DON checked resident #1's Fall Risk Evaluations and acknowledged the risk scores never increased after falls. She said they were incorrectly scored and should have included the resident's prior fall history, changes in condition, and the risk score should have been at least 10, which was considered High. She said it was not acceptable to backdate assessments, as they were expected to be completed immediately or within 24 hours. She stated there were missing interventions in the care plan, and she could not find a baseline care plan. The DON recalled on 10/03/25 during the 3:00 PM to 11:00 PM shift when she worked on the unit, she observed resident #1 slumped over in the chair at times, and she should not have been left unsupervised. She said it was unrealistic to expect CNAs and nurses to provide increased supervision to residents in wheelchairs at the nurses station while they provided medication administration, responded to needs, and assisted other residents to bed. She conveyed resident #1 should have received increased supervision after she had two falls and increased restlessness. In a joint interview with the Nursing Home Administrator (NHA) and DON, the DON stated, we review any falls, make sure there is a care plan, and make sure there is a fall assessment; there isn't a formal Fall Program.In a telephone interview on 10/16/25 at 1:29 PM, resident #1's primary care physician recalled he was aware the resident recently fell out of a wheelchair and required hospital emergency care. He said the facility tried to increase supervision as best they could and also did what was best for the facility. He relayed he expected nurses, CNAs and Therapists to communicate residents needs to prevent falls.On 10/16/25 at 1:45 PM in a telephone interview, the Medical Director said he expected the facility to have an active Falls Prevention Program. He conveyed the facility was not obligated to provide 24/7 1-1 sitters, and families were welcomed to provide them.In a joint interview with the Nursing Home Administrator (NHA) and DON, the NHA recalled there were issues with resident #1's payor source and it was previously discussed that the resident required 1-1 care and he thought she needed to be transferred to a higher level of care. He said the facility could not allow a constant sitter and he didn't have any elopement risks. The NHA stated, neglect is when you leave a resident unattended for a period of time that cannot perform any ADLs for themselves which includes eating or personal care and anything essential.Review of the standards and guidelines titled Abuse, Neglect, and Exploitation dated 1/01/22 read, Neglect means failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy outlined that its prevention practices included identification, ongoing assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to neglect.

Based on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to mitigate the prevention of fall with injury for 1 of 4 residents reviewed for Quality of Care, (#1).The facility's failure to increase supervision for a resident with a history of repeated falls who also received high-risk medications resulted in actual harm.Findings:Review of the medical record revealed resident #1, a [AGE] year-old female was admitted to the facility from an acute care hospital on 7/28/25 with diagnoses including generalized muscle weakness, difficulty in walking, lack of coordination, and cognitive communication deficit.Review of the most recent Modified Minimum Data Set (MDS) Comprehensive Significant Change Assessment with an Assessment Reference Date (ARD) of 9/05/25 revealed during the look back period, resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. The Functional Abilities and Goals assessment showed the resident did not use mobility devices such as a wheelchair or walker and required moderate staff assistance to complete Activities of Daily Living (ADLs) and mobility functions. Walking was not assessed due to medical condition/safety concerns. The resident was incontinent with bladder and bowel functions, had a history of falls since admission/entry or re-entry/prior assessment, and she received high-risk antidepressant, opioid (narcotic pain), and antiplatelet (blood clot prevention) medications. The Modified MDS Comprehensive admission Assessment with an ARD of 8/04/25 noted resident #1 scored 8 out of 15 on the BIMS, had at least 1 fall in the last month prior to admission/entry/re-entry, and at least 1 fall in the last 2-6 months prior to admission/entry/reentry. Both assessments indicated a Care Area was triggered for an identified problem of Confusion/disorientation/forgetfulness, risk of high-risk medication adverse effects including sedation manifested by short-term memory loss, decline in cognitive abilities, drowsiness, and increased risk for Falls with noted positive Care Plan Decisions. On 10/14/25 at 10:45 AM, resident #1 was observed lying in bed in her room with her eyes closed. Two healing bruises were observed on the resident's forehead, measuring approximately 2 Centimeters (CM) in length by 0.5 CM in width. The Hospice provider's Crisis Care Licensed Practical Nurse (LPN) was sitting at the resident's bedside. The nurse said the bruises were from a recent fall, and the resident's status changed to Crisis Care on 10/12/25 during the night shift. On 10/15/25 at 10:52 AM, resident #1 was observed in her room lying in bed. She was awake and somewhat restlessly changing positions. The Crisis Care LPN was sitting at her bedside.The nurses' Clinical admission assessment dated [DATE] noted resident #1 did not have a history of falls in the last month or six months prior to admission/entry/re-entry with one fall prevention intervention to keep the call light within reach. No Safety Education/Notification concerns were identified, and no Care Planning Focus Safety Concerns were indicated.The Care Plan Report's Focuses included: (7/29/25) ADL self-performance deficit related to generalized weakness/medications/effects of medications with an intervention of 1-2-person assistance due to fluctuations of weakness, fatigue, and weight bearing status. On 8/06/25, a Focus was added for an actual fall related to unsteady gait with an intervention for 72-hour neuro-checks, and on 10/03/25, wheelchair to be locked when in use per family request. On 9/16/25 after a second fall, a Focus was added for risk of falls related to impaired balance, impaired cognition, and unsteady gait (walking). Interventions were added for a floor mat while the resident was in bed, neuro checks for 72 hours and keep bed in lowest position while in bed. On 10/06/25, interventions were added to anticipate and meet resident's needs, non-skid footwear when out of bed, ensure the call light is within reach, and encourage the resident to use it for assistance as needed. On 10/06/25, a Focus was added for risk of abnormal bleeding related to use of anticoagulant (blood thinner) medication.There was no fall prevention Care Plan Focus developed from 7/28/25 to 9/16/25, over six weeks,The Order Summary Report showed resident #1 required monitoring for side effects of opioid medications including sleepiness, dizziness, and confusion. Physician's ordered medications included: (8/05/25) Trazodone (anti-depressant) 25 Milligrams (MG) at bedtime for depression/insomnia, (8/22/25) Oxycodone (opiate pain) 10 MG every six hours for pain, (9/10/25) Methadone (opiate pain) 15 MG twice daily for pain, and (9/17/25) Ativan (anti-anxiety) 0.5 MG twice daily, increased (9/24/25) to 0.5 MG every two hours as needed for agitation and anxiety.On 10/15/25 at 11:05 AM, the Therapy Director recalled resident #1 received skilled therapy services during July-August 2025 after admission to the facility. She checked the medical records and explained the resident had significant memory deficits, inattention, and poor safety awareness with scores that were, very poor with severe cognitive decline at the time skilled therapy services ended on 8/30/25. She explained there were daily clinical discussions and weekly meetings where the resident's fall risk levels, plans of care, and interventions were discussed amongst the IDT. She said it was known that resident #1 was a fall risk.Review of the therapy evaluations for Physical Therapy, Occupational Therapy and Speech Therapy dated 7/29/25 all indicated resident #1 was at risk for falls.On 10/14/25 at 2:27 PM, Licensed Practical Nurse (LPN) B said she knew resident #1, and she was frequently included in her assignments during the 7:00 AM to 3:00 PM shift. The nurse recalled on 9/16/25, resident #1 had a second fall in her room. She said she was aware the resident previously fell but she wasn't the nurse then. The nurse explained she was completing medication pass when a Certified Nursing Assistant (CNA) alerted her that resident #1 fell. She said it was common for residents that were known as a fall risk to be placed near the nurses' station, but it was difficult for staff to constantly supervise them, especially during medication pass and when CNAs were tasked with assisting the residents back to bed after dinner. She recalled a fall mat was placed after that fall and explained she took it upon herself to try and check on the resident every hour during her shifts. The nurse explained, after resident #1 was admitted to the facility, she became increasingly confused. She recalled that CNA F told her that on 10/03/25 during the 3:00 PM to 11:00 PM shift, the resident was among other residents placed in wheelchairs at the nurses' station after dinner while they waited for assistance back to bed. The nurse recalled CNA F described that during the shift it got busier, no one was watching resident #1, and she fell.On 10/15/25 at 2:02 PM, CNA F said she knew resident #1, and she was often included in her assignments during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts. She explained it was common practice to have residents sit in their wheelchairs near the nurses' station after dinner while they waited for CNAs to assist them back to bed for the night. She said she was aware resident #1 was confused, frequently tried to get out of bed, and she often found her in bed with her leg dangling over the side. The CNA said staff knew it was important to keep an eye on her. She said the resident often verbalized, get me out of here. The CNA recalled on 10/03/25 after dinner, resident #1 was very agitated sitting in the wheelchair near the nurses station. The resident threw a blanket onto the floor several times. The CNA stated at about 7:45 PM, she noticed the wheelchair was unlocked and observed the resident leaning forward in the chair. She explained she asked the resident to sit back, locked the wheelchair, and told the resident she would return in a few minutes to assist her to bed. She stated at the time she had to help another CNA with another resident. She recalled a few minutes later while she was in another resident's room, she heard resident #4's daughter yelling out for help because someone fell. The CNA explained at that time she headed down the hallway towards the nurses' station where she saw resident #1 on the floor. The CNA said she did not recall seeing any Tasks or Safety directives in the electronic record regarding fall risk precautions for resident #1. She conveyed that CNAs relied on reports to/from each other and nurses about increased awareness for residents with high fall risks. A nurse Progress Note completed by LPN A on 10/03/25 noted resident #1 received Methadone pain medication at 6:00 PM. LPN A's Late Entry Incident Note dated 10/03/25 at 8:20 PM noted resident #1 was in a wheelchair in front of the nurses station during medication pass. While the nurse was in a resident room administering medications, the note read, [resident name] fell out her wheelchair and hit her head on the floor. A progress note completed by LPN A on 10/03/25 indicated resident #1 sustained a laceration to her forehead and 911 was activated for emergency transportation to the hospital and read, resident sent to hospital due to unwitnessed fall.Review of resident #1's medical record revealed hospital records dated 10/03/25, noted resident #1 required emergency department services after an unwitnessed fall. The note stated the resident fell out of her wheelchair and was found with a forehead laceration with blood on her hands and clothes. She was diagnosed with blunt head trauma and a laceration that required sutures.On 10/15/25 at 11:21 AM, the MDS Coordinator explained falls, care plan interventions, and revisions were discussed in clinical meetings every morning, and in weekly Interdisciplinary Team (IDT) review meetings. She recalled resident #1's falls were previously discussed in those meetings, and interventions were reviewed. She said fall interventions were mostly entered into the Care Plan by both the Director of Nursing (DON) and the MDS Coordinator. She explained the Care Area Assessment (CAA) of the MDS triggered fall risk factors and care plan decisions. On 10/16/25 at 9:17 AM, the MDS Coordinator checked resident #1's medical record and confirmed there was incorrect fall history coding in resident #1's MDS's. She checked the Comprehensive Care Plan and acknowledged a Fall prevention care plan was not entered timely, and the fall history prior to admission was missing. She relayed that the previous MDS Coordinator did not thoroughly check all the medical records and must've missed it. She said on 8/05/25, an intervention was entered that read, encourage to use the call light. She checked the BIMS score and confirmed the resident scored 8 out of 15 which indicated cognitive impairment. The MDS Coordinator confirmed the intervention was not a safe, reliable choice for resident #1 because she would not always remember to use the call light, and she had a second fall after that.According to the Agency for Healthcare Research and Quality (AHRQ), a history of a fall is the single best predictor of future falls, and 30-40% of those residents who fall will do so again. Fall Management programs and prompt staff response with proper plan of care development, interventions, and investigation of fall circumstances are crucial fall prevention steps. The AHRQ resource read, Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input. (retrieved on 10/21/25 from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html).Review of the facility's standards and guidelines dated 9/01/21 titled Fall Prevention Program outlined compliance guidelines that included use of standardized risk assessments that categorized low, moderate, and high scores. Nurses initiate interventions of the resident's baseline care plan in accordance with the risk level. The high-risk protocol included additional interventions of increased frequency of rounds, sitter if indicated, medication regimen review, alternate call system access. Risk factors are evaluated when developing a comprehensive care plan. Interventions are monitored for effectiveness, and the plan of care is revised as needed. After a fall, the facility will complete a post-fall assessment, review the resident's care plan and update as indicated, and document all assessments and actions.Review of the facility's undated standards and guidelines titled Incidents and Accidents outlined its purposes included meeting regulatory requirements for analysis, conducting root cause analysis to ascertain causative/contributing factors to avoid and prevent future reoccurrences and improvement of resident care management, and assuring appropriate and immediate interventions and corrective actions were implemented. Investigation of incidents/accidents included completion of a Fall Risk Evaluation when the resident's condition changed.

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. The deficient practice resulted in a pattern of unresolved quality concerns and had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.Findings:On a previous complaint survey dated 2/15/25, Centers for Medicare & Medicaid Services (CMS) Enforcements were issued that included F0600 (Free from Abuse and Neglect), F0610 (Investigate/Prevent/Correct Alleged Violation), F0689 (Free of Accident Hazards/Supervision/Devices). On 7/14/25, a recertification survey was conducted, and Enforcements were issued for F0867 QAPI/QAA Improvement Activities.On 10/16/25 at 2:10 PM, the Nursing Home Administrator (NHA) explained that their QAPI program included non-compliance assessments/review, and identification of identified problems reported by each department during their monthly regular and Ad Hoc (when needed) meetings. He recalled the last monthly meeting was held on 9/30/25. The NHA explained that the program's intention was to identify any deficiencies or trends in each department's monthly reported information, and it was collectively determined what issues the committee decided to work on.The NHA explained the last Performance Improvement Plans (PIPs) for F0610 and F0600 and F0689 Enforcements related to Falls in February 2025 were completed as the QAPI committee determined substantial compliance was met effective 4/01/25. He stated there had been three different Directors of Nursing (DONs) since February 2025 and he was unable to locate the POC documents.The NHA said the DON was responsible to ensure nursing related corrective actions were active and sustained. He said he was unaware how substantial compliance for the citations was determined and didn't have the records to review. The NHA stated there was a failure of DONs to track and ensure measures in place were implemented to sustain corrective measures.The facility did not implement an ongoing, systematic QAPI program to ensure that identified problems were corrected and prevented from recurring. The failure of the facility to maintain complete monitoring documentation and address repeated deficiencies demonstrated that the QAPI program was not effective.Review of the facility's standards and guidelines titled, QAPI Monitoring dated 1/20/22 noted the program's intentions were to systematically monitor performance indicators as part of the QAPI program. Data collection activities to track performance indicators based on data analysis are monitored/evaluated monthly for evaluation of progress towards goals and remain active for a minimum of one calendar year.

Based on observation, interview, and record review, the facility failed to ensure the Director of Nursing (DON) adhered to ethical expectations and professional standards by backdating evaluations with incorrect documentation; lacked evidence of education or competency training for the role, and readily available employee program access. Findings:On 10/16/25 at 12:05 PM, via the telephone, the facility's Human Resource Assistant said she also served the role of Compliance Officer. She explained as part of the compliance program, the facility was expected to have posters readily visible for employees to access contact information and resources. She said she did not attend any clinical or meetings regarding resident care and only visited for employee situations that may include investigations, disciplines, or terminations. She said the Compliance and Ethics Program was outlined with education during employee orientation and included expectations of honesty in documentation and stated, anything that happens to a resident has to be documented honestly and 100% correctly; it affects the care, safety, and health of the residents.On 10/16/25 at approximately 11:00 AM, the DON said the Compliance Program posters were on the Assisted Living Facility (ALF) side of the building, but not on the Skilled Nursing side and provided a rolled-up poster she said the Nursing Home Administrator (NHA) had just received.On 10/16/25 at 12:50 PM, the NHA checked the employee file of the former DON and said he could not locate the signed Job Description, nor the acknowledgement of their Compliance and Ethics Program orientation education.Review of the facility's standards and guidelines dated 1/20/22 and titled Compliance and Ethics Program outlined components that included sufficient resources and authority to assure compliance, ongoing communication through education of standard policies and procedures, and compliance achievement activities, such as monitoring, auditing, reporting systems, and data integrity processes, and annual training all which was meant to promote quality care.

Based on interview and record review, the facility failed to maintain accurate and complete medical records for 1 of 4 residents reviewed for Quality of Care, (#1). Specifically, the Director of Nursing (DON) incorrectly documented and backdated resident records, resulting in inaccurate information in the clinical record and the Minimum Data Set (MDS) Coordinator inaccurately recorded fall histories. This deficient practice had the potential to affect all residents by compromising the accuracy and integrity of resident medical information used to make care decisions.Findings:Review of the medical record revealed resident #1, a 58-year- old female was admitted to the facility from an acute care hospital on 7/28/25 with diagnoses including generalized muscle weakness, difficulty in walking, lack of coordination, and cognitive communication deficit.Review of the most recent Modified Minimum Data Set (MDS) Comprehensive Significant Change Assessment with an Assessment Reference Date (ARD) of 9/05/25 revealed during the look back period, resident #1 scored 8 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated moderate cognitive impairment. The Functional Abilities and Goals assessment showed the resident did not use mobility devices such as a wheelchair or walker and required moderate staff assistance to complete Activities of Daily Living (ADLs) and mobility functions. Walking was not assessed due to medical condition/safety concerns. The resident was incontinent with bladder and bowel functions, had a history of falls since admission/entry or reentry/prior assessment, and she received high-risk antidepressant, opioid (narcotic pain), and antiplatelet (blood clot prevention) medications. The Modified MDS Comprehensive admission Assessment with an ARD of 8/04/25 noted resident #1 scored 8 out of 15 on the BIMS, had at least 1 fall in the last month prior to admission/entry/reentry, and at least 1 fall in the last 2-6 months prior to admission/entry/reentry. Both assessments indicated a Care Area was triggered for an identified problem of Confusion/disorientation/forgetfulness, risk of high-risk medication adverse effects including sedation manifested by short-term memory loss, decline in cognitive abilities, drowsiness, and increased risk for Falls with noted positive Care Plan Decisions. The Fall Risk Evaluation completed upon admission on [DATE] was marked negative for any history of falls in the previous 3 months and noted that resident #1 was able to walk however, a Gait/balance risk assessment was not done and marked, not able to perform function. The evaluation was scored at 9 (moderate/low) risk because of the questioned responses. A score of 10 or higher indicated a high risk. The Risk for Falls section was not marked for a care Focus nor indicated prevention interventions were needed.A Fall Risk Evaluation backdated on 10/05/25 with an effective date of 9/16/25 completed by the former DON indicated resident #1 was disoriented x 3 (person, place, time) at all times, chairbound, there was no Change in Condition in the previous 14 days, no assistive devices (wheelchair) were used, a Gait/balance assessment was not done, and the Fall Risk was again scored at 9 (moderate/low risk).A Fall Risk Evaluation completed by the former DON was backdated on 10/05/25 with an effective date of 10/03/25 and noted a Gait/balance assessment was not completed (not able to perform). Resident #1's fall risk was again scored as 9 (moderate/low).The Fall Risk Evaluation Graph showed Fall Risk Scores of 9 (moderate/low risk) on 7/28/25, 8/06/25, 9/16/25, and 10/03/25. The scores did not change even after resident #1 had three unwitnessed falls at the facility.Two unsuccessful attempts were made to interview the former DON by telephone on 10/15/25 at 1:25 PM and 10/16/25 at 9:07 AM.In an interview on 10/15/25 at 11:21 AM, the MDS Coordinator explained that fall interventions were mostly entered into the Care Plan by both the DON and the MDS Coordinator. She explained the Care Area Assessments (CAAs) of the MDS triggered fall risk factors and care plan decisions. On 10/16/25 at 9:17 AM, she checked resident #1's medical record and confirmed there was incorrect fall history coding in resident #1's MDS's. She checked the Comprehensive Care Plan and acknowledged a Fall prevention care plan was not entered timely, the fall history prior to admission and risks associated with high-risk medications was missing. She relayed that the previous MDS Coordinator did not thoroughly check all the medical records and must've missed it.No fall prevention Care Plan Focus was developed for resident #1's Plan of Care from 7/28/25 to 9/16/25, over six weeks.On 10/15/25 at 11:35 AM, the DON was interviewed and said she had been in the position for about one week. She said as part of her new role, she recently checked resident #1's records and found individualized care plan interventions were missing, and some Fall Risk Evaluations completed by the previous DON were backdated. On 10/16/25 at 9:57 AM, the DON checked resident #1's Fall Risk Evaluations and acknowledged the risk scores never increased after falls. She said they were incorrectly scored and should have included the resident's prior fall history and subsequent falls as a change in condition. She said if the assessments were scored correctly, the risk score would have been at least 10, which was considered High. She said it was not acceptable to backdate assessments as they were expected to be completed immediately or within 24 hours, and nurses were expected to document accuracy in the medical records.Review of the DON and nurses Job Descriptions noted the expectation of abilities to relay correct and accurate information regarding residents' conditions in all communication forms.

The facility failed to ensure food was served to residents was palatable and served at appetizing temperatures for 2 of the approximately 18 residents who received meal trays from the satellite kitchen and ate in their room, of a total sample of 26 residents.Findings:During the initial screening of residents on 7/14/25 and 7/15/25, several residents stated the food often arrived at their room cold. On 7/16/25 at 12:50 PM, five prepared lunch meal trays were observed sitting in the dining area, three on a cart and two on the counter. Certified Nursing Assistant (CNA) A stated she requested the trays be prepared and provided for her but that four of the trays were for assisted diners and therefore had not yet been served to the residents.At that time the non-insulated lids covering the main plate was observed to have a hole in the middle from which the heat from the food could escape. CNA B arrived at the dining area and explained the CNAs request meals from the tray line server one at a time to ensure they were hot when delivered to residents. She confirmed on this occurrence, that procedure was not followed.On 7/16/25 at 1:05 PM, as the last tray was delivered to a resident, temperatures were taken for two of the remaining trays, then the food was tasted by the Certified Dietary Manager (CDM) for appetizing temperatures and palatability. On the pureed meal tray, the pureed Swiss steak was 116 degrees Fahrenheit (F) and tasted slightly warm but was determined by the CDM to not be at an appetizing temperature. For the second tray containing a regular diet, the peas were 106 degrees F, and the potatoes were 100 degrees F. Per the CDM both tasted cold and were deemed not to be at an appetizing temperature. The CDM stated the procedure for meal trays was they were to be requested one at a time and delivered immediately to ensure the food was served at an appetizing temperature, but in this case, that procedure was not followed. She added it was important to ensure food was served at an appetizing temperature for residents, so they have a good dining experience, and were more likely to eat the food to maintain their nutritional status.The residents who received these meals were all unable to communicate their opinion of their meal temperatures.The facility's undated policy entitled Record of Food Temperatures indicated hot foods would be held at 135 degrees F or greater and would be stirred during holding to redistribute heat throughout the food product.

Based on interview, and record review, the facility failed to ensure the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it, failed to include that the signer was allowed to communicate with federal, state, or local officials, health department employees, and a representative Ombudsman, and failed to include evidence that the signer acknowledged they understood the agreement for 9 of 9 residents who signed binding arbitration agreements, of a total sample of 26 residents.Findings:On 7/14/25, the facility provided a sample of their Arbitration Agreement which indicated any party signing the agreement had three (3) days from execution of the agreement to cancel or rescind it, instead of 30 days, as required.On 7/18/25 at 10:30 AM, the Admissions Director stated she was responsible for meeting with the resident/resident representative post-admission to get the documents in the admission packet signed and verified the admission agreement included the arbitration agreement. She stated she reviewed the arbitration agreement with the resident/representative and that nine of the current 34 residents had signed the facility's arbitration agreement. The Admissions Director added she was aware the arbitration agreement was not accurate in regard to the provision of three days to rescind the agreement. She said she was anxious to update and correct the form with the residents. The admission Director provided a copy of a recently admitted residents' arbitration agreement for resident #41 as an example, who was admitted on [DATE] and was the responsible party for his account. Resident #41 signed the arbitration agreement which indicated he had three days from execution of the agreement to cancel or rescind it. Review of the agreement revealed it did not include that the signer was allowed to communicate with federal, state, or local officials, health department employees, and a representative Ombudsman, and did not include evidence that the signer acknowledged they understood the agreement.On 7/18/25 at 11:00 AM, the Administrator stated that even though the facility was in the process of finalizing a new facility contract with an updated arbitration agreement, they could not use it yet because they were waiting for the final inspection before legally changing the name of the facility from its previous name to the new one.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the facility's current QAPI Plan revealed the purpose of the plan was to provide a means to identify and resolve present and potential negative outcomes related to resident care and services; provide structure and processes to correct identified quality and/or safety deficiencies; and to establish and implement plans to correct deficiencies and to monitor the effects of the action plans on resident outcome. The facility had a deficiency cited at F880, for concerns with infection control during the previous recertification survey conducted 9/16/24 through 9/19/24. During this survey, the facility was found to be in noncompliance with F880. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation. On 7/18/2025 at 12:27 PM, the administrator stated the facility had a QAPI committee that met monthly. He explained the committee reviewed department audits as well as survey outcomes, survey window, facility star rating and Quality Measures. He stated when an issue was identified, the QAPI committee would create a performance improvement plan to address the concern and monitored progress through audits reported back to QAPI committee. Findings from the current survey were reviewed with the Administrator. He acknowledged there were repeat citations from the previous recertification survey but was unable to say where the process failure occurred. The Administrator explained he would have to look into the issue further as there was a recent change in ownership and several changes in administration staff. He acknowledged the performance improvement process should continue even with staff changes for the benefit of the residents and staff.

Based on observation, interview, and record review, the facility failed to maintain a system for tracking and monitoring infections for 3 out of 5 residents, (#13, #22, #35) reviewed for transmission-based precautions; and failed to identify and implement a system to prevent the spread of communicable diseases by not encouraging and providing hand hygiene for 16 of 16 residents reviewed for dining at the facility, of a total sample of 26 residents.Findings: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses including dementia with mood disturbances, persistent asthma, chronic kidney disease, type 2 diabetes and muscle weakness. Review of the resident #13's physician orders revealed no orders for contact isolation. Review of her care plan initiated 3/12/25 revealed no focus for transmission-based precautions. Resident #22, resident #13’s roommate, was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following stroke affecting left non-dominant side, congestive heart failure, and cardiomegaly (enlarged heart). Review of resident #22's physician orders revealed no orders for contact isolation. Review of her care plan initiated 2/07/25 revealed no focus for transmission-based precautions. During medication administration observation on 7/16/25 at 9:21 AM, Licensed Practical Nurse (LPN) I prepared medications for resident #13. On the outside of the resident’s door, was a contact precaution sign which indicated that anyone entering the room should wear gown and gloves and perform hand hygiene. The sign did not indicate which resident (or both) was on isolation precautions. Also outside the room was a plastic container for personal protective equipment (PPE) which was empty of gowns. LPN I entered resident #13’s room without donning PPE. In the room, resident #13 was sitting up in bed with the Unit Manager (UM) at her bedside assisting her with breakfast. The UM was seated in the residents’ Geri-chair beside her bed wearing no PPE. LPN I exited the room and entered again without donning PPE. LPN I stood next to the resident’s bed and leaned over to give the resident her medication, all without gloves or a gown. 2. Resident #35 was initially admitted to the facility on [DATE] with diagnosis including dementia, chronic kidney disease, and facial weakness following stroke. Review of the medical record revealed the resident was readmitted to the facility on [DATE] following a hospitalization with a diagnosis of human Metapneumovirus. Physician orders revealed resident #35 had the antibiotic Cefuroxime Axetil 500 milligrams, twice a day for seven days for infection with a start date of 7/10/25. Per the Centers for Disease Control's Appendix A Guideline for Isolation Precautions it is recommended for infections with human metapneumovirus contact plus standard precautions including use of a mask were used for the duration of the illness, (retrieved on 8/01/25 from www.cdc.gov). On 7/16/25 at 9:26 AM, an isolation sign for droplet precautions was observed on resident #35’s door. A plastic container for PPE was nearby but had no gowns. Review of the electronic medical record (EMAR) revealed the resident did not receive the medication on 7/11/25 at 9:00 AM with an administration note which read, “resident not swallowing and holding medication in mouth.” Further review of the EMAR revealed the resident did not receive the medication on 7/12/25 at 9:00 AM with an administration note which read, “call pharmacy to stat.” Review of the EMAR revealed the resident did not receive the medication again on 7/15/25 at 9:00 AM, with an administration note that indicated, “resident not swallowing medication.” Review of the resident's physician orders revealed there were no orders for droplet isolation. Review of his care plan initiated 3/27/25 revealed no focus for transmission-based precautions or antibiotic therapy. On 7/17/25 at 9:18 AM, Certified Nursing Assistant (CNA) D was observed placing resident #35’s meal tray down on the plastic container which held PPE before entering the resident’s room. CNA D stated she needed to go find PPE since there was an isolation sign for droplet precautions on the door and the container of PPE was empty. CNA D returned and stated the Director of Nursing (DON) informed her resident #35 was not on isolation for droplet precautions and therefore PPE was not required. On 7/17/25 at 9:23 AM, CNA D reported that resident #35 was not on isolation for droplet precautions and therefore she did not need to wear PPE when delivering the resident’s meal tray. She then wondered if the assigned nurse could remove the droplet isolation sign from the resident’s door. On 7/16/25 at 9:48 AM, the DON explained both she and the UM were responsible for infection control at the facility. She stated that the UM was responsible for making sure all PPE supplies were outside the room that was on isolation precautions as well as ensure the appropriate signage was on the door. The DON acknowledged that residents #22 and #13 had no current orders for isolation contact precautions. She was unable to provide a reason why the room had a contact isolation precaution sign on the door if the residents inside did not actually have an order for contact precautions. When DON was informed of resident #35 having a droplet isolation precaution sign on his door and an empty PPE supply box outside, she stated she “didn’t think that room was on precautions,” but said she would look into it. On 7/17/25 at 9:55 AM, the DON confirmed she verified whether residents #13 and #22 had orders for isolation precautions and determined they were not supposed to be on isolation precautions. She acknowledged she did not check to see if they had the correct signage for precautions. She stated that the position of Infection Preventionist was shared between herself and the UM. The DON stated her expectation was for the UM to perform daily rounds to verify which residents were on isolation precautions and refill the PPE supplies outside rooms if needed. On 7/17/25 at 11:36 AM, the DON confirmed resident #35 did not have an order for isolation for droplet precautions nor a care plan focus for it. She stated that while reviewing the resident’s medical record she noted he was admitted to the facility with orders for an antibiotic for treatment of Human Metapneumovirus (HMPV) and he was to remain on droplet isolation precautions until the course of antibiotics was complete. The DON explained that upon admission an order for droplet isolation precautions should have been added to the resident’s EMAR, but it was not. The DON said she relied on the infection control section of their healthcare software to track infections and antibiotics, but she did not actually review the antibiotic orders to verify their accuracy or to determine if any transmission-based isolation precautions were required. The DON explained she expected the UM to monitor the orders and acknowledged infections and antibiotics had not been properly tracked. On 7/18/25 at 11:28 AM, the DON said when a resident was on any type of transmission-based isolation precautions (TBP) an order was added to the resident’s EMAR so staff could easily identify which resident was on isolation precautions. The DON reiterated that while she and the UM shared the role of Infection Preventionist, the UM was responsible for performing the daily rounds of the facility to ensure accurate signage for TBP on resident rooms and to ensure PPE containers were stocked with appropriate supplies. The DON confirmed she was also responsible for monitoring of infections, antibiotics and TBP. The DON was unable to say how incorrect signage and an empty PPE container for residents #13 and #25 was left in place if infections and TBP were monitored as part of their daily surveillance including walking past that room without correcting the issues. When asked if part of her monitoring and tracking of infections included making sure all the doses of an antibiotic were given, she replied “no”. She stated she expected nurses to put information such as missed doses of antibiotics in their 24-hour report book as well as to notify the doctor. In the case of a resident missing doses of an antibiotic, she acknowledged the physician should be notified and then typically doses were added to extend the course of the antibiotic, so the resident received the full dose. The DON stated she was unaware resident #35 had missed three doses of his antibiotic. 3. On 7/14/25, the dining room was observed from 12:00 to 12:35 PM during the lunch service. No hand hygiene was offered by staff to any of the 13 residents eating there. On 7/15/2025 at 11:50 AM, two Activities staff finished an activity with residents and announced to the residents they were going to move everyone to the dining room for lunch. Resident #10, #43, along with two additional residents were moved directly from the room with the activity into the dining room and stayed there until they ate. At 11:57 AM, resident #43 was transported to his room to add a 2nd hospital gown to cover his back and was then transported back to the dining room without washing his hands. No hand hygiene was offered to any of the 12 residents who ate lunch in the dining room for this meal. On 7/17/25 at 8:50 AM, resident #10 stated she ate breakfast in her room and ate lunch and dinner in the dining room. She added that staff did not offer her a way to clean her hands before breakfast nor was she offered a way to clean or disinfect her hands prior to the meals in the dining room. Resident #10 said it would be nice to be offered a way to clean our hands since we touch lots of things during the day. On 7/17/25 at 9:02 AM, Certified Nursing Assistant (CNA) A delivered breakfast, raised the head of the bed, and set up the tray for resident #42, but did not offer hand hygiene. The resident stated the aide assigned to provide her care today did not assist with washing her face and hands before breakfast like she preferred. At 9:04 AM, CNA A delivered breakfast to resident #10 and did not offer hand hygiene. CNA A explained she was not the assigned CNA for resident #42 today, it was CNA C. At 9:07 AM, CNA C confirmed she did not offer to wash residents #10 and #42 this morning before their meal because they were asleep when she arrived. She stated she didn't offer hand hygiene to residents prior to their meals but said it was a good idea. CNA C conveyed it was important to have residents clean their hands before meals to help prevent illness and the spread of germs. In a joint interview on 7/17/25 at 9:26 AM with the DON and the UM, they said the DON was the primary Infection Control nurse, but the UM assisted her. The DON and UM stated they were not aware staff had not offered/assisted residents to have their hands and faces washed before breakfast when they ate in their room. They acknowledged residents brought into the dining room for lunch and dinner were not offered hand hygiene prior to the meals. The DON and UM added, it was important to offer hand hygiene before meals to prevent germs as residents touched things throughout the day and was important to perform before meals. The UM acknowledged she had not provided education to staff on washing residents' hands before meals but had provided education for cleaning their own hands. The facility’s policy entitled Assistance with Meals, dated September 2013, indicated all employees who provided assistance to residents with meals would be trained and demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. The facility job description for Infection Preventionist (IP) revised April 2012 listed the responsibilities of the position to include, develop, maintain and periodically update infection control precautions. The document indicated the IP was responsible to ensure adequate supplies of PPE were on hand and readily available to personnel who perform procedures that involved exposure to bodily fluids. The description detailed the IP was responsible to ensure all nursing service personnel follow established isolation precautions and aseptic technique to include standard/universal precautions. The facility assessment most recently updated 8/01/24 indicated, “the infection prevention program will include detection, prevention and control of infections among residents and personnel through on-going monitoring. The Infection Preventionist will be responsible for the overall daily functions of the infection prevention program to include surveillance and maintaining a line listing of infections.”

Based on interview, and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, of a total sample of 26 residents, (#06 and #09).Findings: 1. Resident #06 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation, hypertensive heart disease, type 2 diabetes and benign prostatic hyperplasia (enlarged prostate). Review of resident #06's financial record revealed he began a Medicare Part A skilled nursing stay on 4/23/25 with last covered day on 5/31/25. He remained in the facility and was considered private pay effective 6/01/25. A SNF Beneficiary Protection Notification review revealed resident #06 received a Notice of Medicare Non-Coverage (NOMNC) at the end of his Medicare Part A stay but did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Resident #09 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive system, benign prostatic hyperplasia with lower urinary tract symptoms, paroxysmal atrial fibrillation and hypertensive heart disease with heart failure. Review of resident #09's financial record revealed he began a Medicare Part A skilled nursing stay on 5/05/25 with last covered day on 6/13/25. He had managed Medicaid as his primary payer effective 6/14/25. A SNF Beneficiary Protection Notification review revealed resident #09 received a NOMNC at the end of his Medicare Part A stay but did not receive a SNF ABN. Review of residents who discharged from a Medicare Part A stay in the last six months revealed there were seven residents who discharged from a Medicare Part A stay without using all available days and remained in the facility. On 7/17/25 at 10:15 AM, the Regional Accounts Receivable Director stated there was a change as to who was responsible for issuing the beneficiary forms around the time these forms were missed. She explained the Regional Social Services Director (SSD) issued them previously, but the responsibility was passed to the facility SSD. She stated the facility SSD was not made aware of the need to issue a SNF ABN along with the NOMNC when a resident remained in the facility. She acknowledged they should have been issued to residents #06 and #09. The facility's policy and procedure for Medicare Advance Beneficiary and Medicare Non-Coverage Notices indicated if the facility believed that Medicare would not pay for an otherwise covered skilled services, the resident or representative would be notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s).

Based on interview, and record review, the facility failed to make transportation arrangements for a resident to a specialty medical care appointment, for 1 of 1 residents reviewed for transportation, of a total sample of 26 residents, (#8). Findings: Review of resident #8's record revealed an admission date of 8/17/22. Her diagnoses include spinal stenosis (narrowing), opioid dependence, hereditary and idiopathic neuropathy (nerve pain), chronic pain syndrome, fusion of spine, fibromyalgia, bursitis (inflammation of fluid filled sacs) of right hip and connective tissue stenosis of neural canal of lumbar region. On 7/14/25 at 11:27 AM, the resident stated there were often issues related to her appointments and transportation. She explained she had missed some appointments before and was supposed to have a Magnetic Resonance Imaging (MRI) appointment today which was set up by her pain management physician. The resident conveyed when she talked to staff this morning about her appointment, they said they were not aware of it and so no arrangements were set up. Resident #8 expressed she was very upset because the appointment was made months in advance and required her to be sedated due to her claustrophobia. Review of resident #8's electronic medical record (EMAR) revealed a progress note dated 5/08/25 at 1:57 PM, written by the Social Services Director which indicated the resident had a scheduled appointment for intravenous (IV) sedation for MRI, and a computed tomography (CT) scan on 7/21/25 at 1:00 PM, to arrive at 11:00 AM with a staff member to be transported by the local public transportation company. Review of a note written on 5/08/25 at 1:54 PM, indicated resident #8 had an appointment scheduled for IV sedation for MRI and CT scan on 7/14/25 at 2:30 PM, to arrive at 1:00 PM with a staff member, transportation to be provided by local public transport company. On 7/16/25 at 3:08 PM, the Social Service Director confirmed she wrote the two progress notes on 5/08/25 about the resident's appointments. She stated she did not typically handle transportation and appointments, but the resident was more comfortable with her than other staff. The Social Service Director explained her process was to write information down and then pass it along to nursing staff for them to handle. She confirmed that back in May, the resident was using the local public transportation company but had since been switched to a different transportation company. The Social Service Director acknowledged she did not call the new transportation company to arrange transport for the appointment. She clarified that appointments were put into the resident's orders by nursing, but the Social Service Director could not remember who she passed the new information to at the time of the appointment. On 7/16/25 at 12:15 PM, in a joint interview with the Director of Nursing (DON) and the Unit Manager (UM), the UM said she arranged transportation for resident #8 to her appointments. She explained the resident made her own appointments and notified the facility of the time, date and location of said appointment. The UM continued that she would text the transportation company with the resident's appointment information when she was informed of the appointment. She said the facility kept a transport calendar with all resident appointments for the month. Review of transportation calendar on 7/16/25 at 3:20 PM, with the UM revealed no appointment for resident #8 on 7/14/25 for transportation to her MRI and CT. The calendar did show an appointment for 7/21/25. The UM said she added the 7/21/25 appointment to the calendar on 7/15/25 after she had contacted the pain management physician. She confirmed another appointment was added for September as a make-up appointment for the missed appointment from 7/14/25. On 7/16/25 at 3:35 PM, the DON stated that their process for resident appointments was to write an order in the resident's EMAR listing the date, time, and nature of the appointment. The DON acknowledged there was no order for the resident's appointment on 7/14/25 nor for the one on 7/21/25 until 7/15/25, after they were informed by resident #8 of the missed 7/14/25 appointment. The DON confirmed the progress note on 5/08/25 by the Social Service Director with the appointment details. She stated she was unsure how she missed that. The facility policy titled Resident Transportation revised September 2017 indicated the facility would meet the needs for residents' transportation.

Based on observation, interview, and record review, the facility neglected to provide necessary care and services to prevent falls and a fall-related injury and ensure appropriate post-fall monitoring and evaluation, for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4); and failed to maintain effective processes to educate staff and offer adequate supervision to meet the needs of all residents at risk for falls. The facility's failure to appropriately monitor residents with cognitive and/or physical impairments resulted in actual harm for resident #4, and placed all residents who required increased supervision at risk for injury. Resident #4, a physically and cognitively impaired resident, received blood thinner medication and had a history of repeated falls. On 12/22/24, the Certified Nursing Assistant (CNA) assigned to supervise residents in the fall prevention program in the activity room left the residents unattended, and resident #4 fell from her wheelchair to the floor. Ten days later, another CNA left the resident alone in the activity room and she had another unwitnessed fall from the wheelchair. Assigned nurses neither initiated neurological checks nor notified with the physician until almost 12 hours after the fall when staff discovered the resident had a bruise and a golf ball sized hematoma on her forehead. The resident suffered pain and anxiety, and required transfer to the hospital for diagnostic testing to rule out a brain bleed. Findings: Cross reference F689. Review of the medical record revealed resident #4, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, stroke, lack of coordination, repeated falls, generalized muscle weakness, unsteadiness on her feet, right knee contracture, anxiety disorder, paranoid schizophrenia, and Alzheimer's disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 10/16/24 revealed resident #4 had a Brief Interview for Mental Status score of 6/15 which indicated she had severe cognitive impairment. She had fluctuating inattention which changed in severity and continuous disorganized thinking. Resident #4 had functional limitation in range of motion with impairment of one leg and used a wheelchair for mobility. She required substantial or maximal assistance for mobility and transfers and did not walk. The MDS assessment showed resident #4 received a high-risk drug, an anticoagulant or blood thinner, in the look back period. Resident #4's medical record revealed a care plan for fall risk, initiated on 2/07/23, which indicated she was unable to ambulate or transfer independently and had fall risk factors including decreased mobility, weakness, psychiatric medications, and cognitive deficits. The goal was resident #4 would not sustain a major fall-related injury by utilizing fall precautions as evidenced by observation and documentation. Interventions included participation in the fall risk program, remind to ask for help but recognize that the resident might not remember to ask, and escort to activity programs. A care plan for impaired mobility, initiated on 2/22/24, revealed resident #4 required ongoing assistance with mobility. The goal was she she would be out of bed daily in her wheelchair and transfer with assistance from one staff member. Review of a care plan for cognition, initiated on 2/22/24, revealed the resident's confusion and a language barrier affected her comprehension. Interventions included provide a safe and structured environment. On 2/14/25 at 12:24 PM, and 2:10 PM, the Director of Nursing (DON) explained the facility initiated a fall prevention program to provide enhanced or increased monitoring for residents at risk for falls. The DON stated either activities assistants or CNAs who were assigned to the floor monitored these residents in the activity room. She verified resident #4 was at high risk for falls and needed to participate in the fall prevention program. The DON reviewed resident #4's fall on 12/22/24 at 1:45 PM. She stated resident #4 was one of the residents in the fall prevention program. She explained the resident was found on the floor and the assigned CNA verified she was not in the activity room at the time. The DON said, We were doing 1-hour rotations for fall prevention and all CNAs shared the responsibility. She stepped out to give a resident a shower on instruction of a nurse. She stated the facility educated CNAs and nurses regarding endorsing the supervision task to another staff member before leaving the room. Review of an Education/In-Service Attendance Record dated 12/22/25 and titled 1 to 1 Supervision revealed the Administrator educated staff on the expectations for one-to-one supervision of residents. The program description read, When on 1:1 supervision as assigned, you cannot leave the resident(s) you are supervising unless coverage is there to relieve you. If you need to leave and no coverage, notify nurse. When on 1:1 you are responsible for that resident. Reconciliation of the attendance sheet with the facility's employee list revealed signatures for a total of 13 staff members including 4 of 11 Registered Nurses (RNs), 2 of 7 Licensed Practical Nurses (LPN) and 7 of 27 CNAs. On 2/14/25 at 10:25 AM, Activities Assistant P was seated in the activity room with four residents. She explained none of the residents required one-to-one supervision, but she watched over them while they were in the room. On 2/15/25 at 9:34 AM, Activities Assistant Q stated she was assigned to the activity room every Saturday from about 9:30 AM until lunchtime. She explained not all residents in the room were at risk for falls, and indicated only one of the six residents present was a fall risk. Although resident #4 was in the room, Activities Assistant Q pointed to another resident and when asked, denied resident #4 was the person at risk for falls. On 2/15/25 at 2:07 PM, the Administrator verified as the facility's Risk Manager, his duties included implementing interventions and processes to prevent recurrence of incidents and ensure the safety of residents. He confirmed resident #4 fell in the activity room on 12/22/24 when the assigned CNA left the residents unattended, and as a result, he initiated education on expectations for the fall prevention program to ensure the residents received the required level of supervision. The Administrator was informed only 13 of 45 nursing staff received the in-service, and no activities staff were included even though they were assigned to monitor residents in the activity room. He acknowledged the in-service did not reach an adequate number of staff and it was apparent that education did not continue after the day he initiated it. On 2/14/25 at 12:24 PM, the DON verified resident #4 had another unwitnessed fall in the activity room on 1/01/25 at 10:30 PM. She explained the resident was with a CNA who was charting in the activity room, and the CNA left her unattended to respond to a call light. The DON stated at the time the assigned nurse assessed her, the resident had no injuries, but the following day staff discovered a hematoma on her forehead. She confirmed the assigned night shift nurse did not perform neurological checks and the developing hematoma went unnoticed. According to the Agency for Healthcare Research and Quality (AHRQ), there is an increased risk of intracranial hemorrhage (bleeding in the brain) in elderly patients on anticoagulant therapy. The AHRQ indicates important clinical communications include documentation of the incident, outcome, and initial and ongoing observations, and an updated care plan in the medical record; and the medical provider should be notified at the time of the incident. Since there may be late manifestations of head injury even after 24 hours, it is necessary to perform neurological checks or neurochecks for 72 hours to evaluate and monitor residents after falls. Neurochecks include monitoring of vital signs, pupil size and reaction to light, reflexes, movement, and level of consciousness (retrieved on 2/24/25 from www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html). On 2/15/25 at 10:03 AM, the DON stated her expectation was nurses would adhere to accepted standards of practice and conduct post-fall neurochecks immediately after the incident, every 15 minutes for one hour, then every 30 minutes, with increasing intervals up to 72 hours, or until discontinued by the physician. Review of an Interdisciplinary Team (IDT) progress note dated 1/02/25 revealed on 1/01/25, resident #4 was agitated and attempted to get out of bed. The note indicated staff intervened for safety reasons, assisted her to her wheelchair, and brought her to the unit's common are for observation. The document revealed a while later, resident #4 was found on the floor. The assigned nurse called the Advance Practice Registered Nurse (APRN) to report the fall and then gave shift change report regarding the incident to the oncoming night shift nurse. The IDT note showed no actions taken related to closely monitoring the resident's status during the night shift, additional attempts to notify the provider, and obtaining appropriate orders. The document revealed the provider arrived at the facility the following morning to round and assessed resident #4 at that time. The physician instructed staff to send the resident to the hospital for evaluation due to her fall and head injury with the risk factor of receiving blood thinner medication. On 2/14/24 at 10:42 AM, resident #4's daughter stated her mother fell in the activity room a little over a month ago. She explained it was a scary incident as her mother was on blood thinners and hit her head when she fell . She recalled her mother's face was badly bruised for a while, but fortunately she did not suffer a brain bleed. The resident's daughter stated hospital staff emphasized that her mother needed to got to the hospital for evaluation after any falls with possible head injuries. She stated the facility informed her the CNA who was with her mother got up and left her alone in the activity room. On 2/14/25 at 3:52 PM, RN M stated resident #4 was at high risk for falls and often required increased supervision from staff to ensure her safety. She explained there were several other residents who were at high risk for falls and providing adequate supervision for them all was challenging. RN M recalled on 1/01/25, resident #4 was agitated and staff brought her to the nurses' station to monitor her. RN M stated she was occupied with another resident who needed to be transferred to the hospital and she told the three CNAs on the unit that someone needed to watch resident #4. She recalled when she finished with the other resident, she heard a moan from the activity room, and discovered resident #4 on the floor. RN M said, They weren't paying attention to me. I don't know why she was abandoned in the activity room. I felt like it was insubordination by the CNAs as several times I told them to sit with her. She explained the resident did not appear to have any injuries and she handed over her care to the oncoming night shift nurse. RN M confirmed she did not initiate neurochecks even though the fall was unwitnessed and it was unknown if the resident hit her head. She explained the resident was on her back and appeared to have slid to the floor. RN M acknowledged the resident's use of a blood thinner increased her risk for a serious brain bleed related to a head injury. She stated she called the APRN and left a message but never received a call back, and she did not attempt to notify or obtain orders from another provider. On 2/14/25 at 1:36 PM, in a telephone interview, LPN K recalled she received shift change report from RN M on 1/01/25 regarding resident #4's fall, and was told the post-fall assessment was negative and she did not seem to have hit her head. LPN K stated RN M informed her the APRN had not yet returned her call. She remembered when she arrived for her shift, all staff were arguing about who was supposed to have been supervising the resident. She stated a CNA sat with resident #4 until she started falling asleep in the wheelchair and staff then put her to bed. LPN K stated the resident slept throughout the night and she did not see her until the next morning when the day shift CNA got her out of bed and brought her out of her room. LPN K said, I looked at her and noticed discoloration to the side of her head. I said she doesn't look right. She confirmed she had not followed up with the APRN during her shift nor perform neurochecks since RN M had not initiated them. LPN K acknowledged if a resident had an unwitnessed fall, neurochecks should be done because there might be a head injury. She explained residents on blood thinners who had an unwitnessed fall should be sent to the hospital for testing. On 2/15/25 at 11:43 AM, the DON verified although resident #4 was a known fall risk, she had two unwitnessed falls over a 10-day period when CNAs left her unattended in the activity room. However, she stated she felt the resident was adequately supervised on both occasions as she did not have a care plan for one-to-one supervision. She acknowledged the first fall occurred when the assigned CNA left the group of residents in the fall prevention program and the second fall occurred after a CNA ignored a nurse's explicit instruction to remain with resident #4. The DON confirmed resident #4's physician was not informed of the second fall for almost 12 hours, and the resident remained in the facility without being appropriately monitored by nurses, but she reiterated, I would not say it was neglect. Review of the facility's policy and procedures for the Abuse Prevention Program, revised in August 2006, revealed residents had the right to be free from abuse and neglect. The policy listed components for the prevention of neglect that included staff training, identification of occurrences and patterns of potential abuse or neglect, conducting ongoing review and analyses of incidents, and implementing changes to prevent future occurrences. Review of the Facility assessment dated [DATE] revealed the facility was able to meet the needs of residents with common diseases, conditions, and physical and cognitive disabilities such as impaired cognition, anxiety disorder, behavior that required intervention, Alzheimer's disease, muscle weakness, and a history of falling. The Facility Assessment revealed staff would provide person-centered care by identifying hazards and risks and preventing abuse and neglect.

Based on interview, and record review, the facility failed to provide adequate supervision to prevent falls and fall-related injury for 1 of 4 residents reviewed for fall risk, of a total sample of 8 residents, (#4). The facility's failure to appropriately monitor residents with cognitive and/or physical impairments resulted in actual harm for resident #4, and placed all residents who required increased supervision at risk for injury. Resident #4, a physically and cognitively impaired resident, received blood thinner medication and had a history of repeated falls. On 12/22/24, the Certified Nursing Assistant (CNA) assigned to supervise residents in the fall prevention program in the activity room left the residents unattended, and resident #4 fell from her wheelchair to the floor. Ten days later, another CNA left the resident alone in the activity room and she had another unwitnessed fall from the wheelchair. Assigned nurses neither initiated neurological checks nor notified the physician until almost 12 hours after the fall when staff discovered the resident had a bruise and a golf ball sized hematoma on her forehead. The resident suffered pain and anxiety, and required transfer to the hospital for diagnostic testing to rule out a brain bleed. Findings: Cross reference F600. Review of the medical record revealed resident #4, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included atrial fibrillation, stroke, lack of coordination, repeated falls, generalized muscle weakness, unsteadiness on her feet, right knee contracture, anxiety disorder, paranoid schizophrenia, and Alzheimer's disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 10/16/24 revealed resident #4 had a Brief Interview for Mental Status score of 6/15 which indicated she had severe cognitive impairment. The document indicated she had fluctuating inattention which changed in severity, and continuously present disorganized thinking. The resident had functional limitation in range of motion with impairment of one leg, used a wheelchair for mobility, and required substantial or maximal assistance for self-care and mobility. The MDS assessment showed resident #4 received a high-risk drug, an anticoagulant or blood thinner, in the look back period. A Fall Risk Screen dated 9/16/24 revealed a score of 16 which indicated resident #4 was at high risk for falls. Resident #4's medical record revealed a care plan for fall risk, initiated on 2/07/23, indicated she was unable to ambulate or transfer independently and had fall risk factors including decreased mobility, weakness, psychiatric medications, and cognitive deficits. The care plan revealed she fell at least four times between July and December 2024. The document was updated on 12/18/24 to reflect a fall without injury when she attempted to go to the bathroom. A revision dated 12/23/24 revealed the resident slid from her wheelchair onto the floor and did not sustain any injuries. The goal was resident #4 would not sustain a major fall-related injury by utilizing fall precautions as evidenced by observation and documentation. Interventions included participation in the fall risk program, non-slip pad for the wheelchair seat, remind to ask for help but recognize that the resident might not remember to ask, and escort to activity programs. A care plan for impaired mobility, initiated on 2/22/24, revealed resident #4 required ongoing assistance with mobility. The goal was she she would be out of bed daily in her wheelchair and transfer with assistance from one staff member. Review of a care plan for cognition, initiated on 2/22/24, revealed the resident's confusion and a language barrier affected her comprehension. Interventions included provide a safe and structured environment. Review of an incident report dated 12/22/24 at 1:45 PM revealed resident #4 fell to the floor from her wheelchair in the activity room. The document indicated she was uninjured and staff assisted her back to the wheelchair. Review of staff statements obtained during the incident investigation revealed resident #4 was one of a group of residents in the facility's activity room. The residents were supposed to be under direct supervision of an assigned CNA, who explained she left the residents in the room to attend to another resident who needed a shower. Statements from both Registered Nurses (RNs) on schedule revealed resident #4 was found on the floor with her coloring book nearby. A Post Fall Evaluation dated 1/01/25 at 11:30 PM, revealed ten days later, resident #4 fell in the facility's activity room at 10:30 PM. The document indicated the unwitnessed fall occurred because she was unattended in activity room. RN M's documentation revealed she instructed CNAs three times to not leave the resident unattended. She wrote, Resident left unattended in activity room, while I was giving report to [Emergency Medical Services]to send another resident to the hospital due to critical abnormal labs. The document indicated a hematoma was noted on resident #4's head the following day, on 1/02/25. Review of resident #4's Physician Orders revealed on 12/02/24, her physician prescribed Warfarin Sodium 6 milligrams once daily at 5:00 PM. There was an order dated 1/02/25 to transfer her to the hospital for ecchymosis or bruising and a hematoma on her forehead after a fall. Warfarin is an anticoagulant or blood thinner drug that reduces the formation of blood clots and can cause major or fatal bleeding. The manufacturer's instructions to providers indicate the use of Warfarin for geriatric patients, particularly those with cognitive issues, requires more frequent monitoring for bleeding in any situation or with any physical condition where added risk of hemorrhage is present (retrieved on 2/19/25 from www.drugs.com/pro/warfarin.html). A hematoma is a raised, bruised area resulting from a collection of clotted blood due to an injury or trauma (retrieved on 2/19/25 from www.my.clevelandclinic.org/health/diseases/15235-bruises). Falls can cause very serious head injuries, especially if the person is taking blood thinners. Older persons who fall and hit their heads should see a physician immediately to ensure they do not have a brain injury (retrieved on 2/20/25 from www.cdc.gov/falls/data-research/facts-stats/). Review of the Resident Transfer Form dated 1/02/25 revealed resident #4's diagnoses at the time of her transfer to the hospital were fall, blood thinners, and dementia. The document showed the resident had an injury to the left side of her forehead. Resident #4's hospital record revealed a computed tomography (CT) scan of her head, done on 1/02/25, found no hemorrhage or skull fractures, but showed soft tissue swelling in the left frontal scalp. On 2/14/24 at 10:42 AM, resident #4's daughter stated her mother fell in the activity room a little over a month ago. She explained it was a scary incident as her mother was on blood thinners and hit her head when she fell . She recalled her mother's face was badly bruised for a while. The resident's daughter said, Thanks to God she didn't have a serious injury inside her head. At the hospital they told me since she was on [Warfarin], she should get checked out there after a fall. She stated the facility informed her the CNA who was with her mother got up and left her alone in the activity room. On 2/14/25 at 3:52 PM, RN M described resident #4 is a well-known fall risk who needed staff supervision, sometimes one-to-one, to ensure she did not crawl out of bed or slide out of her wheelchair. She recalled the resident was agitated on the night of 1/01/25, so she asked CNAs to keep her in a common area and monitor her closely. RN M stated while she attended to another resident in a crisis situation, she repeatedly looked towards the nurses' station where resident #4 sat in her wheelchair, and repeatedly instructed the CNAs to ensure someone stayed with her. RN M stated a little later she was in the hallway and heard a moan from the activity room. She explained she discovered the resident on the floor, parallel to her wheelchair, and there was no CNA present in the room. RN M stated she assessed resident #4 and noted no injuries, so staff returned her to the wheelchair. She stated there were no new fall prevention interventions for this resident, and residents at risk for falls were placed in the activity room with CNAs rotating through the room to watch them. She explained the facility did not always have enough staff to monitor residents who needed more supervision. On 2/15/25 at 9:14 AM, the Director of Rehabilitation (Rehab) confirmed resident #4 had cognitive issues and required close monitoring to promote her safety. She reviewed an Occupational Therapy Evaluation completed on 11/22/24 which indicated the resident was at risk for falls due to impaired safety awareness and decision-making. The Director of Rehab explained resident #4 was not able to stand and transfer without moderate assistance from one person, and if she was not inclined to cooperate, it might be necessary for two people to assist for safety reasons. The Director of Rehab said, She is impulsive and thinks she can do stuff. She stated the interdisciplinary team spoke about a reacher after the fall in January 2025 as a possible intervention to prevent falls. She explained due to the resident's poor cognition, she probably would not use a reacher effectively. She verified falls were a leading cause of injuries for the elderly, and stated some falls could be prevented if residents could be educated and followed commands. The Director of Rehab acknowledged supervision was the most important approach to keep resident #4 and other cognitively impaired residents safe. On 2/14/25 at 12:24 PM and 1:30 PM, the Director of Nursing (DON) discussed resident #4's recent falls in the activity room. She explained on 12/22/24, the resident slid from her wheelchair when she reached to pick up coloring items that fell to the floor. She stated the care plan was revised to include a a non-slip pad for her wheelchair to prevent her from sliding. However, the DON acknowledged the exact circumstances of the fall were unknown as it was unwitnessed. She verified the resident fell when the CNA assigned to ensure the safety of residents in the fall prevention program left the room. Although resident #4's fall occurred when she was not supervised, the care plan was not updated to reflect her need for supervision, and the DON maintained a non-slip pad was an appropriate intervention for that circumstance. The DON stated after the resident's fall on 1/01/25, she asked the therapy department to re-evaluate her for wheelchair positioning and a reacher device. She confirmed the resident's fall occurred after a CNA again left her alone in the activity room. The DON verified although the CNA should not have left the resident unattended, and nursing documentation revealed she needed close monitoring, the care plan was not revised to show she required increased supervision. She reiterated the interventions related to assessing the resident for proper positioning in the wheelchair and use of a reacher were appropriate Review of the facility's Falls-Clinical Protocols, revised in March 2018, revealed the physician would identify medical conditions affecting fall risk including cognitive impairment and musculoskeletal abnormalities, and note the risk for significant complications of falls such as an increased risk for bleeding in residents who took anticoagulants. The document indicated staff and the physician would attempt to identify underlying causes, develop pertinent interventions to try to prevent subsequent falls, and monitor the effectiveness of the approaches.

Based on observation, interview, and record review, the facility failed to maintain sufficient staff to provide adequate supervision and meet care needs to ensure the safety and well-being, according to the plans of care, for all residents of the facility. Findings: Review of the Facility assessment dated [DATE] revealed the facility had 39 licensed beds and the average daily census over the previous three months was 32 residents. The document indicated the facility was able to meet the needs of residents with common diseases, conditions, and physical and cognitive disabilities such as impaired cognition, anxiety disorder, behavior that required intervention, Alzheimer's disease, muscle weakness, and a history of falling. At the time the Facility Assessment was completed, the census was 30 residents and approximately 50% of the residents were totally dependent on staff for assistance with dressing, transfers, toileting, and mobility. The document indicated one resident was independent for mobility and two residents were independent for toileting and transfers. All other residents required the assistance of one to two staff for transfers, toileting, and mobility, and there were no residents who were independent with all activities of daily living. The Facility Assessment revealed staff would provide support to meet care needs for mobility and prevention of falls or falls with injury by assisting with transfers and activity programming, and provide person-centered care by identifying hazards and risks. On 2/14/25 between 10:20 AM and 10:40 AM, during tour of the facility, Certified Nursing Assistants (CNAs) entered and exited residents' rooms to provide care. All staff appeared rushed as they went from room to room and did not pause to interact with residents in the hallways or common areas. Multiple call lights were observed, with an average staff response time of approximately five minutes. CNAs entered the rooms, turned off call lights, and exited almost immediately to continue their rounds. Review of the staffing board revealed the census was 33 residents and there were two nurses and three CNAs working. On 2/14/25 at 10:58 AM, the Administrator stated the facility was usually staffed with three to four CNAs on the day and evening shifts, and two to three CNAs on the night shift, depending on the census. He explained the facility has always exceeded the State minimum requirements for staffing. On 2/15/25 at 9:40 AM, during tour of the facility, as CNAs gave care to residents, they appeared hurried as they rushed from task to task and the call light response time was greater than five minutes. Call lights in two rooms were turned off by staff who immediately exited the rooms, and were quickly pressed again by residents. On 2/14/25 at 3:52 PM, Registered Nurse (RN) M explained resident #4 was at high risk for falls and staff would often need to initiate one-to-one supervision to ensure her safety. She stated there were currently several residents who were at risk for falling, and the high acuity care needs sometimes created dangerous situations. When asked if the facility maintained adequate staff, she said, Staffing is definitely a concern. I have brought it up to the DON [Director of Nursing] and Administrator. RN M explained insufficient staffing was not an isolated thing and even if four CNAs were scheduled, when one called off, as happened yesterday, there were only three CNAs left to meet the residents' needs. RN M explained nursing staff determined that in addition to residents who required increased supervision, almost two-thirds of the residents required two-person assistance for safety or care. She confirmed the facility's fall prevention program involved CNAs who had resident care assignments doing 1-hour rotations to sit in the activity room with residents at risk for falls. RN M explained staff were busy during the evening shift and there are not always enough staff to watch the residents who needed more supervision. On 2/14/25 at 4:27 PM, CNA F was seated in the activity room with eight residents. She explained she was doing her 1-hour rotation in the room until 5:00 PM. She confirmed she was currently assigned to care for 11 residents, but only one person in the activity room was on her assignment. When asked who provided care for her residents while she did rotations in the activity room, she stated other CNAs answered her residents' call lights, if they were not busy. CNA F said, But I cannot really say if they are changing anyone. If I have showers scheduled, they have to wait. To change some people that use a [mechanical lift], it takes two people to put them back to bed and into the chair again. That means it can't always be done. On 2/14/25 at 4:34 PM, CNA E confirmed all CNAs were required to take turns in the activity room to provide one-to-one care for residents at risk for falls. She explained when there were only three CNAs scheduled, it was difficult to complete all required tasks for the shift. She said, One person sitting in the room leaves only two on the floor. Everybody is busy and it's hard to take care of your people and another assignment too. If I am watching someone's assignment, I can't do showers or anything that will take a lot of time. If I do, then that leaves only one CNA on the floor. On 2/14/25 at 4:48 PM, CNA D confirmed she had to sit with residents in the activity room for one hour at a time. She explained the other CNAs on the unit answered call lights for the CNA assigned to the fall prevention program. She stated if there were only three CNAs scheduled, it was hard to give appropriate care to assigned residents. On 2/15/25 at 10:11 AM, CNA B verified she was required to do 1-hour rotations in the activity room although she was assigned to care for nine residents. She explained the facility was usually staffed with three CNAs and it was very hard to manage with that number of staff as many residents were at risk for falls. She said, You have to stop care and go sit for an hour. We have told the DON and Administrator and they know that it would be better with four. It would be better for us not to have to rotate. CNA B confirmed she was to expected to do rounds every two hours and some residents complained that they call and CNAs do not get to them timely. On 2/15/25 at 10:28 AM, Licensed Practical Nurse (LPN H) acknowledged nursing staff were supposed to closely monitor residents at risk for falls. She explained nurses tried to assist CNAs by responding to call lights during the time they were assigned to the activity room. She stated she was sure the CNAs could be overwhelmed and it did not seem like an optimal care situation. LPN H said, I have to help CNAs, but I have my job. I feel like we could absolutely improve on staffing. On 2/15/25 at 10:46 AM, CNA O hesitated when informed he was to be interviewed by State Survey Agency staff. He asked how long the interview would take as he had to return to his assigned residents to provide activities of daily living care and did not have much time. CNA O verified he took turns with other CNAs to rotate through the activity room when activities were not there. He stated the other CNAs covered his assignment during the time he was off the floor. CNA O said, It would be preferable to have an assigned CNA in that room. On 2/15/25 at 11:00 AM, CNA L, stated she was assigned to care for 11 residents including five who were totally dependent and others who were at risk for falls. She said, To be honest, I am not giving the best care possible to my residents as I can't leave the fall risks in the activity room. She explained if her assigned residents needed care, the other CNAs or nurses could respond to call lights. She confirmed the residents who did not use the call light would have to wait until she was finished with her hour-long activity room rotation. CNA L stated the facility's Administrator and DON were aware of how difficult it was for staff to do the one-to-one rotation. She stated staff informed the members of facility management that they needed additional help in the form of an extra CNA. CNA L said, We were told by the person who did scheduling that the facility has to go by numbers and it depends on the census. On 2/15/25 at 11:15 AM, CNA A stated residents who were agitated and/or at risk for fall risks posed a challenge on the days when the facility did not have enough staff. She explained CNAs sometimes resorted to putting residents in wheelchairs and taking them along as they worked or placing them beside the nurse. On 2/15/25 at 2:53 PM, CNA G stated she felt the facility was usually understaffed, especially on the 3:00 PM to 11:00 PM shift. She explained if there was a call off, there would usually only be two CNAs in the facility. She said, Imagine what that is like. Watching the people who fall and with more than 15 residents each. She added that there were many residents who required assistance from two staff as they transferred with a mechanical lift and it was almost impossible to get help if the other CNA is in the activity room. CNA G said, It is not fair. Staffing is horrible. They must be trying to save money. On 2/15/25 at 1:57 PM, CNA C explained the requirement to supervise the residents at risk for falls in the activity room took up at least two and sometimes three hours out of her 8-hour shift. She said, It absolutely gets in the way of caring for my residents. We have to take 1-hour turns and we get overloaded. We get angry because we can't do our own job. They need someone in the room. She explained CNAs were so behind on their work by the end of the shift that they could not leave on time. CNA C stated she often continued to work with patients and chart after shift change report. She verified the facility used to schedule four CNAs for days and evenings, but recently it is usually three CNAs. On 2/15/25 at 2:44 PM, CNA I stated CNAs had to do rotations in the activity room to monitor up to ten residents who were at risk for falls. She described feeling burnt out and physically exhausted when she got home due to the demands of the job. CNA I said, It is supposed to be one-to-one, but it is really one CNA to seven or more. Staff have told them it isn't good. You are like a prisoner in that room, looking out while your own residents are not getting the right care. Yes, someone might answer the call lights, but they are not doing everything else in the line of giving care. On 2/15/25 at 12:04 PM and 12:20 PM, the Administrator and DON stated they were not aware staff were overwhelmed and had concerns related to not being able to meet residents' care needs, nor that staffing ratios were a problem due to the requirement for CNAs to leave their assigned residents and sit in the activity room for one hour rotations. He explained activity department staff also assisted with supervision of residents in the fall prevention program. He was informed interviews with activities staff revealed they were not aware of which residents in the room required close supervision. The Administrator stated activities staff assisted from about 9:00 AM until lunchtime and then returned by 1:30 PM and stayed until about 3:00 PM. He stated after activities staff left the room, nurses were expected to jump in and assist call lights and sitting with residents. He acknowledged nurses had assignments of 15 to 20 residents. The Administrator confirmed staffing fluctuated with the census but acknowledged it should also reflect residents' needs. The DON confirmed a significant number of the facility's residents had dementia and exhibited the confusion, agitation, restlessness typical of sundowning behavior associated with this diagnosis. She explained the behaviors usually started in the evening at about 5:00 PM and could continue for hours. The Administrator acknowledged in light of increased behaviors on the 3:00 PM to 11:00 PM shift, the absence of activities staff after 3:00 PM was not helpful to staff caring for this population. On 2/15/25 at 12:52 PM, the facility's Staffing Coordinator stated she was responsible for determining how many nurses and CNAs were scheduled for each shift, in conjunction with the Administrator and DON. She explained she utilized the census to schedule staff according to the number of residents in the facility. As an example, the Staffing Coordinator stated for the current census of 33, she was allowed to schedule no more than three CNAs for the day and evening shifts. She explained she needed approval from administration to schedule four CNAs. The Staffing Coordinator verified CNAs and nurses had complained to her regarding the difficulties of supervising the residents in the fall prevention program while caring for their assigned residents. She confirmed she relayed staff concerns to the Administrator and DON more than once, but they reminded me of the numbers related to the census. The Staffing Coordinator stated she reported their response to staff, .that we can only have a certain amount of staff based on census. She stated she as not aware there was no maximum limit for staffing or that staffing should reflect the different levels of care and supervisions necessary to meet residents' needs. She acknowledged staff workload and patient care would be much better with four CNAs, but she was not usually able to do that unless there were at least 35 or 36 residents. The Staffing Coordinator stated she noticed that after dinnertime, some of the residents got more agitated and it took up the CNAs' time to sit with them, watch, or keep checking while they put other residents to bed and assisted with showers. The Staffing Coordinator validated CNAs were accurate when they claimed there had been a change in staffing ratios in the last few months. She explained since a recent change of ownership, the facility now placed more of an emphasis on staffing according to the census.

Based on interview, and record review, facility staff failed to promote safety during transfers with a mechanical sit-to-stand lift to prevent an accident with major injury for 1 of 3 residents reviewed for incident investigation, of a total sample of 8 residents, (#1). The failure to ensure a mechanical lift had functional and back up batteries prior to performing a transfer, and failure to take appropriate care based on potential hazards during a manual transfer resulted in actual harm. Resident #1 sustained a right shoulder dislocation, required transfer to a higher level of care, and suffered a decline in his functional range of motion. Findings: Review of the medical record noted resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] after a hospitalization . His diagnoses included hemiplegia or paralysis affecting his right dominant side, difficulty speaking, lack of coordination, and dislocation of the shoulder joint. The Annual Minimum Data Set (MDS) assessment with assessment reference date of [DATE] revealed he had a Brief Interview for Mental Status score of 15 out of 15, which indicated his cognition was intact. The MDS assessment showed the resident had difficulty communicating some words or finishing his thoughts, but he was able to if prompted or given time. The document indicated the resident required extensive physical assistance from two persons for bed mobility, transfers, toilet use, dressing, and personal hygiene. The MDS assessment revealed resident #1 had functional limitation in range of motion of one arm. Review of resident #1's medical record revealed physician orders dated [DATE] for an X-ray of the right shoulder for a diagnosis of pain, and to send the resident to the hospital related to a dislocated right shoulder. An Accident/incident note dated [DATE] at 8:16 AM, documented by Licensed Practical Nurse (LPN) A, read, Resident complains of pain to the right shoulder related to being suspended in the sit to stand above his wheelchair. [As needed] pain medication has been given as ordered.Family and doctor have been notified and [an immediate] order for a X-ray to the right shoulder is in place. Review of the resident's radiology report revealed the date of exam was [DATE]. The document was signed by the radiologist on [DATE] at 11:59 AM and read, Humeral head impaction fracture: to his right shoulder and indicated there was a dislocation of the joint. Review of the hospital After Visit Summary dated [DATE] indicated the reason for the resident's visit was shoulder pain. The document revealed his diagnoses were anterior dislocation of the right shoulder and acute pain of the right shoulder. A nursing progress note dated [DATE] at 7:38 AM read, Monitoring resident related to dislocated Right shoulder. Resident denies pain or discomfort at this time. Review of the physician's progress note with date of encounter of [DATE] at 12:30 PM, revealed the resident had shoulder pain that had been occurring for days, had been worsening, and was aggravated by movement. The document read, There is a sling in place to the right shoulder.Shoulder dislocation.Manually manipulated back in to place in ED [Emergency Department]. Review of the facility's Risk Management Tracking Tool revealed an entry on [DATE] for resident #1 regarding an incident that occurred on [DATE]. The document indicated staff used a mechanical lift to transfer the resident out of bed and into his wheelchair, but during the transfer, the lift stopped functioning. The document revealed the resident was suspended over his wheelchair and became anxious and tried to turn around, so staff assisted him out of the lift and completed the transfer into his wheelchair by slipping his arms out of the lift's support straps. The Risk Management Tracking Tool indicated the resident later complained of right shoulder pain, so the physician was notified, and the facility obtained orders for an X-ray and pain medication. The X-ray result showed a right shoulder dislocation, and the physician gave an order to send resident #1 to the Emergency Department for further evaluation. On [DATE] at 2:00 PM, the Registered Nurse (RN) / Interim Unit Manager (UM) stated she was out of town when resident #1's incident with injury occurred on [DATE]. She recalled when she returned, she heard about an issue with the sit-to-stand mechanical lift. She recalled she was informed the lift would not go down because the battery might have died , and ultimately the transfer caused resident #1's shoulder dislocation. The RN / Interim UM stated the sit-to-stand lift had an emergency release, but she was not sure if staff attempted to use it. On [DATE] at 3:49 PM, Certified Nursing Assistant (CNA) B recalled the day she transferred resident #1 from his bed to his wheelchair with a sit-to-stand mechanical lift and the lift got stuck and would not go down. CNA B stated the resident was suspended in the sling above the wheelchair. She explained they replaced the battery but the lift still did not work and the emergency switch would not function. She said, Since the resident was suspended, we had to act fast. CNA B explained LPN A, who had been assisting her with the transfer, removed resident #1's arms from the sling and allowed him to slump down into the wheelchair. CNA B stated they did not have enough room to lower the resident slowly and gently into the wheelchair beneath him, and he complained of arm pain when the transfer was completed. On [DATE] at 4:26 PM, in a telephone interview, LPN A recalled resident #1 was on her assignment on [DATE]. She stated she was at her medication cart when CNA B informed her that the sit-to-stand lift was not working. LPN A stated after she instructed CNA B to get another battery, she left the medication cart and went into the resident's room. LPN A explained when she arrived at the room, she observed resident #1 suspended from the sit-to-stand lift. She stated she attempted to lower the resident, but neither the battery functioned nor the emergency switch worked. She recalled CNA B wanted her to release the sling straps on both sides of the resident and they positioned him in the wheelchair. LPN A stated resident #1 did not complain of pain at that time, but when he complained later on, she notified the physician and obtained an order for an X-ray. She confirmed the X-ray showed the resident had a dislocation of the right shoulder and he was sent out to the ED for further evaluation. On [DATE] at 4:50 PM, the Executive Director confirmed staff were trained on the facility's protocols for use of mechanical lifts and they were expected to always utilize two people for all mechanical lift transfers, to lower residents with the emergency button if the lift stopped working, and to ensure batteries were placed on the charger after use on the 3:00 PM to 11:00 PM shift, and remained there overnight. On [DATE] at 5:45 PM, the Maintenance Director stated the facility had a total of three mechanical lifts, two full body lifts and one sit-to-stand lift. He explained the facility leased the mechanical lifts and the leasing company serviced the equipment annually. The Maintenance Director stated he was made aware of the incident regarding the sit-to-stand lift after the fact. He stated he checked the lift and noted the problem was a dead battery. The Maintenance Director explained he placed a new battery and the sit-to-stand lift functioned. He stated the facility had four battery charging stations and when he evaluated all the batteries, he discovered one battery would not remain charged, so he took it out of service. The Maintenance Director had no documentation to verify his actions after the incident, and explained he assumed the Director of Nursing would have documented since there was no problem with the lift itself. When asked about the emergency switch, the Maintenance Director said, If the lift had a dead battery, nothing will work. He verified the facility did not replace the sit-to-stand lift as he only placed a new battery. Review of the User Manual for the sit-to-stand lift revealed documentation under the heading Warning and Caution read, Please note that a lifted patient cannot be lowered down when battery is out of power. On [DATE] at 6:15 PM, the Executive Director shared an incident report dated [DATE], prepared by Licensed Practical Nurse (LPN) A, that showed at 7:40 AM, Certified Nursing Assistant (CNA) B notified her that resident #1 was stuck in the sit-to-stand lift. The CNA reported the resident was suspended over his wheelchair because the lift's battery was dead, as were all the other replacement batteries. The incident report noted LPN A assisted in removal of the resident's arm from the support strap, complained of pain to the arm and a follow up X-ray showed he had a dislocated shoulder. The Executive Director explained findings from an interview with CNA B indicated the sit-to-stand lift's battery was not charged and she called the nurse to help her get the resident into his wheelchair. The Executive Director stated CNA B said the battery seemed to be out, the lift was stuck, and the resident was calling out to be lowered from the lift. When asked if CNA B was transferring the resident by herself when the lift stopped working, the Executive Director said, It does not show whether someone was there or not there. The facility had no other witness statements included in the documents presented by the Executive Director. There was no evidence that the resident and his roommate were interviewed after the incident, although they were both alert, oriented, and without cognitive impairment. On [DATE] at 8:42 AM, in a telephone interview, the resident's son explained his father's right side and vocal cords were paralyzed. He recalled that on [DATE], the facility called at 8:20 AM and a staff member informed him,there was a bit of accident, but Dad's fine. The son stated he was told his father would receive Tylenol for pain. He recalled his father called later and complained of pain and asked, What shall I do? The son stated the facility called again at 2:30 PM, approximately six hours after the incident, to notify him that his father was on the way to the hospital Emergency Department (ED) because an X-ray showed an issue. He said, It was not the first, second, or third time that the [sit-to-stand] lift had not worked. He stated it took the facility seven hours from the time of the incident to send his father to the hospital. The son verbalized the roommate told him his father was in the corner of his room crying and saying he was in pain. He explained resident #1 was paralyzed on his right side, so he assumed the pain must have been excruciating if he was crying. He recalled, The surgeon said it was one of the worse dislocations he had seen. On [DATE] at 10:00 AM, 10:53 AM, and 1:43 PM, the incident was discussed with the Executive Director. He described the incident as human error and a one-time event. However, he validated facility staff should follow all procedures and regulations. On [DATE] at 3:04 PM, resident #1 was seated in his motorized wheelchair in his room. In a soft voice, he described the events of [DATE]. The resident explained the nurse and the CNA got him out of bed with the sit-to-stand lift, but as the lift lowered him to the wheelchair it stopped because the battery was dead. He recalled staff tried four different batteries while he was suspended in the lift sling, but all the batteries were dead. Resident #1 recalled the nurse tried to lower him to the wheelchair, but .did it wrong. She held my left shoulder and my right arm bumped into the wheelchair, and my shoulder popped. He recalled his arm hurt and he realized his shoulder was dislocated. The resident stated his memory was vague, but he thought he waited at least three to four hours after the incident before he was sent out to the hospital. Review of the medical record showed no documentation to indicate what time the resident was transferred to the hospital on [DATE]. Review of the resident's Plan of Treatment for Rehabilitation with start of care on [DATE] and onset date of [DATE], revealed his primary diagnosis was dislocation of the right shoulder joint and pain in the right shoulder. The document read, resident referred following a recent change in status due to [right] shoulder dislocation.suffered [right] shoulder dislocation following incident at SNF [Skilled Nursing Facility]. The document indicated an X-ray done on [DATE] identified a fracture of the head of the right humerus which caused right shoulder pain and .impacting burden of care during transfers with caregivers. The facility's policy Reporting Accidents and Incidents indicated Each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observation, interview and record review, the facility failed to ensure that 1 of 2 sampled residents was supervised to prevent an avoidable fall that resulted in injury during toileting (#75). Findings: Resident #75 was observed on 12/14/15 at 11:46 AM in bed. She was talkative and had good eye contact. She was interviewed on 12/14/15 at 2:35 PM with her son at the bed side. She remained in bed throughout the interview. On 12/15/15 at 8:30 AM, she was in her bed with the blanket pulled up under her chin. On 12/14/15 at 3:02 PM, the 7 AM-3 PM nurse caring for Resident #75 revealed the resident had a fall in the past 30 days, on 11/23/15. She said the certified nursing assistant (CNA) found her on the floor in the bathroom, had dislocated her shoulder and hip, and went to the hospital for surgery. Record review revealed Resident #75 who was admitted to the facility on [DATE] with a known history of falls with injuries. Her [DIAGNOSES REDACTED]. She is also on anti-anxiety, pain, and anti-hypertensive medications which increases the risk for fall. Review of the Hospital's Physical Therapy Evaluations dated 10/31/15 indicated that the resident needed maximum assistance of 2 people for toilet transfers. Her judgment for safety was severely impaired, had decreased awareness of safety, and she needed frequent cues for safety due to poor memory. Review of the Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was 10/15. A score of 8-12 indicates the resident has moderate cognitive impairment. The resident's decisions were poor and she required reminders, cues and supervision. Her functional status showed that she required extensive physical assistance with 1 person for all activities of daily living (ADLs). She was only able to stabilize with 1 person assisting her to move on and off the toilet. She was frequently incontinent of bladder and wore an incontinent brief. She had a history of [REDACTED]. Review of the 14 Day MDS assessment dated [DATE] indicated that the resident's BIMS remained the same, and that she declined in ambulation off the unit from being extensive assistance to now total dependence. She remained the same as prior assessment in needing 1 person physical assistance with going to the bathroom. Review of the Care Conference notes dated 11/19/15 indicated that the resident was not capable of attending because she was confused. Review of the nurse's note dated 11/23/15 revealed that the resident fell at 7 AM. She was found on the floor in front of the toilet, complained of pain all over, and was confused and agitated. The physician was notified and X-rays were ordered. The resident had a history of [REDACTED]. At 11 AM on 11/23/15, the resident complained of pain on the left side and X-rays were taken of the left shoulder, left hip and left femur. Pain medications were given to control the pain. At 3:15 PM on 11/23/15, the resident was transported via ambulance to the hospital. Review of the Final Report from the hospital dated 11/24/15 revealed that Resident #75 was readmitted to the hospital on [DATE] with left hip pain and had a dislocated left hip and left shoulder. She required emergent surgical intervention to repair the left hip dislocation. The left shoulder was not repaired. A sling was applied to hold the arm in place. Resident #75 had a care plan initiated on 11/05/15 for Fall Risk, Hip Fracture, and Self-Care Deficits related to post hospitalization for [DIAGNOSES REDACTED]. Interventions included ½ side rails as enablers, bed and chair alarms, wheelchair for locomotion on/off unit, assist as required, assist with ADLs and mobility as required, set-up all needed ADL equipment prior to starting. The CNA failed to set-up all needed ADL equipment as required as evidence by not having an incontinent brief ready to use when the resident was placed on the toilet on 11/23/15. Review of Rehabilitation Screening note dated 11/23/15, the day of the resident's fall, indicated that education was done with the CNA staff to not leave resident #75 alone in the bathroom unsupervised. Review of the facility's policy and procedure for Fall Prevention Program revealed that the facility failed to follow their policy to provide adequate supervision to prevent accidents. The facility policy read, All residents will receive adequate supervision, assistance and assistive devices to prevent accidents. Each resident at risk will be identified for accidents and/or fall, and adequately plans care and implements procedures to prevent accidents. CNA D was assigned to Resident #75 on 11/23/15 and was familiar with the resident's care since she had been also caring for her prior to the fall. On 12/16/15 at 12:14 PM, she said that the resident had poor memory, had bed and chair alarms, would try to get up on her own, and needed a lot of re-enforcement, restating and instructions. She said that this resident required extensive assistance with dressing, transfer, and toileting. CNA D said extensive assistance meant that the resident needs to be watched. She said she would not leave her alone in the bathroom, would stay with the resident in the bathroom, and would pull the call cord for assistance if necessary. On the day of the fall 11/23/15, CNA D said that when she came on duty, the resident's light was already on and the nurse and CNA A were in the room with her. CNA D indicated on the day of the fall when she cared for the resident, she was instructed to not move her. CNA D also said that she had not received any specific education in the care of resident's post-operative needs after hip surgery prior to or since this resident's fall. On 12/16/15 at 1:21 PM, physical therapist (PT) B said that he did the initial certification for Resident #75 for therapy on 11/05/15. He indicated that the facility was aware that this resident had a history of [REDACTED]. He said that on admission, the resident needed moderate assistance at all times. He explained that moderate assistance meant the resident could not walk alone, was weight bearing as tolerated to left lower extremity, needed verbal cuing due to poor memory, and physical assistance of the therapist and a hemi-walker (a walker designed for individuals to use only one hand or arm). The PT said the resident has existing dementia, and said the son told him that she forgets and has poor recall. The PT said he instructed nursing staff to transfer the resident from the bed to the wheelchair and then from the wheelchair to the toilet. When asked if he had instructed staff to not leave the resident alone; he said all residents who are a fall risk and have alarms are not to be left in the bathroom. The PT stated Residents with cognitive deficits are not to be left alone in the bathroom period. I would instruct the CNA not to leave the resident alone even if she wants privacy and to stay close enough so that she can see the resident. On 12/16/15 at 2:35 PM, the DON and the unit manager confirmed that Resident #75 had a fall around 7 AM on 11/23/15 in the bathroom of room 121. They confirmed that this resident was improving in therapy from the time of her admission to prior to the fall and at the present time, the resident is bed bound, unable to have the head of the bed up more than 10 degrees, and wears an immobilizer device on the left lower extremity at all times. The DON also said that she now has an Occupational Therapist (OT) at her bedside for all meals since she has to eat lying down to help prevent complications related to possible aspiration of food. On 12/16/15 at 3:50 PM, room 121 bed B, the room where Resident #75 resided on the day of the fall, revealed that the toilet was on the far left of the bathroom and there was a total blind spot of view of the toilet since it has a wall directly in front of it. On 12/16/15 at 4:21 PM, the director of nursing (DON) said that the facility does not have enough staff to provide 1 on 1 supervision for residents. On 12/16/15 at 4:43 PM, Physical Therapy Assistant (PTA) C said Resident #75 was at the facility for 2 weeks and he did 90% of her treatments. He said the last treatment he did was on 11/20/15 prior to her fall on 11/23/15. The PTA said the resident could remember his face but could not recall his name and needed redirection and cuing during her therapy. The PTA indicated the resident wore a sling on her left arm at all times. The PTA revealed that the resident initially required a moderate amount of assistance to walk 20 feet with a hemi-walker and by 11/20/15, she only need a minimal amount of assistance, becoming more stable and stronger for transfers, and could walk 50 feet with hand held assistance of the therapist. On 12/17/15 at 9:25 AM, an observation was made of the resident in her room lying in bed with the OT at her beside assisting her with eating breakfast. The resident's bed was up 10 degrees, she had a blanket covering her lower extremities. The OT said that the resident liked to eat and that she currently has a brace on her left lower leg which wrapped around her waist that remains on at all times. The OT said that she was completely bed bound and unable to get out of the bed because the physician did not want her to flex the left hip any more than 10 degrees. On 12/17/15 at 10:55 AM, CNA A said that the resident was weak on the left side and wore a sling on the left arm. She said she assisted the resident from the bed to the wheelchair, wheeled her into the bathroom, and assisted her from the wheelchair to the raised toilet seat over the commode. She said she left the wheelchair in the bathroom in front of the sink. She said she left the resident alone in the bathroom, headed across the room to the dresser to obtain an incontinent brief. On her way to the dresser, she heard a thump, looked around saw the resident on the floor. She said the resident had fallen forward. She said after the resident fell , she went back in the bathroom to pull the call cord for assistance. CNA A said she was never instructed or trained by therapy or the nursing staff to care for this resident. On 12/17/15 at 11 AM, the maintenance manager measured the distance and reported a 9-foot span from the opening of the bathroom door to where the CNA said she was at the time of fall. The dresser was 15 feet away from the opening of the bathroom door. Although the facility had fall preventative measures in place for a resident who had a known history of repeat falls with fractures and cognitive impairment, they failed to provide adequate supervision. The lack of supervision with toileting resulted in the resident requiring a re-hospitalization for a dislocated left hip and shoulder which required emergent surgical intervention. Due to the facility's lack of supervision, the resident has had a decline in her functional ability. The resident was able to walk 50 feet with cuing and stand by assistance prior to fall and is currently completely bed bound and not able to sit up in bed more than 10 degrees in bed.

Based on observation, record review and interview the facility's Quality Assurance (QA) Committee did not evaluate and identify deficits in the facility's fall/accident prevention program in order to identify and correct quality deficiencies to ensure the safety and wellness of residents residing in the facility for 5 of 5 residents (#6, 31, 38, 41 & 52) reviewed for falls out of 25 sampled residents. Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on 5/11/13 and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from 3/02/13 to 5/09/13. The resident hit her head on 3/02/13. Injuries occurred on 3/30/13 and 5/04/13 in the form of skin tears. The resident also sustained swelling to the left side of her forehead on 5/04/13. Resident #6 fell 4 times from 4/09/13 to 4/28/13. On 5/13/13 he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from 3/07/13 to 5/04/13. She sustained skin tears on 3/07/13 and received a large bruise to the right side of her face and a skin tear to her right arm on 5/04/13. Resident #38 fell 11 times from 1/17/13 to 5/15/13. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on December 21, 2012. As of the exit date of the survey on 5/18/13, the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a [MEDICAL CONDITION] and 3 fractured bones respectively. The facility failed to evaluate each fall and failed to modify and implement individualized interventions to reduce avoidable falls and prevent injury when necessary after successive falls as of the exit date of the survey on 5/18/13. These practices resulted in immediate jeopardy starting on 12/21/12 and it was determined to be ongoing as of the exit date of 5/18/13. Findings: Cross reference F323. 1. Resident #31 readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. This tool indicated the scored a 24 out of possible 38 possible points. A score of 10 or higher indicates a risk for falls. Review of the annual Minimum (MDS) data set [DATE] revealed that the resident is cognitively impaired and was dependent of staff for bed mobility, transfer, dressing personal hygiene, locomotion and bathing. The resident fell in the shower room on 12/21/12 and sustained 3 skin tears to the right arm. The resident's fall care plan was not updated with new goals or interventions to prevent falls. The quarterly minimum data set ((MDS) dated [DATE] indicated that the resident's cognition remained the same and the resident was still dependent on staff to meet all care needs. The resident fell again on 5/11/13 in the TV room and sustained a fractured nose, fractured wrist and fractured bones around the right eye. Upon return from the hospital on [DATE], the resident's fall care plan remained the same since the time of admission. On 5/18/13 at 11:20 am the Unit Manager (UM) was interviewed. She confirmed that staff was not in the TV room when resident #31 fell on [DATE]. She also stated, "We do not have staff in the TV room to supervise residents." 2. Resident #41 was observed on 5/17/13 at 9:20 am at the nurses' station, in a straight back wheelchair. The resident was leaning forward with her head almost parallel to her lap. There was a pillow on her lap and a doll on top of the pillow. The pillow was slipping off the resident's lap. At that time, an alarm was attached to the wheelchair. No staff were at the nurse's station at this time. Several minutes later at 9:35 a.m., the resident was still leaning forward, but the cord/string from the chair alarm was now not attached to the resident. At this time the UM came out of the office, located behind the nurses' station, looked at the resident, but did not intervene. Several seconds later, a Certified Nursing Assistant (CNA) arrived in the area, cued, and repositioned the resident, the pillow, and placed the doll under the resident's right arm. The CNA reattached the cord from the alarm to the resident. Then the CNA wheeled the resident toward her room. Record review revealed the resident fell 8 times in a 2 month period from 3/2/13 to 5/9/13. The resident fell 5 of 8 times in her room and 2 of 8 times in the Activity/Day/TV Room. The TV room is approximately 6 feet across form the nurse's station. It was determined that if staff were sitting behind the nurse's station the entire TV room could not been seen. Review of the resident's Minimum Data Set ((MDS) dated [DATE] indicated that the resident was totally dependent on staff for bed mobility, transfer, dressing, personal hygiene and locomotion. The resident's current fall care plan was initiated on 2/2013. Since that time, the care plan was updated on 5/04/13 to indicate the resident had a fall. However, the care plan goals and fall interventions remained the same since the care plans inception of 2/2013. 3. Resident #6 is cognitively impaired with a BIMS score of 3 out of 15 which means the resident is cognitively impaired. On the day of admission, 4/09/13, the resident fell out of his wheelchair twice at 7:40 p.m. and 8:10 p.m., respectively. The resident's fall care plan was initiated on 4/10/10. The resident fell 2 more times on 4/18/13 and 4/28/13 for a total of 4 falls in less that 1 month. On 5/14/13 at 12:06 p.m. the resident's POA was interviewed via phone. The POA stated that she was not satisfied with the care in the facility and did not think there was enough staff to properly take care of her father-in-law. On 5/15/13 at 11:50 am the resident's direct care CNA #I was interviewed. She described the resident as being very demanding. She indicated the resident always wanted to get up first. The CNA said that the resident required a lot of assistance and was capable of using the call bell, but he usually calls out for help. CNA #I was not aware of any procedures or protocols for fall precaution/prevention. She said the nurses tell her at report if someone is a fall risk. Staff I added, "After you been here awhile, you figure it out." Later that day at 2:50 p.m., the resident's direct care nurse #D was interviewed. Nurse #D stated that when a resident falls, she completes an Incident Report. She was asked what new fall interventions are put in place and she said the resident is brought to the nurse's station so that staff can keep a closer eye on the resident. Review of the MDS dated [DATE] indicated the resident required extensive assistance from staff for bed mobility, transfer, walking in corridor, and dressing. The resident was totally dependent of staff for locomotion both on and off the unit and for personal hygiene. Further review of the resident's care plan revealed that the fall preventions interventions remained the same since 4/10/13. The care plans were not evaluated after falls on 4/18/13 and 4/28/13. 4. Resident #38 is a cognitively impaired resident receiving hospice services. The resident fell 11 times between 1/27/13 to 5/15/13. The resident's third fall at the facility was on 3/13/13 and he was sent to the hospital for a laceration to his forehead. The resident returned to the facility and fell another 8 times. The fall risk evaluation scored the resident a 26. A score of 10 or higher indicates at risk for falls. The resident's recent MDS indicated that he was rarely understood and his cognition was severely impaired. The resident required extensive assistance from staff for bed mobility, transfer and dressing. The resident was totally dependent on staff for personal hygiene, bathing and locomotion. The resident's active [DIAGNOSES REDACTED]. The residents fall care plan was dated 3/29/13 and was not evaluated or updated after subsequent falls and not after the other 8 falls. On 5/16/13 at 11:10 am resident 38's hospice nurse was interviewed. She stated the resident was at risk for falls based upon her assessment. Hospice fall intervention tool dated 3/21/13 indicated the hospice nurse recommend an alarm to both wheelchair and bed. She also recommended mats on the floor at bedside. On 4/30/13 the physician wrote an order for [REDACTED]. The first reference to mats in the Incident Reports was on 4/13/13. The note read 'Observed on mat on floor by his bed. Therefore, it could not be determined when mats were initiated by staff. On 5/15/13 at 6:15 p.m. resident #38's direct care nurse # G stated she has worked in the facility for about a year and that she's usually on the 3-11 shift. She stated she was not aware of any protocol for fall precautions and had not had any in-services this year related to fall prevention. She stated when a resident falls, she completes and Incident report that is turned into the Director of Nursing (DON). During the interview resident #38's alarm was sounding and nurse G left the interview to respond to the alarm. When she returned, approximately 10 minutes later, she explained that the resident was found on the floor by the Unit Manager. She stated, "I will probably have to complete the Incident Report and I did not even witness the incident." Further review of the resident's fall care plan revealed that the goals and fall interventions remained the same since 3/29/13. The care plan was not updated with the latest interventions of the call bell and mats on the floor in room. 5. Resident #52 is an alert and cognitively aware resident. She had 3 falls from 3/07/13 to 5/4/13. The resident attempts to transfer herself without staff assistance. On 5/14/13, the resident stated she fell in the bathroom attempting to transfer herself form the chair to the toilet. She also stated there is not always enough staff to help her get on the toilet. The resident's fall care plan was updated to reflect that the resident fell on [DATE] and sustained a bruise on her right cheek and a skin tear to her right arm due to the fall. The fall interventions were never changed or modified on the plan of care. 6. Review of the fall care plans for resident #6, #31, #38, #41 and #52 revealed that these residents all had the same fall interventions: A. Educated resident in safety awareness B. Remind resident to call when needing assistance C. Keep call light and most frequent used personal items within reach D. Assess medication for contributing factors E. Move room closer to the nurse's station if necessary F. Shoes well fitting with non-slip soles G. Gripper Socks H. PT/OT evaluation for strength training and gait I. Assist res. To and from toilet J. Maintain room and pathway free of clutter, from furniture, tables etc. On 5/17/13 at 1:30 p.m. the MDS/Care Plan coordinator (CPC) stated she creates all care plans except for Dietary and Social Services. In regards to falls she stated the floor nurse' are responsible for the interventions. She explained that if a resident falls the floor nurse will decide if the resident needs an alarm. The CPC stated the fall is discussed in morning meeting and she will update the care plan with the new intervention. When asked how direct care is staff informed about new interventions, the she stated, "They can read the care plans." On 5/17/13 at 5:00 p.m. the Administrator and DON were interviewed about the Facility's QA program. There was no evidence the QA committee identified that all 5 residents had the same fall interventions and that the care plans were not individualized for each resident or evaluated. Also, the QA committee failed to ensure the that the Care Plan staff were reviewing the fall interventions to determine the effectiveness of each of the approaches. Based on the amount of falls for the cognitively impaired residents, #6, #31, #38, #41, the QA Committee failed to demonstrate the effectiveness of how "Re-Educating Resident on Safety Awareness" was still effective. The DON stated that they track falls each month. They considered having more than 5 falls in a month as a high amount of fall incidences. They stated that when a resident falls, the nurse documents on the Incidence Report form. Therapy screens the resident to determine if the resident should receive therapy services. If therapy does not pick up the resident, Therapy will in-service the nursing staff, on repositioning the resident. In comparing falls for February, March and April 2013, the DON stated they had more falls in March and that the facility census was higher in March in comparison to February and April. The DON could not explain the low fall rate in February. The DON stated she noticed a trend in March that the frequency of falls occurred on the weekend between 7 a.m. and 11 a.m. The QA committed did not trend falls for their location i.e. resident room verses common areas such has hallways and TV room. She attributed the increase in falls on the weekends due a decrease in activities on the weekends in comparison to the work week. However, activities are only one aspect of the resident's life from 7 a.m. to 11 a.m.. In that time period, staff are performing activities of daily living (ADLs) with the residents and breakfast is also served within that time frame. The QA committee did not analyze falls during before or after ADL Care and before or after breakfast. During morning ADL Care, if all CNAs are providing individual care, the QA committee should determine if there are enough staff available to provide the level of supervision to prevent falls that are not directly working with a CNA. It was not apparent the QA committee reviewed falls in the context with staffing patterns. The DON stated they staff according to the census. There was no indication that staffing was being done with the consideration of resident care needs, especially safety. 7. The QA committee failed to ensure that each falls/accidents were investigated in accordance with facility policy. On 5/15/13 at 8:45 a.m. during an interview with the DON, she revealed that she was also the Risk Manager and stated that she did not keep an Incident Log with names/dates/incidents/ or follow-up information. She stated when a resident has a fall; the assigned nurse completes an Incident Report and sends to her. She then makes a copy of the Incident Report for Therapy Department and keeps the original. She stated that falls are discussed in the morning meetings and the MDS Coordinator updates the care plans. She stated examples of interventions included mats at bedside, non-skid socks, bed in low position, move resident rooms closer to the nurse's station if they can, and if they absolutely have too, use alarms on bed and chair. When asked why the investigative portion of the incident reports had not been completed, she stated, " I use to fill out the information on the form, but I don ' t anymore. You can find the information in the nurse ' s notes; I don ' t have an additional investigative form. " When asked why she was not following the "Accident and Incidents-Investigating and Reporting" policy and procedures, she did not respond. Review of the policy, "Accidents and Incidents-Investigating and Reporting" revealed that all accidents or incidents involving residents, employees, visitors, etc. occurring on the premises must be investigated and reported to the administrator. An incident report form must be completed for all reported incidents. The nurse supervisor/charge nurse must be immediately informed so that medical attention can be provided. The nurse supervisor/charge nurse and or the department director or supervisor must conduct an immediate investigation of the incident including the date and time incident took place, the nature of injury, circumstances surrounding the incident, where the incident took place, names or witnesses and their accounts of the accident/incident, injured person ' s account of the accident/incident, time injured person attending physician was notified, as well as time physician responded and his/her instructions, dated and time injured person family was notified and by whom, condition of the injured person to include vital signs, disposition of the injured (transferred to hospital, put to bed, etc.), any corrective action taken, follow up information, signature of person completing the report. According to the policy, "The Accident/Incident report and the Accident Investigation Report Form" was to be submitted to the administrator no later than 24 hours after the occurrence of the accident/incident. Since the Risk Manager/DON did not complete the Investigative Report Form, which was the investigative component of the process, the Incident Reports and nurse's notes lacked crucial information pertaining to the circumstances surrounding the incidents, names or witnesses's of the incidents and their accounts of the accident/incident, details involving the injured person's account of the incident, details of the physicians response to the incident and his/her instructions, details of the family member contacted (name/relationship), and details related to the disposition of the injured. There was evidence of corrective action or follow up information regarding their investigations Review of the Managing the Risk and Liability of Falls documentation given for review by the DON, indicated that Fall Risk Evaluations should be completed on all residents within the first 3 hours of Admission, with any change of condition, and after a fall. Once a resident has been identified as " at risk for fall " there should be documented evidence of intervention to reduce the risk of fall from occurring. If the resident continues to fall, the care plan should reflect goal changes or approach changes. All new fall prevention measures should be introduced to current employees through an in-service and incorporated into new employee orientation. Review of the facility Fall Risk Evaluations revealed that they were initiated upon admission, but only updated on a quarterly basis. None of the assessments indicated that they were updated after each fall. The only evidence of intervention was documented orders for bed and chair alarms recommended by hospice nursing to be put in place for the hospice residents. Repeat falls were not reflected or updated with goal changes or approach changes on the care plans or fall risk evaluations.

Based on observation, record review and interview the facility neglected to provide services necessary to avoid physical harm. They did not provide supervision and effective assistive devices to prevent accidents with injury. The facility also neglected to use resources such as care planning and quality assurance to review and ensure all safety measures met the individual needs of residents. The result of the facility ' s neglect resulted in Immediate Jeopardy for 5 of 5 residents who had falls with injury (#6, 31, 38 41 & 52) and put other residents who needed supervision or used assistive devices at risk for harm or injury. The sample was 25. Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on [DATE] and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from [DATE] to [DATE]. The resident hit her head on [DATE]. Injuries occurred on [DATE] and [DATE] in the form of skin tears. The resident also sustained swelling to the left side of her forehead on [DATE]. Resident #6 fell 4 times from [DATE] to [DATE]. On [DATE] he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from [DATE] to [DATE]. She sustained skin tears on [DATE] and received a large bruise to the right side of her face and a skin tear to her right arm on [DATE]. Resident #38 fell 11 times from [DATE] to [DATE]. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on [DATE]. As of the exit date of the survey on [DATE], the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a [MEDICAL CONDITION] and 3 fractured bones respectively. These practices resulted in immediate jeopardy starting on [DATE] and it was determined to be ongoing as of the exit date of [DATE]. Findings: Cross refer to F323 and F520. 1. Resident #41 was observed on [DATE] at 9:20 a.m. at the nurses' station, in a straight back wheelchair. The resident was leaning forward with her head almost parallel to her lap. There was a pillow on her lap and a doll on top of the pillow. The pillow was observed to be slipping off the resident's lap. At that time an alarm was noted attached to the wheelchair and there was not any staff at the nurse's station. Several minutes later at 9:35 a.m. the resident was observed again still leaning forward but the cord/string from the chair alarm was not attached to the resident. At that time the Unit Manger (UM) came out of the office that is located the nursing station and looked at the resident but did not intervene. Several seconds later a Certified Nursing Assistant (CNA) arrived in the area and cued and repositioned the resident, pillow and placed the doll under the resident ' s right arm. The CNA reattached the cord from the alarm to the resident. Then the CNA started wheeling the resident towards her room. Record review revealed the resident fell 8 times in a 2 month period from [DATE] to [DATE]. The resident fell 5 of 8 times in her room and 2 of 8 times in the Activity/Day/TV Room. The TV room is approximately 6 feet across form the nurse's station. It was determined that if staff were sitting behind the nurse's station the entire TV room could not been seen. Review of the resident's Minimum Data Set ((MDS) dated [DATE] indicated that the resident was totally dependent on staff for bed mobility, transfer, dressing, personal hygiene and locomotion. The resident is totally incontinent with both bowl and bladder. Under Cognitive Patterns, Section C, the MDS showed that Brief Interview for Mental Status (BIMS) should not be conducted with the resident because the resident is rarely/never understood. The resident has short-term and long-term problem. The resident ' s cognitive skills for daily decision making is severely impaired - never/rarely made decisions (C1000=3). The resident's fall care plan dated [DATE] had the following approaches: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. On [DATE] the car plan was updated with 'Found lying on floor TV Room skin tear to forehead. The approaches remained the same since [DATE] and new interventions had never been added. 2. Resident #31 was readmitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. The resident continued to be at risk for falls and on [DATE] the resident fell in the shower. The sustained 3 skin tears to the right arm. Record review revealed the resident fell again in the TV room on [DATE] at 9:45 a.m. The resident was observed face down and blood was on the floor. The resident was transferred to the hospital and diagnosed with [REDACTED]. On [DATE] at 11:20 a.m. the Unit Manager was interviewed. She confirmed that staff was not in the TV room when resident #31 fell on [DATE]. She also stated, "We do not have staff in the TV room to supervise residents." Review of the Minimum Data Set ((MDS) dated [DATE] documented the resident was not able to repeat 3 words, not able to answer the correct month or year; and resident was not able to be interviewed for mental status. It was documented the resident was easily distracted, out of touch and disorganized. Review of the recent MDS dated [DATE] indicated the resident requires extensive assistance, from staff, in bed mobility, transfer, walking, locomotion, dressing and personal hygiene. The resident is totally incontinent of both bowl and bladder. Also, the MDS did not include the resident's fall from [DATE]. The resident's fall care plan dated [DATE] had the goal 'Resident will remain free from injury and the following approaches were listed: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. The care plan was reviewed and re-dated [DATE] but the interventions remained the same. The care plan was not updated with new interventions even after the resident fell on [DATE] and then again on [DATE]. 3. Resident #6 is cognitively impaired with a BIMS score of 3 out of 15 on a scale of ,[DATE]. (,[DATE] = severe impairment, ,[DATE] = moderate impairment, and ,[DATE] =cognitively intact). The intent of conducting the BIMS is to determine the individual's attention, orientation, and the ability to register and recall new information. The resident had 4 falls in less than one month ([DATE] to [DATE]). On [DATE] 12:06 p.m. the residents POA was interviewed via phone. On [DATE] at 12:06 p.m. during a telephone interview with the resident's daughter in law, who was the Power of Attorney (POA), she revealed that she was not satisfied with the assistance and supervision the facility staff was providing for her father-in-law, and did not think there was enough staff to properly take care of him. On [DATE] at 11:50 am the resident's direct care CNA # I was interviewed. She described the resident as being very demanding. She indicated the resident always wanted to get up first. The CNA added that the resident required a lot of assistance and was capable of using the call bell, but he usually calls out for help. Staff #I was not aware of any procedures or protocols for fall precaution/prevention. She said the nurses tell her at report if someone is a fall risk. Staff #I added, "After you been here awhile, you figure it out." Later that day at 2:50 p.m. the resident's direct care nurse # D was interviewed. Nurse #D stated that when a resident falls, she completes an Incident Report. When asked what new fall interventions are put in place? She explained that the resident is brought to the nurse's station so that staff can keep a closer eye on the resident. Review of the MDS dated [DATE] indicated the resident was extensive assist, from staff, for bed mobility, transfer, walking in corridor, dressing. The resident was totally dependent of staff for locomotion both on & off the unit and personal hygiene. The resident was frequently incontinent of both bowel and bladder. The resident's fall care plan was initiated on [DATE] and it noted the resident's fall on [DATE]. The fall prevention interventions are the following: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. The review date of this care plan is noted to be on [DATE]. However the interventions stayed the same since admission. New interventions were not added even after the resident fell a third and a fourth time on [DATE] and [DATE], respectfully. 4. Resident #38 is a cognitively impaired resident that is on hospice. The resident fell 11 times between [DATE] to [DATE]. The resident's third fall at the facility was on [DATE] and he was sent to the hospital for a laceration to his forehead. The resident returned to the facility and fell another 8 times. The fall risk evaluation of the resident scored a 26. A score of 10 or higher indicates at risk for falls. The resident's recent MDS dated [DATE] indicated that he was rarely understood and his cognition was severely impaired. The resident required extensive assistance, from staff, for bed mobility, transfer and dressing. The resident was totally dependent on staff for personal hygiene, bathing and locomotion. The resident active [DIAGNOSES REDACTED]. The resident's fall care plan dated [DATE] listed the following fall interventions: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. On [DATE] at 11:10 am the resident's hospice nurse was interviewed. She stated the resident was at risk for falls based upon her assessment. Hospice fall intervention tool dated [DATE] indicated the hospice nurse recommend an alarm to both wheelchair and bed. She also recommended mats on the floor at bedside. On [DATE] the physician wrote an order for [REDACTED]. The care plan was never updated to reflect the alarm to chair & bed, low bed with mats. The first reference to mats in the Incident Reports was on [DATE]. The note read 'Observed on mat on floor by his bed.' Therefore it could not be determined when mats were imitated by staff. On [DATE] at 6:15 p.m. resident #38's direct care nurse #G stated she has worked in the facility for about a year and that she's usually on the ,[DATE] shift. She stated she was not aware of any protocol for fall precautions and had not had any in-services this year related to fall prevention. She stated when a resident falls, she completes and Incident report that is turned into the Director of Nursing (DON). During the interview resident #38's alarm was sounding and nurse #G left the interview to respond to the alarm. When she returned, approximately 10 minutes later, she explained that the resident was found on the floor by the Unit Manager. She stated, "I will probably have to complete the Incident Report and I did not even witness the incident." 5. Resident #52 is an alert and cognitively aware resident. She had 3 falls from [DATE] to [DATE]. It is noted that the resident attempts to transfer herself without staff assistance. On [DATE] the resident stated she fell in the bathroom attempting to transfer herself from the chair to the toilet. She also stated there is not always enough staff to help her get on the toilet. The resident's fall care plan dated [DATE] had the following interventions: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. Staff updated the care plan to reflect that the resident fell on [DATE] and the resident sustained [REDACTED]. The fall interventions were never changed or modified. On [DATE] at 1:30 p.m. the MDS/Care Plan coordinator (CPC) stated she creates all care plans except for Dietary and Social Services. In regards to falls, she stated the floor nurses are responsible for the interventions. She explained that if a resident falls, the floor nurse will decide if the resident needs an alarm. The CPC stated the fall is discussed in morning meeting and she will update the care plan with the new intervention. When asked how direct care is staff informed about new interventions? The CPC stated, "They can read the care plans." The facility staff was asked about falls investigations for residents #6, #31, #38, #41 and #52. The facility submitted Incident Reports as their fall investigations. There were missing incident reports for resident #41 for a fall on [DATE] and for resident #6 for a fall on [DATE]. On [DATE] at 8:45 a.m. the Director of Nursing (DON) stated she not keep an Incident/Fall log. She stated that when a resident has a fall the resident's direct care nurse completes an Incident Report and sends it to her. She makes a copy of the Incident Report for the Therapy Department. She stated that falls are discussed in morning meetings and the CPC updates the care plans. When asked why the investigative portion of the incident reports had not been completed? The DON stated, "I used to fill out the information on the form, but I don't anymore." She added that the information could be found in the nurse's notes, "I don't have an additional investigative form." When asked why she was not following the Accident and Incident-Investigation and Reporting Policy & Procedure that was provided to the survey team, the DON had no response. Review of the policy for Accidents and Incidents-Investigating and Reporting and Managing the Risk and Liability of Falls revealed that all accidents or incidents involving residents, employees, visitors, etc occurring on the premises must be investigated and reported to the Administrator. An incident report form must be completed for all reported incidents. The nurse supervisor/charge nurse must be immediately informed so that medical attention can be provided. The nurse supervisor/charge nurse and or the Department Director or Supervisor must conduct an immediate investigation of the incident including the date and time the incident took place, names or witnesses and their accounts of the accident/incident, injure person's account of the accident/incident, time of injured person attending physician was notified, as well as time physician responded and hi/her instructions, dated and time injured person family was notified and by whom, condition of the injured person to include vital signs, disposition of the injured (transferred to hospital, put to bed, etc.), any corrective action taken, follow up information, signature of person completing the report. The Accident/Incident report and the Accident Investigation Report Form are to be submitted to Administrator no later than 24 hours after the occurrence of the accident/incident. Review of the Managing the Risk and Liability of Falls indicated that fall risk evaluations should be completed on all residents with the first 3 hours of Admission, with any changes of condition and after a fall. Once a resident has been identified as 'at risk for fall' there should be documented evidence of intervention to reduce the risk of fall from occurring. If the resident repeats a fall, the care plan should reflect goal changes or approach changes. All new fall prevention measures should be introduced to current employees through an in-service and incorporated into new employee orientation. Twenty Six Incident Reports provided by the facility for residents #6, #31, #38, #41 and #52 were reviewed. It was determined that the staff did not follow the facility ' s policy for completing the form. In 18 of 26 reports it could not be determined if the staff completing the form, was the first person to respond to the resident or just summarized the occurrence. The facility neglected to get staff statements and perform an in-depth investigation on how the each resident fell . Resident #52 is an alert and cognitively resident. In two of the three falls that resident #52 had, staff neglected to interview the resident to determine why she fell why she did not call for assistance. Staff neglected to document the disposition of the resident in 12 of 26 reports. In 24 of 26 reports, corrective action was not documented. The facility neglected to develop a staff education plan. On [DATE] at 1:35 p.m. the Human Resource Coordinator stated that nursing does the staff in services, then gives her the certificate and she puts it in the employees' file. She also stated that if staff obtain continuing education units (CEUs) outside the facility, i.e. CPR, etc., they can bring in a copy of the certificate and she will put into their files. She indicated that the unit manager (UM) provides some of the education. Later that day at 2 p.m., the UM brought in the test that the staff were given, indicating the tests are evidence of her in-services. Review of the in-service sign in sheet revealed that all the names appeared to have been written by the same person. The UM confirmed that she writes the names of the staff on the in-service sign in sheets. She stated that if she does not leave the sign in sheet at the nurse's station because it will get lost. She stated she puts the name on the sign in sheet when the staff turns in his/her test. The UM provided a few tests that staff had taken, but the tests were not graded. The UM indicated she does not grade the test. There was no evidence that these tests were evaluated to determine if staff had the correct answer or required further education based upon not having the correct answer. There was no indication that staff received in-services related to fall prevention. On [DATE] at 6:15 p.m. the DON was interviewed. When asked about her education plan she said, "I do not have a written plan, I just have it in my head." On [DATE] at 1:15 p.m. CNA #L stated she has worked at the facility for 3 years and thought she had an in-service for fall precautions last year. She stated the staff used to get in-services every payday, but stated there have been any in-services for 2013. Several minutes later at 1:30 p.m., CNA #K stated she has worked at the facility for 6.5 years. She stated they used to get in-service on payday and she thought she had a fall precaution in-service a couple of weeks ago, but she was not sure. Later that day at 2:15 p.m. CNA #M stated she has worked at the facility for 3.5 years. She stated that her last fall precaution in-service was 1.5 to 2 years ago.

Based on observation, record review and interview the facility neglected to provide services necessary to avoid physical harm. They did not provide supervision and effective assistive devices to prevent accidents with injury. The facility also neglected to use resources such as care planning and quality assurance to review and ensure all safety measures met the individual needs of residents. The result of the facility ' s neglect resulted in Immediate Jeopardy for 5 of 5 residents who had falls with injury (#6, 31, 38 41 & 52) and put other residents who needed supervision or used assistive devices at risk for harm or injury. The sample was 25. Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on [DATE] and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from [DATE] to [DATE]. The resident hit her head on [DATE]. Injuries occurred on [DATE] and [DATE] in the form of skin tears. The resident also sustained swelling to the left side of her forehead on [DATE]. Resident #6 fell 4 times from [DATE] to [DATE]. On [DATE] he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from [DATE] to [DATE]. She sustained skin tears on [DATE] and received a large bruise to the right side of her face and a skin tear to her right arm on [DATE]. Resident #38 fell 11 times from [DATE] to [DATE]. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on [DATE]. As of the exit date of the survey on [DATE], the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a [MEDICAL CONDITION] and 3 fractured bones respectively. These practices resulted in immediate jeopardy starting on [DATE] and it was determined to be ongoing as of the exit date of [DATE]. Findings: Cross refer to F323 and F520. 1. Resident #41 was observed on [DATE] at 9:20 a.m. at the nurses' station, in a straight back wheelchair. The resident was leaning forward with her head almost parallel to her lap. There was a pillow on her lap and a doll on top of the pillow. The pillow was observed to be slipping off the resident's lap. At that time an alarm was noted attached to the wheelchair and there was not any staff at the nurse's station. Several minutes later at 9:35 a.m. the resident was observed again still leaning forward but the cord/string from the chair alarm was not attached to the resident. At that time the Unit Manger (UM) came out of the office that is located the nursing station and looked at the resident but did not intervene. Several seconds later a Certified Nursing Assistant (CNA) arrived in the area and cued and repositioned the resident, pillow and placed the doll under the resident ' s right arm. The CNA reattached the cord from the alarm to the resident. Then the CNA started wheeling the resident towards her room. Record review revealed the resident fell 8 times in a 2 month period from [DATE] to [DATE]. The resident fell 5 of 8 times in her room and 2 of 8 times in the Activity/Day/TV Room. The TV room is approximately 6 feet across form the nurse's station. It was determined that if staff were sitting behind the nurse's station the entire TV room could not been seen. Review of the resident's Minimum Data Set ((MDS) dated [DATE] indicated that the resident was totally dependent on staff for bed mobility, transfer, dressing, personal hygiene and locomotion. The resident is totally incontinent with both bowl and bladder. Under Cognitive Patterns, Section C, the MDS showed that Brief Interview for Mental Status (BIMS) should not be conducted with the resident because the resident is rarely/never understood. The resident has short-term and long-term problem. The resident ' s cognitive skills for daily decision making is severely impaired - never/rarely made decisions (C1000=3). The resident's fall care plan dated [DATE] had the following approaches: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. On [DATE] the car plan was updated with 'Found lying on floor TV Room skin tear to forehead. The approaches remained the same since [DATE] and new interventions had never been added. 2. Resident #31 was readmitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. The resident continued to be at risk for falls and on [DATE] the resident fell in the shower. The sustained 3 skin tears to the right arm. Record review revealed the resident fell again in the TV room on [DATE] at 9:45 a.m. The resident was observed face down and blood was on the floor. The resident was transferred to the hospital and diagnosed with [REDACTED]. On [DATE] at 11:20 a.m. the Unit Manager was interviewed. She confirmed that staff was not in the TV room when resident #31 fell on [DATE]. She also stated, "We do not have staff in the TV room to supervise residents." Review of the Minimum Data Set ((MDS) dated [DATE] documented the resident was not able to repeat 3 words, not able to answer the correct month or year; and resident was not able to be interviewed for mental status. It was documented the resident was easily distracted, out of touch and disorganized. Review of the recent MDS dated [DATE] indicated the resident requires extensive assistance, from staff, in bed mobility, transfer, walking, locomotion, dressing and personal hygiene. The resident is totally incontinent of both bowl and bladder. Also, the MDS did not include the resident's fall from [DATE]. The resident's fall care plan dated [DATE] had the goal 'Resident will remain free from injury and the following approaches were listed: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. The care plan was reviewed and re-dated [DATE] but the interventions remained the same. The care plan was not updated with new interventions even after the resident fell on [DATE] and then again on [DATE]. 3. Resident #6 is cognitively impaired with a BIMS score of 3 out of 15 on a scale of ,[DATE]. (,[DATE] = severe impairment, ,[DATE] = moderate impairment, and ,[DATE] =cognitively intact). The intent of conducting the BIMS is to determine the individual's attention, orientation, and the ability to register and recall new information. The resident had 4 falls in less than one month ([DATE] to [DATE]). On [DATE] 12:06 p.m. the residents POA was interviewed via phone. On [DATE] at 12:06 p.m. during a telephone interview with the resident's daughter in law, who was the Power of Attorney (POA), she revealed that she was not satisfied with the assistance and supervision the facility staff was providing for her father-in-law, and did not think there was enough staff to properly take care of him. On [DATE] at 11:50 am the resident's direct care CNA # I was interviewed. She described the resident as being very demanding. She indicated the resident always wanted to get up first. The CNA added that the resident required a lot of assistance and was capable of using the call bell, but he usually calls out for help. Staff #I was not aware of any procedures or protocols for fall precaution/prevention. She said the nurses tell her at report if someone is a fall risk. Staff #I added, "After you been here awhile, you figure it out." Later that day at 2:50 p.m. the resident's direct care nurse # D was interviewed. Nurse #D stated that when a resident falls, she completes an Incident Report. When asked what new fall interventions are put in place? She explained that the resident is brought to the nurse's station so that staff can keep a closer eye on the resident. Review of the MDS dated [DATE] indicated the resident was extensive assist, from staff, for bed mobility, transfer, walking in corridor, dressing. The resident was totally dependent of staff for locomotion both on & off the unit and personal hygiene. The resident was frequently incontinent of both bowel and bladder. The resident's fall care plan was initiated on [DATE] and it noted the resident's fall on [DATE]. The fall prevention interventions are the following: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. The review date of this care plan is noted to be on [DATE]. However the interventions stayed the same since admission. New interventions were not added even after the resident fell a third and a fourth time on [DATE] and [DATE], respectfully. 4. Resident #38 is a cognitively impaired resident that is on hospice. The resident fell 11 times between [DATE] to [DATE]. The resident's third fall at the facility was on [DATE] and he was sent to the hospital for a laceration to his forehead. The resident returned to the facility and fell another 8 times. The fall risk evaluation of the resident scored a 26. A score of 10 or higher indicates at risk for falls. The resident's recent MDS dated [DATE] indicated that he was rarely understood and his cognition was severely impaired. The resident required extensive assistance, from staff, for bed mobility, transfer and dressing. The resident was totally dependent on staff for personal hygiene, bathing and locomotion. The resident active [DIAGNOSES REDACTED]. The resident's fall care plan dated [DATE] listed the following fall interventions: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. On [DATE] at 11:10 am the resident's hospice nurse was interviewed. She stated the resident was at risk for falls based upon her assessment. Hospice fall intervention tool dated [DATE] indicated the hospice nurse recommend an alarm to both wheelchair and bed. She also recommended mats on the floor at bedside. On [DATE] the physician wrote an order for [REDACTED]. The care plan was never updated to reflect the alarm to chair & bed, low bed with mats. The first reference to mats in the Incident Reports was on [DATE]. The note read 'Observed on mat on floor by his bed.' Therefore it could not be determined when mats were imitated by staff. On [DATE] at 6:15 p.m. resident #38's direct care nurse #G stated she has worked in the facility for about a year and that she's usually on the ,[DATE] shift. She stated she was not aware of any protocol for fall precautions and had not had any in-services this year related to fall prevention. She stated when a resident falls, she completes and Incident report that is turned into the Director of Nursing (DON). During the interview resident #38's alarm was sounding and nurse #G left the interview to respond to the alarm. When she returned, approximately 10 minutes later, she explained that the resident was found on the floor by the Unit Manager. She stated, "I will probably have to complete the Incident Report and I did not even witness the incident." 5. Resident #52 is an alert and cognitively aware resident. She had 3 falls from [DATE] to [DATE]. It is noted that the resident attempts to transfer herself without staff assistance. On [DATE] the resident stated she fell in the bathroom attempting to transfer herself from the chair to the toilet. She also stated there is not always enough staff to help her get on the toilet. The resident's fall care plan dated [DATE] had the following interventions: 1) Educated resident in safety awareness 2) Remind resident to call when needing assistance 3) Keep call light and most frequent used personal items within reach 4) Assess medication for contributing factors 5) Move room closer to the nurse's station if necessary 6) Shoes well fitting with non-slip soles 7) Gripper Socks 8) PT/OT evaluation for strength training and gait 9) Assist res. To and from toilet 10) Maintain room and pathway free of clutter, from furniture, tales etc. Staff updated the care plan to reflect that the resident fell on [DATE] and the resident sustained [REDACTED]. The fall interventions were never changed or modified. On [DATE] at 1:30 p.m. the MDS/Care Plan coordinator (CPC) stated she creates all care plans except for Dietary and Social Services. In regards to falls, she stated the floor nurses are responsible for the interventions. She explained that if a resident falls, the floor nurse will decide if the resident needs an alarm. The CPC stated the fall is discussed in morning meeting and she will update the care plan with the new intervention. When asked how direct care is staff informed about new interventions? The CPC stated, "They can read the care plans." The facility staff was asked about falls investigations for residents #6, #31, #38, #41 and #52. The facility submitted Incident Reports as their fall investigations. There were missing incident reports for resident #41 for a fall on [DATE] and for resident #6 for a fall on [DATE]. On [DATE] at 8:45 a.m. the Director of Nursing (DON) stated she not keep an Incident/Fall log. She stated that when a resident has a fall the resident's direct care nurse completes an Incident Report and sends it to her. She makes a copy of the Incident Report for the Therapy Department. She stated that falls are discussed in morning meetings and the CPC updates the care plans. When asked why the investigative portion of the incident reports had not been completed? The DON stated, "I used to fill out the information on the form, but I don't anymore." She added that the information could be found in the nurse's notes, "I don't have an additional investigative form." When asked why she was not following the Accident and Incident-Investigation and Reporting Policy & Procedure that was provided to the survey team, the DON had no response. Review of the policy for Accidents and Incidents-Investigating and Reporting and Managing the Risk and Liability of Falls revealed that all accidents or incidents involving residents, employees, visitors, etc occurring on the premises must be investigated and reported to the Administrator. An incident report form must be completed for all reported incidents. The nurse supervisor/charge nurse must be immediately informed so that medical attention can be provided. The nurse supervisor/charge nurse and or the Department Director or Supervisor must conduct an immediate investigation of the incident including the date and time the incident took place, names or witnesses and their accounts of the accident/incident, injure person's account of the accident/incident, time of injured person attending physician was notified, as well as time physician responded and hi/her instructions, dated and time injured person family was notified and by whom, condition of the injured person to include vital signs, disposition of the injured (transferred to hospital, put to bed, etc.), any corrective action taken, follow up information, signature of person completing the report. The Accident/Incident report and the Accident Investigation Report Form are to be submitted to Administrator no later than 24 hours after the occurrence of the accident/incident. Review of the Managing the Risk and Liability of Falls indicated that fall risk evaluations should be completed on all residents with the first 3 hours of Admission, with any changes of condition and after a fall. Once a resident has been identified as 'at risk for fall' there should be documented evidence of intervention to reduce the risk of fall from occurring. If the resident repeats a fall, the care plan should reflect goal changes or approach changes. All new fall prevention measures should be introduced to current employees through an in-service and incorporated into new employee orientation. Twenty Six Incident Reports provided by the facility for residents #6, #31, #38, #41 and #52 were reviewed. It was determined that the staff did not follow the facility ' s policy for completing the form. In 18 of 26 reports it could not be determined if the staff completing the form, was the first person to respond to the resident or just summarized the occurrence. The facility neglected to get staff statements and perform an in-depth investigation on how the each resident fell . Resident #52 is an alert and cognitively resident. In two of the three falls that resident #52 had, staff neglected to interview the resident to determine why she fell why she did not call for assistance. Staff neglected to document the disposition of the resident in 12 of 26 reports. In 24 of 26 reports, corrective action was not documented. The facility neglected to develop a staff education plan. On [DATE] at 1:35 p.m. the Human Resource Coordinator stated that nursing does the staff in services, then gives her the certificate and she puts it in the employees' file. She also stated that if staff obtain continuing education units (CEUs) outside the facility, i.e. CPR, etc., they can bring in a copy of the certificate and she will put into their files. She indicated that the unit manager (UM) provides some of the education. Later that day at 2 p.m., the UM brought in the test that the staff were given, indicating the tests are evidence of her in-services. Review of the in-service sign in sheet revealed that all the names appeared to have been written by the same person. The UM confirmed that she writes the names of the staff on the in-service sign in sheets. She stated that if she does not leave the sign in sheet at the nurse's station because it will get lost. She stated she puts the name on the sign in sheet when the staff turns in his/her test. The UM provided a few tests that staff had taken, but the tests were not graded. The UM indicated she does not grade the test. There was no evidence that these tests were evaluated to determine if staff had the correct answer or required further education based upon not having the correct answer. There was no indication that staff received in-services related to fall prevention. On [DATE] at 6:15 p.m. the DON was interviewed. When asked about her education plan she said, "I do not have a written plan, I just have it in my head." On [DATE] at 1:15 p.m. CNA #L stated she has worked at the facility for 3 years and thought she had an in-service for fall precautions last year. She stated the staff used to get in-services every payday, but stated there have been any in-services for 2013. Several minutes later at 1:30 p.m., CNA #K stated she has worked at the facility for 6.5 years. She stated they used to get in-service on payday and she thought she had a fall precaution in-service a couple of weeks ago, but she was not sure. Later that day at 2:15 p.m. CNA #M stated she has worked at the facility for 3.5 years. She stated that her last fall precaution in-service was 1.5 to 2 years ago. On [DATE], the facility implemented sufficient measures to decrease the severity/scope to E, but the facility remains out of compliance with F224.

Based on observation, interview and record review the facility failed to implement a system for fall prevention for 5 of 5 residents (#6, 31, 38, 41 & 52) reviewed for falls out of 25 sampled residents. All 5 residents have a history of multiple falls and falls with injuries. They all have conditions that put them at risk for continued avoidable falls and potential for serious injury. The facility also failed to keep the environment free of hazards. Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on 5/11/13 and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from 3/02/13 to 5/09/13. The resident hit her head on 3/02/13. Injuries occurred on 3/30/13 and 5/04/13 in the form of skin tears. The resident also sustained swelling to the left side of her forehead on 5/04/13. Resident #6 fell 4 times from 4/09/13 to 4/28/13. On 5/13/13 he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from 3/07/13 to 5/04/13. She sustained skin tears on 3/07/13 and received a large bruise to the right side of her face and a skin tear to her right arm on 5/04/13. Resident #38 fell 11 times from 1/17/13 to 5/15/13. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on December 21, 2012. As of the exit date of the survey on 5/18/13, the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a head laceration and 3 fractured bones respectively. The facility failed to evaluate each fall and failed to modify and implement individualized interventions to reduce avoidable falls and prevent injury when necessary after successive falls as of the exit date of the survey on 5/18/13. These practices resulted in immediate jeopardy starting on 12/21/12 and it was determined to be ongoing as of the exit date of 5/18/13. Findings: 1. A review of the medical record revealed resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The FRE tool evaluates: History of falls, Cognitive status/behavioral symptoms, vision status, balance, systolic blood pressure and vitals, age, health conditions/risk factors and medications. The form indicates a resident who scores a 10 or higher is at risk for falls. Resident #31's score was 24. The facility provided a policy "Managing the Risk and Liability of Falls " which directed staff that the fall risk evaluations should be completed on all residents within the first 3 hours of admission, with any change of conditions, and after a fall. Review of the physician's orders [REDACTED]. The side effects are: Somnolence, decreased concentration, dizziness, light headedness and vertigo. Tramadol HCL 50 mg 2 tablets (100 mg) by mouth daily for pain. Side effects are: dizziness, vertigo, somnolence, agitation, hallucinations and syncope. Review of the Minimum Data Set ((MDS) dated [DATE] documented the resident was not able to repeat 3 words, not able to answer the correct month or year; and resident was not able to be interviewed for mental status. It was documented the resident was easily distracted, out of touch and disorganized. In Section G- Activities of Daily Living (ADL ' S) it was documented the resident needed extensive assist of two persons for bed mobility, transfer, walking in corridor and was totally dependent for locomotion on unit. Section G- Balance during transitions, documented the resident was not steady, only able to stabilize with human assistance. On 2/28/13 a quarterly review using the MDS, Section J1800, documented the resident had not had any falls since admission or prior to assessment, whichever is more recent. However, it was documented in the resident's medical record she had sustained a fall on 12/21/12, since the prior assessment. Review of nursing documentation, dated 12/21/12 at 2:00 p.m., revealed resident #31 fell in the shower room and sustained three skin tears to her right arm. There was no further nursing documentation found in the medical record regarding the fall or reassessment of her injuries. On 5/16/13 at 4:00 p.m. resident #31 was observed in her wheel chair in the hallway, unattended. She had a cast on her right arm and bruising to the right side of her face. An interview was conducted with unit manager (UM) on 5/18/12 at 11:20 a.m. regarding the resident's fall on 12/21/12 and she said, "The resident lost her balance and slid to the floor hitting her arm on the shower chair. The certified nursing assistant (CNA) was drying the resident 's peri area after her shower, so the resident was standing while in the shower room." The UM said the CNA who was assisting the resident on 12/21/12 was no longer employed by the facility. Review of the nursing care plan dated 12/13/12 did show any evidence the interventions or goals on the care plan had been reviewed or modified as necessary to prevent accidents, falls and/or injuries even after the resident had sustained a fall with injury on 12/21/12. Review of nursing documentation revealed the resident sustained [REDACTED]. An interview was conducted with RN #E regarding the fall that occurred on 5/11/13 on 5/17/13 at 1:35 p.m. She said, "Residents are normally taken to the TV room after meals. The resident must have tried to get out of her chair and fell . A resident saw the incident and got the attention of a CNA and nurse. I went to the TV room and saw resident on the floor. The resident was face down on the floor and there was blood on the carpet." Review of the nursing note dated 5/11/13 at 11:00 a.m. documented "the resident was out of bed in wheelchair for breakfast and was put in TV room after breakfast. Around 9:45 a.m. nurse's attention was called to TV room. Resident found on floor face down and blood noted on floor. Resident was assessed and 911 initiated. Laceration noted to lower forehead. Resident was transported to hospital around 10:00 a.m." There was no evidence of neurological (neuro) checks being completed or documented on resident #31 on 5/11/13 after an unwitnessed fall. An interview was conducted with the administrator on 5/17/13 at 5:30 p.m., and she said neuro checks are to be performed on any resident who sustains an unwitnessed fall. The resident was transferred to an acute care hospital for evaluation on 5/11/12 at 10:00 a.m. as a result of injuries sustained. An interview was conducted with CNA #K on 5/17/13 at 1:30 p.m. She was not the CNA assisting the resident on 12/21/12, but she indicated resident #31 likes to have her feet up and said the resident is always trying to get out of her wheel chair into a recliner chair when in the TV room. CNA #K was asked, when she assists the resident to the TV room why didn ' t ' t she put the resident into the recliner chair and she said, "She would try to get out of that chair too." CNA #K said she was not aware of any chair or bed alarms being used for this resident. She said "There are no mats on the floor that I know of." An interview was conducted with the UM on 5/18/13 at 11:20 a.m. She confirmed the resident fell on [DATE] and there were no staff members in the TV room supervising the resident at the time of the fall. She also stated, "We do not assign staff to the TV room to supervise residents." Observation of the TV room on 5/18/13 at 11:25 a.m. from the nursing station, revealed there were several residents in the TV room. There was no staff observed in the TV room and all the residents could not be visualized from the nursing station. The resident was readmitted to the facility on [DATE] at 1:45 p.m. with bruising to left arm, bilateral knee abrasions, bruising to right eye and forehead, and a cast on her right arm. Review of the physician's history and physical from the hospital dated 5/11/12 at 5:13 p.m., revealed the resident had sustained a fracture to the right distal radius and a right orbital floor fracture, as well as nasal fracture and forehead abrasions. Her mental status upon readmission to the facility was assessed as confusion, dementia, and unable to orient. Review of the fall assessment tool dated 5/14/13 did not document any change in the resident 's fall status. The total score was 24, the same as the resident 's score before the second fall on 5/11/13. Review of the resident ' s care plan revealed interventions and goals were not modified as necessary to prevent accidents, falls, and/or injury. Resident #31 was observed 5/17/13 at 9:15 a.m. sitting in the nurses ' station. She was sitting next to another resident and was observed leaning down in her wheelchair with her head between her legs, reaching for a doll. She had a chair alarm, but it had become unattached. There was no staff nearby. The UM appeared behind the nursing station in approximately 2-3 minutes, but she did not notice the resident was leaning down and the resident's alarm was not attached. Resident #31 was observed at 1:50 p.m. on 5/17/13 lying in her bed with her eyes closed. The resident ' s room was not the closest resident room to the nurses ' station. 2. Resident #41, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's previous living arrangement was assisted living facility (ALF). She had history of multiple falls. She was sent to a hospital in January 2012 with right hip fracture with open reduction internal fixation (ORIF). She then was admitted to skilled nursing facility (SNF) for rehabilitation and returned to ALF. She was readmitted to SNF with [DIAGNOSES REDACTED]. The resident has been under hospice care since March 2013. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/2013 assessed the resident ' s speech clarity as ' no speech-absence of spoken words ' (B0600=2); ability to understand others as ' rarely/never understands ' (Section B0800=3). Under Cognitive Patterns, Section C, the MDS showed that Brief Interview for Mental Status (BIMS) should not be conducted with the resident because the resident is rarely/never understood. The resident has short-term and long-term problem. The resident ' s cognitive skills for daily decision making is severely impaired - never/rarely made decisions (C1000=3). Under Functional Status (Section G), the resident is assessed as total dependence with 2 plus persons physical assist for bed mobility, total dependence with one person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, and personal hygiene. Fall history on admission (J1700) indicated the resident did not have a fall any time in the last month and 2-6 months prior to admission. The resident did not have any fracture related to a fall in the 6 months prior to admission. Fall Risk Evaluations were done on 2/04/13 and 5/17/13 with a total score of 16 and 22 respectively. The Fall Risk Evaluation indicated a resident who scores a 10 or higher is at risk, consider environmental risk factors in resident ' s interventions. A review of the resident ' s medication administration record (MAR) for the period of 5/1/13-5/31/13 showed the resident has received the following medications: [REDACTED] Citalopram Tab 20 mg. one capsule by mouth (PO) daily. Diagnosis (Dx.) Depression. Side effects (listed on MAR): insomnia, drowsiness, nausea, diaphoresis, xerostomia. Haloperidol tab 1 mg, one tablet PO twice daily, and Haloperidol tab 1 mg, one tablet PO every 6 hours as needed. Dx. Anxiety. Side effects (listed on MAR): dystonic reaction, constipation, weight gain, blurred vision. Levothyroxin tab 50 mcg, one tablet PO daily. Dx. [DIAGNOSES REDACTED]. Side effects (listed on MAR): seizure, coma, angina pectoris, myocardial infarction, angioedema. Lorazepam Tab 0.5 mg, one tablet PO twice daily. Dx. Anxiety. Side effects (listed on MAR): sedation, weakness, dizziness, unsteadiness, suicidal ideation, pancytopenia. Mirtazapine Tab 15 mg, one capsule PO at bedtime. Dx. Depression. Side effects (listed on MAR): severe sedation, insomnia, drowsiness, constipation, fatigue, weight gain. Seroquel 50 mg, PO every 8 hours. Dx. Atypical psychosis. Side effects (listed on MAR): dizziness, headache, weakness, drowsiness, agitation, constipation. Ativan 0.5 mg PO every 6 hours, as needed. Dx. Anxiety. Side effects (listed on MAR): sedation, weakness, dizziness, unsteadiness, suicidal ideation, pancytopenia. A review of nurse ' s notes indicated the resident had frequently tried to get out of bed and/or wheelchair. The notes listed: on 1/31/13 (3-11 p.m.) trying to get out of chair constantly, on 2/01/13 at 6:00 a.m. attempting to exit chair, on 2/02/13 at 9 p.m. attempting to exit chair, on 2/03/13 at 2:30 a.m. multiple attempts to get out of bed (OOB), on 2/04/13 at 4:00 p.m. resident was observed exiting bed, on 2/04/13 at 6:30 a.m. observed resident on floor beside chair, on 2/8/13 at 10:15 p.m. frequently climbs OOB - doesn't comprehend request not to get up. A further review of nurse ' s notes revealed that the resident fell on the following dates: 3/02/13, time 2:35 p.m. A housekeeper saw the resident climbed out of bed and walked towards wheelchair and fell on floor. The resident stated she hit her head. Physician and resident ' s daughter were informed. Physician ordered to send the resident to a hospital, but the daughter refused. 3/08/13, time 12:15 am. Bed alarm sounded, resident was found on floor sitting beside bed. Resident denied pain. 3/23/13, time 10:30 p.m. The resident was found on floor in room. 3/30/13, time 10:40 a.m. The resident found on floor lying on right arm. Skin tears noted to right arm. Order received for X-ray of Right shoulder and bilateral hips. 4/05/13 time 10:15 p.m. Resident alarm sounded. CNA (certified nursing assistant) found resident lying on the floor next to her bed. No apparent injuries noted. 4/26/13 time 2:00 p.m. Resident observed sitting on the floor by her wheelchair. Denied pain, no injuries noted. 5/04/13 time 1:30 pm. Resident observed laying on the floor in the TV room at front of her wheelchair. Skin tear and bump left side of forehead. Alert and responsive. Daughter refused to have her sent to hospital, on neurochecks. 5/09/13 time 11:25 p.m. Resident observed in room sitting on floor beside roommate's bed. No injury noted. No s/s (sign/symptom) pain noted. An interview was conducted on 5/16/13 at about 6:00 p.m. with the director of physical therapy. She stated the 4/08/13 screening was the only screening document she found on the resident. The resident was not a candidate for therapy. When asked why the resident was not screened after other falls, she stated therapy department would get involved after nursing interventions did not work. She further stated resident #41 is also under hospice care that has more control over resident care. On 5/15/13 at about 11:00 a.m., the resident was observed sitting in a wheelchair at nurse ' s station. There were staff present at the nurse ' s station. The resident then was standing up and leaning forward with hands on the armrest of the wheelchair. No staff were observed to supervise the resident. After the staff at the nursing station did not intervene, the surveyor brought the resident ' s actions to their attention and a staff member got up and went to the resident to assist her to sit down. Observation at 9:20 a.m. on 5/17/13 found the resident at the nurses ' station in a wheelchair with straight back, leaning forward. No nursing staff were present at the nursing station. The chair alarm was on the resident. At 9:35 a.m., she was still leaning forward and the chair alarm was not attached to her. The Unit Manager (UM) saw her, but did not intervene at that time. A CNA came over, spoke with her and took her back to her room. No support for positioning was observed for this resident. The director of physical therapy department was interviewed on 5/18/13 at about 1:00 p.m. in the resident room. She stated the resident ' s wheelchair back can go back for tilting. A Gerichair was replaced by this wheelchair from hospice, but the Gerichair was discontinued on 4/03/13 according to hospice notes. On 5/16/13 at about 4:30 p.m. an interview was conducted with the UM in regards to fall precautions. She stated the facility would use floor mats and chair and bed alarm as a fall precaution. If a resident came in from a hospital due to falls, she said, "we would know that we have to put the resident in low bed." A fall risk assessment is done when the MDS coordinator gives a list of residents to update. On 5/17/13 at 2:40 p.m. an interview was conducted with the housekeeping staff #S who witnessed the resident's fall on 3/02/13. She stated she saw the resident was trying to get out of wheelchair in the resident room. She told the resident to sit down. Then she called a CNA to come to the room, but she didn't remember the CNA's name. By the time the CNA came in, the resident was found on the floor. On 5/18/13 at 11:55 a.m. and 12:15 p.m. an interview was conducted with nurse #R, the licensed practical nurse (LPN) who documented the resident ' s falls on 4/26/13 and 5/04/13. She stated that on 4/26/13 she observed the resident on the floor in front of the wheelchair in TV/activity room. She was told by other residents in the room that the resident was sliding off the wheelchair. On 5/04/13, she observed resident #41 on floor. She was told by other resident in TV room about the fall. 3. Resident #6 was admitted to the facility on [DATE] following an acute care stay. A History and Physical from the hospital dated 4/05/13 indicated the chief complaint was that the resident had a fall with right sided facial droop, and right-sided weakness. His most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that he was severely cognitively impaired with a cognitive summary score on his Brief Interview for Mental Status (BIMS) of 3/15 on a scale of 00-15. (00-07 = severe impairment, 08-12 = moderate impairment, and 13-15 =cognitively intact). The intent of conducting the BIMS is to determine the individual's attention, orientation, and the ability to register and recall new information. The MDS Assessment indicated that he was exhibiting verbal behavior directed toward others, and rejection of care. His functional status indicated that he needed extensive assistance with bed mobility, transfers, and dressing (with a 1-2 person assist), and he was totally dependent on assist with toilet use and personal hygiene (with 1-2 person assist). His balance was not steady. His Active [DIAGNOSES REDACTED]., anxiety disorder, and depression. Health Conditions indicated no falls since admit/reentry. Skin conditions indicated skin tears, pressure reducing device for bed, application of dressings, and to apply ointment as needed. Medications included antidepressant, antianxiety, and a diuretic. Speech Therapy (ST) started 4/10/13 to ongoing, occupational therapy (OT) started 4/10/13 and ongoing, and physical therapy (PT) started 4/10/13 and was ongoing. His Admission Nursing Evaluation dated 4/09/13 indicated physical functioning ranged from assist to dependent on bed mobility, transfer, walking, and dressing. His Fall Risk Evaluation completed 4/09/13 indicated a score of 20 (with scale of 10 or higher at risk). The only intervention documented on the form was to keep call light within reach. Nurse Aide's Information Sheet was not dated but indicated that the resident had good eye sight, was aphasic in speech, was to be turned an repositioned every 2 hours with 1 person assist, was to use half rails, had right left leg paralysis, right side of face paralysis, locomotion included wheelchair, and assist transfers, mental status included forgetful, and the behavior section was left blank (not filled out). physician's orders [REDACTED]. hours for pain, and Ativan gel 0.5 mg topically twice a day as needed for increased anxiety. Amlodipine side effects included edema, palpitations, headache, fatigue, flushing, nausea, dizziness, drowsiness. Coreg side effects included dizziness, weakness, fatigue, diarrhea, weight gain, and hyperglycemia. Mirtazapine side effects include severe sedation, insomnia, drowsiness, constipation, fatigue, and weight gain. Namenda side effects included dizziness, headache, hypertension, confusion, syncope. Xanax side effects included insomnia, dizziness, depression, drowsiness. The resident's multiple [DIAGNOSES REDACTED]. The resident ' s current list of medications and some of the potential side effects related to those medications including: sedation, blood pressure variations (hypotension, hypertension), dizziness, confusion, syncope, and drowsiness were all potential factors contributing to the higher risk for falls. Review of physician progress notes [REDACTED]. PT Notes dated 4/10/13 indicated skilled services provided to increase balance to weight shifting laterally to promote right side awareness and body image. It was noted 'Pt. continues to show improvements in weight shifting and weight distribution of RLE and torso to midline position.' OT notes dated 4/10/13 indicated patient seen and treated for [REDACTED]. It was noted 'Pt. shows improvements in increased activity tolerance. Able to actively participate in feeding and simple grooming tasks. able to complete sequences with verbal cues to initiate and remain on task. Signed 5/9/13.' His care plan dated 4/10/13 indicated the potential for injury related to falls and the goal was that the resident would remain free from injuries. Interventions included educate the resident in safety awareness, remind resident to call when needing assistance, keep call light and most frequently used personal items in reach, assess medications from contributing factors, make sure all staff aware that resident was at high risk for falls, move to room closer to nurse ' s station, shoes well-fitting with non-slip soles, gripper socks, PT/OT evaluation for strength training and gait. Assist resident to and from the toilet, maintain room and pathways free of clutter from furniture, tables, etc. The care plan did not reflect the record of falls found in the nurse's notes and/or incident reports: 4/9/13 fell from wheelchair trying to stand x 2 4/13/13 Attempted to transfer and fell to the floor 4/18/13 Found on floor in front of wheelchair (No incident report found) 4/28/13 Found on floor next to elevator door. The 4/09/13 nurse's note indicated resident was admitted from hospital, " fell out of wheelchair at 7:40 p.m. and 8:10 p.m. No injury. Family and physician notified. Vital signs taken. " The notes from 4/18/13 indicated, " resident was found on floor at 3:45 in front of his wheelchair stated that he tried to stand. No injury observed. Denied pain. Physician and son notified. Vital signs taken. " The nurse's note dated 4/28/13 indicated, " resident was found on the floor beside elevator next to his wheelchair. No complaints of pain. Family and physician notified. Vital signs recorded. " On 5/13/13 at 7:35 a.m. resident #6 was observed attempting to get out of bed. When the surveyor asked if he was okay, he stated, "no come help me." The resident was instructed to use his call bell, but he got up anyway and transferred himself to the chair beside the bed. His gait/balance was very unsteady. The resident was wearing a brief and had a large reddened area to his right upper thigh. The bed was in low position, the room was dark (blinds closed) and there were no mats beside the bed. There were no alarms on his chair or bed. Approximately 5 minutes later, certified nursing assistant (CNA) #L entered the room and stated that the resident fell earlier, and she explained "that's why he has a bruise on his leg." On 5/13/13 at 8:00 a.m. an observation revealed the resident in the dining room sitting in his wheelchair while eating his breakfast. At 9:00 a.m. an observation revealed the resident in the dining room eating breakfast again. Resident #6 was observed moving around the hallways, and back and forth into the dining room, unassisted by staff. On 5/13/13 at 12:10 p.m., in an interview with nurse #T, she revealed that the resident fell on [DATE]. She read from the nurse's note: 'resident found on floor in front of wheelchair tried to stand no injuries,' and on 4/28/13 'resident was found on floor at bedside next to wheelchair no injuries.' She stated that the resident was physically capable of getting out of bed on his own, but that he always called for assistance prior to attempting to get out of bed. At 12:30 p.m. an observation revealed the resident was in the dining room sitting at the table in his wheelchair eating lunch. He was eating on his own unassisted by staff. On 5/14/13 at 12:06 p.m. during a telephone interview with the resident's daughter in law, who was the Power of Attorney (POA), she revealed that she was not satisfied with the assistance and supervision the facility staff was providing for her father-in-law, and did not think there was enough staff to properly take care of him. She explained that her mother-in-law was in the skilled nursing part of the facility, but since they, she and her husband, were unhappy with the lack of care she was receiving, they moved her to the Assisted Living Facility (ALF) portion of the building and hired a private aide to assist her. She stated that the private aide goes down to the skilled side to get resident #6 and take him to visit his wife. She also expressed her dissatisfaction with the way staff interacted with her father-in-law. She said she was aware that he was not always cooperative with taking his medications, but she thought that they should treat him with more respect and dignity. On 5/14/13 at 9:05 a.m. an observation revealed an aide in the resident's room assisting him to get dressed. During an interview at that time, she revealed that she did not work for the facility. She said she was hired to assist the resident's wife upstairs in the ALF, but she had to come downstairs to help transport the resident to see his wife. She stated that she cares for both of them at times, and sits with them outside. On 5/15/13 at 11:50 a.m. during an interview with the resident's assigned CNA #I, she revealed the resident required a lot of assistance. She said he always wanted to get up first and he was very demanding. She said he was capable of using the call bell, but usually called out for help. She said when he first came in he had some falls, but she was not sure if he had any recently. She said he refused to go to activities and just wanted to be with his wife. She explained that a private aide comes to pick him up and take him to his wife in the ALF. She was not aware of any procedures or protocols for fall precaution/preventions. She said the nurses tell her at report if someone is a fall risk and "after you have been here awhile, you figure it out." On 5/18/13 at 11:30 a.m. an observation revealed the resident going down the hallway in his wheelchair followed by a private aide. He was headed towards his room. An observation at that time revealed multiple bruises and a scabbed area to his left elbow. On 5/15/13 at 2:50 p.m. during an interview with the assigned Nurse #D, she stated that she was not aware of any protocol for fall prevention and that when a resident had a fall, she completed an Incident Report. She said the Incident Report went to the Risk Manager/Director of Nursing so she could determine if new interventions needed to be put in place. When asked what new interventions are put in place, she explained that they bring the resident to the nurse's station so that they can keep a closer eye on them. 4. Resident #38 was readmitted to the facility on [DATE] following an acute care stay. His most recent MDS assessment dated [DATE] indicated that he was rarely understood and cognitive skills severely impaired. He had short and long term memory impairment and was unable to complete the BIMS. He exhibited signs of delirium and disorganized thinking. His functional status indicated that he required extensive assistance with bed mobility, transfers, and dressing (with a 1 person assist), and was totally dependent for assistance (with 1 person assist) with toilet use, bathing, personal hygiene, and locomotion off the unit. His balance was not steady. His Active [DIAGNOSES REDACTED]. The Health Conditions sections indicated a fall history, and since admission reentry, the resident had a fall with minor injury. The skin conditions section indicated skin tears. His medications included insulin, and the assessment indicated he was on Hospice Care. The Care Area Triggers (CAT) Worksheet indicated that the resident has had a significant decline and is now under the care of Hospice for Failure to Thrive. It was noted that the resident requires increased assist with functional mobility and often forgets to call for assistance before rising. He has a history of falls with ongoing poor safety awareness. Skin is intact at this time. The resident has had skin tears, but no open pressure areas noted. The Admission/Nursing Evaluation dated 3/12/13 indicated assist with 1 on all activities of daily living (ADLs), incontinent of bowel and bladder., and 2 small skin tears to right lower legs. The Fall Risk Evaluation dated 3/12/13 indicated a score of 26. A score of 10 or higher indicates at risk for falls. There were no interventions listed on the fall risk form. The Nurse Aide 's Information Sheet was not completed or left blank relating to mental status, turn and position, locomotion, behavior, side rails, eye, hearing, and speech. The physician's orders [REDACTED]. Side effects of Keppra indicated infection, psychoneurosis, weakness, drowsiness, anxiety, depression, agitation. Side effects of Dilantin indicated irreversible cerebellar dysfunction, asterixis (tremor of the hand when the wrist is extended) , and chorea (abnormal involuntary movement). The resident's multiple [DIAGNOSES REDACTED].

Based on observation, record review and interview the facility failed to effectively prevent falls/accidents and efficiently use resources to maintain the highest practicable measure of safety for 6 of 25 sampled residents (#6, 31, 38, 41 & 52). The administration failed to ensure adequate evaluation of falls/accidents in order to assess risk, implement effective safety approaches, and ensure the Quality Assessment Committee addressed resident safety issues. Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on 5/11/13 and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from 3/02/13 to 5/09/13. The resident hit her head on 3/02/13. Injuries occurred on 3/30/13 and 5/04/13 in the form of skin tears. The resident also sustained swelling to the left side of her forehead on 5/04/13. Resident #6 fell 4 times from 4/09/13 to 4/28/13. On 5/13/13 he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from 3/07/13 to 5/04/13. She sustained skin tears on 3/07/13 and received a large bruise to the right side of her face and a skin tear to her right arm on 5/04/13. Resident #38 fell 11 times from 1/17/13 to 5/15/13. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on December 21, 2012. As of the exit date of the survey on 5/18/13, the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a [MEDICAL CONDITION] and 3 fractured bones respectively. The facility failed to evaluate each fall and failed to modify and implement individualized interventions to reduce avoidable falls and prevent injury when necessary after successive falls as of the exit date of the survey on 5/18/13. These practices resulted in immediate jeopardy starting on 12/21/12 and it was determined to be ongoing as of the exit date of 5/18/13. Findings: Cross refer to F224, F280, F323, F520. The administration failed to utilize Care Plan Staff, Nursing Staff and the Quality Assurance (QA) Committee to effectively identify, track and implement new safety interventions to prevent further falls/injuries for residents #6, #31, #38, #41, #52. Review of the Fall Care plans for each of the residents revealed that the residents all had the same fall interventions: 1. Educate resident safety awareness 2. Remind resident to call when needing assistance 3. Keep call light and most frequent use personal items within reach 4. Assess medications for contributing factors 5. Make sure that all staff members are aware that resident is at high risk for falls 6. Move to room closure to nurse's station if necessary 7. Shoes well fitting with non-slip soles 8. Gripper Socks 9. PT/OT evaluation for strength training and gait 10. Assist res to and from toilet 11. Maintain room and pathways free of clutter from furniture, tables, etc. Care plans should include measurable objectives and timetables to meet each resident's specific medical, nursing, and mental and psychosocial needs. 1. Resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A score of 10 or higher means the resident is at risk for falls. The resident fell on [DATE] in the shower room and sustained 3 skin tears to the right arm. Review of the resident's Fall Care plan did not show any evidence of interventions or goals had been modified as necessary to prevent future falls/injuries after the resident fell on [DATE]. The resident's fall care plan was not modified to include interventions and goals to prevent future falls/ injury after the resident fell on [DATE]. The resident fell again on 5/11/13 at 9:45 a.m. and sustained injuries. The resident was found face down in the television room on the nursing unit. On 5/16/13 at 4:00 p.m. resident #31 was observed in her wheel chair in the hallway, unattended. She had a cast on her right arm and bruising to the right side of her face In an interview was conducted with the administrator on 5/17/13 at 5:30 p.m., she said neurological (neuro) checks are performed on any resident who sustains an unwitnessed fall. There was no evidence of neuro checks being completed or documented on resident #31 on 5/11/13 after an unwitnessed fall. The resident was transferred to an acute care hospital for evaluation on 5/11/13 at 10:00 a.m. An interview was conducted with the unit manager (UM) 5/18/13 at 11:20 a.m. She confirmed the resident fell on [DATE] and there were no staff members in the TV room supervising the resident at the time of the fall. She also stated, " We do not assign staff to the TV room to supervise residents." Observation of the TV room [ROOM NUMBER]/18/13 at 11:25 a.m. from the nursing station revealed there were several residents in the TV room, there was no staff observed in the TV room and all the residents could not be visualized from the nursing station. 2. Resident #6 was admitted [DATE]. His Fall Risk Evaluation completed on 4/09/13 indicated a score of 20. A score of 10 or higher means the resident is at risk for falls. The only intervention documented on the form was to keep call light within reach. Review of resident #6's current Fall Care plan revealed that it has remained the same since March 2013. The care plan was never updated for the alarms and mats of the floor. There was no indication that the residents fall interventions had bed reviewed. The facility continued to rely on the alarm even though direct care staff indicated it was not effective. Nurse's note dated 4/09/13 indicated the resident fell out of wheelchair at 7:40 p.m. and 8:10 p.m. The resident did not sustain and injury from either fall. On 4/13/13 the resident fell to the floor attempting to transfer. Nurse's notes dated 4/18/13 indicated that the resident was found on the floor at 3:45 p.m. in front of his wheelchair. No injuries were observed. Nurse's note dated 4/28/13 indicated that the resident was found on the floor beside the elevator next to his wheelchair and there were no apparent injuries. On 5/13/13 at 7:35 a.m. an observation revealed resident #6 attempting to get out of bed. When asked if he was okay, he stated, "no come help me" During this observation, the resident was instructed to use his call bell to ask for assistance, but he got up anyway and transferred to the chair beside the bed. His gait/balance was very unsteady. During the resident's transfer to the chair, a large reddened area to his right upper thigh. Approximately 5 minutes later, certified nursing assistant (CNA) #L entered the room and stated that the resident fell earlier, and she explained "that's why he has a bruise on his leg." The bed was in low position, the room was dark (blinds closed) and there were no mats beside the bed. There were no alarms on his chair or bed. On 5/13/13 from 8:00 a.m. to 9:00 a.m. resident #6 was observed moving around the hallways, and back and forth into the dining room eating breakfast unsupervised by staff. On 5/13/13 at 12:10 p.m. staff interview with nurse #T, she revealed that the resident fell on [DATE]. She read from the nurse's note: "resident found on floor in front of wheelchair tried to stand no injuries, and on 4/28/13 "resident was found on floor at bedside next to wheelchair no injuries." She stated that the resident was physically capable of getting out of bed on his own, but that he always called for assistance prior to attempting. At 12:30 p.m. an observation revealed the resident was in the dining room sitting at the table in his wheelchair eating lunch. On 5/15/13 at 2:50 p.m. during an interview with the assigned Nurse #D, she stated that she was not aware of any protocol for fall prevention and that when a resident had a fall, she completed an Incident Report. She said the Incident Report went to the Risk Manager/Director of Nursing so she could determine if new interventions needed to be put in place. When asked what new interventions are put in place, she explained that they bring the resident to the nurse ' s station so that they can keep a closer eye on them. Review of the resident's current Fall Care plan revealed that the care plan had not been updated with new goals or interventions to prevent future falls. 3. Resident #38 was re-admitted to the facility on [DATE] following an acute care stay. Fall Risk Evaluation dated 3/12/13 indicated a score of 26 A score of 10 or higher means the resident is at risk for falls. There were no interventions listed on the form. His care plan dated 4/04/13 indicated the potential for injury related to falls with the goal that the resident would remain free from injuries. Interventions included educate the resident in safety awareness, remind resident to call when needing assistance, keep call light and most frequently used personal items in reach, assess medications from contributing factors, make sure all staff aware that resident was at high risk for falls, move to room closer to nurse's station, shoes well-fitting with non-slip soles, gripper socks, PT/OT evaluation for strength training and gait. Assist resident to and from the toilet, maintain room and pathways free of clutter from furniture, tables, etc. The only fall listed on the care plan was dated 4/13/13 fell out of bed with no injury noted. Interventions were not updated to reflect this fall. Review of the nurse's notes and incident reports revealed that the resident fell 11 times from 1/27/13 to 5/15/13 with no update to the care plan and no new interventions listed on the care plan. The resident was actually transferred from his room to a new room farther from the nurse ' s station. The following information was listed in the nurses' notes: 1/27/13 Resident was in wheelchair and slipped onto floor with skin tear to right hand. 2/25/13 Resident was observed sitting on the floor by his bed asking " can somebody help me? " 3/13/13 Resident observed on floor right laceration to forehead with bump -sent to hospital 3/17/13 CNA heard resident saying " somebody help me " as she entered room-found on floor on his buttocks. 3/18/13 Resident observed lying down on the floor by his bed. 3/31/13 Nurse observed resident yelling out and on floor. 4/2/13 Found on floor in his old room. 4/13/13 Observed on mat on floor by his bed. 4/23/13 CNA called nurse and resident noted on floor with wound to back of head. 4/27/13 On floor in his room with wheelchair on top of him. 5/15/13 Nurse found resident lying on his back beside the bed. On 5/13/13 at 7:45 a.m. an observation revealed the resident resting in bed flat on his back. His bed was in low position, there were no mats on the floor beside his bed, the room was dark with the blinds closed, and the half side rails were up. Resident was unable to respond to questions, but stated repeatedly in a loud voice, "What can I do? On 5/13/13 at 12:30 p.m. an observation revealed the resident sitting at a table in the dining room in his wheelchair. Food was served to resident, but he was not eating, and no staff in the dining room offered to assist him. He was sitting at the table with his eyes closed. On 5/17/13 at 9:20 a.m. an observation revealed the resident resting in bed with his eyes closed. The room was dark with the blinds pulled and there were no mats at bedside. His wheelchair was in front of his bed blocking the entrance to his room. On 5/13/13 at 12:22 p.m. during an interview with nurse #T, she said the resident fell on [DATE] and 4/27/13. On 5/15/13 at 10:07 a.m. during an interview with CNA #I, she stated she was not assigned to the resident, but stated that he attempted to get out of bed often and the bed alarm would go off alerting them to get to the room. She added that it was usually too late by the time they get there, the resident "is already on the floor." She stated that the resident often sleeps during the day. On 5/15/13 at 6:15 p.m. during an interview with the resident ' s assigned nurse #G, she revealed that she had been employed for approximately a year and normally worked the 3-11 p.m. shift. She stated that she was not aware of any protocol for fall precautions and had not had any in-service this year related to fall prevention/precaution. She said that when a resident fell , she completed an incident report that was turned in to the Director of Nursing. During the interview, resident #38's bed alarm was sounding off and she left the interview to respond to the alarm. When she returned to the interview approximately 10 minutes later, she explained that the resident was found on the floor by the Unit Manager. She stated, " I will probably have to complete the incident report and I did not even witness the incident. " When asked how the CNAs know the resident is fall risk, she stated that "we tell them in report." On 5/16/13 at 11:10 a.m. during an interview with the hospice nurse assigned to the resident, she revealed that if a resident has a fall the facility was to call and notify them immediately. She explained that she ordered bed and chair alarms for the resident because he was having multiple falls. Review of the record revealed that the Fall Risk Assessment was dated 3/20/13, but the Physician's order was not written until 4/30/13 and indicated 'Fall precautions, alarms to chair and bed. Bed in low position with side mats.' She stated that she assesses the resident and makes recommendations and documents the information. She then relays the information to the facility nursing staff to coordinate care with the attending physician. When asked if she was aware that the resident had fallen again last night, she responded, "No, no one called me." She explained that there was a colored sheet of paper in the front of the resident ' s chart with the telephone numbers to call 24 hours per day/ 7 days per week. The instructions indicated to call immediately for any of the following: change in resident ' s condition, resident fall, medication change request, resident/family concern, resident approaching death, and at time of death. She stated at most facilities she attends the care conferences for her residents, but here, "I am not invited -am not notified to attend. " On 5/16/13 at 11:30 a.m. during an interview with the UM, she revealed that she had completed the incident report for #38 on 5/15/13, but did not notify the hospice nurse of the resident's fall on 5/15/13. She stated she did not know she needed to call the hospice nurse when the resident falls. Review of the resident's record revealed instructions from hospice to call immediately for reasons including: change in resident ' s condition and resident fall. 4. Resident #52 was admitted to the facility on [DATE] following an acute care stay. The Fall Risk Evaluation dated 2/28/13 indicated a score of 16. A score of 10 or higher means the resident is at risk for falls. History of Falls indicated 3 or more during the last 90 days. The only fall listed on the care plan was dated 5/04/13 and noted "found on floor bruise on right cheek skin tear to right arm." The following information was listed in the nurses' notes: 3/07/13 Found on floor skin tear to left and right elbow 3/24/13 Found on floor by chair in room; attempted to transfer without assistance. 5/04/13 Resident attempted to transfer without assistance found on bathroom floor. Right forearm and elbow contusion to right cheek. On 5/13/13 8:55 a.m. an observation revealed the resident sitting in her wheelchair in the entry to her room. She had a large bruise to the right side of her face below her eye. On 5/13/13 at 12:32 p.m. during an interview with the assigned nurse #T, she revealed that the resident was found on the floor in the bathroom while trying to transfer without assistance. On 5/14/13 at 9:35 a.m. an observation revealed the resident sitting in her wheelchair in her room. When asked how she got the bruise to her face, she explained that she fell in the bathroom while trying to transfer from chair to toilet. She said there was not always enough staff to help her get on the toilet and knew she was suppose to wait, but she could only wait so long. On 5/15/13 at 10:10 a.m. an observation revealed the resident in her room sitting in her wheelchair. During an interview with the resident at that time, she said her foot was hurting her, and that she was having more pain since her last fall earlier this month. Her right ankle area was visibly swollen in comparison to the left. When asked if she needed pain medication, she stated "oh, they will bring it when they have time." On 5/15/13 at 12:45 p.m. during an interview with the assigned CNA #I, she revealed that she thought resident #52 fell approximately 3 weeks ago. She stated that the resident was complaining of pain since the fall and she usually tells the nurse. She added that the resident did need assistance with transfer, but usually called for assistance. On 5/15/13 at 2:50 p.m. during an interview with the assigned nurse #D, she stated that the resident was usually good about asking for help and that she was not aware of any falls that she had recently. She stated that the therapy department was working with her daily. On 5/17/13 at 1:10 p.m. an observation of the resident revealed that she was sitting in her wheelchair in the lobby area where they conduct activities. During an interview at that time, she explained that she was not feeling well and wanted to return to her room. She stated she had been having nausea and vomiting and just wanted to go to bed; she said "I don ' t know why they just ignore me." The Activity Director approached the resident at that time and transported her back to her room. 5. Resident #41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident has been under hospice care since March 2013. Fall Risk Evaluations were done on 2/04/13 and 5/17/13 with a total score of 16 and 22 respectively. The Fall Risk Evaluation indicated a resident who scores a 10 or higher is at risk, consider environmental risk factors in resident's interventions. A review of nurse's notes indicated the resident had frequently tried to get out of bed and/or wheelchair. On 1/31/13 (3-11 p.m.) trying to get out of chair constantly, on 2/01/13 6:00 a.m. attempting to exit chair, on 2/02/13 9 p.m. attempting to exit chair, on 2/3/13 2:30 a.m. multiple attempts to get out of bed (OOB), on 2/04/13 at 4:00 p.m. resident was observed exiting bed, on 2/4/13 6:30 a.m. observed resident on floor beside chair, on 2/8/13 10:15 p.m. frequently climbs OOB - doesn ' t comprehend request not to get up. A further review of nurse ' s notes revealed that the resident fell on the following dates: 3/02/13, time 2:35 p.m. A housekeeper saw the resident climbed out of bed and walked towards wheelchair and fell on floor. The resident stated she hit her head. Physician and resident ' s daughter were informed. Physician ordered to send the resident to a hospital, but the daughter refused. 3/08/13, time 12:15 a.m. Bed alarm sounded, resident was found on floor sitting beside bed. Resident denied pain. 3/23/13, time 10:30 p.m. The resident was found on floor in room. 3/30/13, time 10:40 a.m. The resident found on floor lying on right arm. Skin tears noted to right arm. Order received for X-ray of Right shoulder and bilateral hips. 4/05/13 time 10:15 p.m. Resident alarm sounded. CNA (certified nursing assistant) found resident lying on the floor next to her bed. No apparent injuries noted. 4/26/13 time 2:00 p.m. Resident observed sitting on the floor by her wheelchair. Denied pain, no injuries noted. 5/04/13 time 1:30 p.m. Resident observed laying on the floor in the TV room at front of her wheelchair. Skin tear and bump left side of forehead. Alert and responsive. Daughter refused to have her sent to hospital, on neurochecks. 5/09/13 time 11:25 p.m. Resident observed in room sitting on floor beside roommate's bed. No injury noted. No s/s (sign/symptom) pain noted. An interview was conducted on 5/16/13 at about 6:00 p.m. with the director of physical therapy. She stated the 4/8/13 screening was the only screening document she found on the resident. The resident was not a candidate for therapy. When asked why the resident was not screened after other falls, she stated therapy department would get involved after nursing interventions did not work. She further stated resident #41 is also under hospice care that has more control over resident care. On 5/15/13 at about 11:00 a.m., the resident was observed sitting in a wheelchair at nurse ' s station. There were staff present at the nurse ' s station. The resident stood up and leaned forward with hands on the armrest of the wheelchair. Staff did not intervene when the resident stood up until the surveyor brought it to their attention and a staff member got up and went to the resident to sit her down. Observation at 9:20 a.m. on 5/17/13 found the resident at nurses ' station in wheelchair with straight back position and she was leaning forward. No nursing staff were present at the station. A chair alarm was attached to her. At 9:35 a.m., she continued to lean forward and the chair alarm was not attached to her. Unit Manager saw her, but did not intervene at that time. A CNA came over, spoke with her and took her back to her room. Support for positioning was not provided for this resident. The director of physical therapy department was interviewed on 5/18/13 at about 1:00 p.m. in the resident room. She stated the resident's wheelchair back can go back for tilting. On 5/16/13 at about 4:30 p.m. an interview was conducted with the unit manager in regards to fall precautions. She stated the facility would use floor mat, chair, and bed alarm as a fall precaution. If a resident came in from a hospital due to falls, she said, " we would know that we have to put the resident in low bed. " A fall risk assessment is only done when the MDS coordinator gives a list of residents to update. On 5/17/13 at 2:40 p.m. an interview was conducted with the housekeeping staff # S who witnessed the resident's fall on 3/02/13. She stated she saw the resident was trying to get out of wheelchair in resident room. So she told the resident to sit down. Then she called a CNA to come to the room, but she didn't remember the CNA's name. By the time the CNA came in, the resident was found on the floor. On 5/18/13 at 11:55 a.m. and 12:15 p.m. an interview was conducted with Staff #R, the licensed practical nurse (LPN) who documented the resident's falls on 4/26/13 and 5/4/13. She stated that on 4/26/13 she observed the resident on the floor in front of the wheelchair in TV/activity room. She was told by other residents in the room that the resident was sliding off the wheelchair. On 5/04/13, she said she observed the resident #41 on floor. She was told by other resident in TV room about the fall. On 5/16/13 at 6:15 p.m. during an interview with the Rehab Therapy Director, she revealed that the therapy department receives a copy of the Incident Report related to falls and they discuss falls in the morning meetings. She said therapy uses a screening tool to determine if therapy would benefit the resident with related to a decline in function for transfers, ambulation, bed mobility, and they in-service the staff to anticipate the resident ' s needs (for toileting or increased involvement with activities. When asked to provide a copy of the screening tool for resident #6, and #52, she stated that she did not do a screening on those residents because they were " picked up " for therapy. She stated she did not pick up resident #38 because he was a hospice patient and the goal of therapy was to improve or return the resident to their previous level of functioning. When asked to provide the documentation for education of the staff regarding falls and anticipating needs, she could not provide any information. On 5/15/13 at 8:45 a.m. during an interview with the Director of Nursing (DON), she revealed that she was also the Risk Manager and stated that she did not keep an Incident Log with names/dates/incidents/ or follow-up information. She stated when a resident has a fall, the assigned nurse completes an Incident Report and sends it to her. She then makes a copy of the Incident Report for Therapy Department and keeps the original. She stated that falls are discussed in the morning meetings and the Minimum Data Set (MDS) Coordinator updates the care plans. She stated example of interventions included mats at bedside, non-skid socks, bed in low position, move them closer to the nurse's station if they can, and if they absolutely have to-use alarms on bed and chair. When asked why the investigative portion of the incident reports had not been completed, she stated, " I used to fill out the information on the form, but I don't anymore. You can find the information in the nurse ' s notes. I don ' t have an additional investigative form." When asked why she was not following the policy on Accident and Incidents-Investigating and Reporting that she provided, she did not respond. Review of the policy for Accidents and Incidents-Investigating and Reporting revealed that all accidents or incidents involving residents, employees, visitors, etc. occurring on the premises must be investigated and reported to the administrator. An incident report form must be completed for all reported incidents. The nurse supervisor/charge nurse must be immediately informed so that medical attention can be provided. The nurse supervisor/charge nurse and or the department director or supervisor must conduct an immediate investigation of the incident including the date and time incident took place, the nature of injury, circumstances surrounding the incident, where the incident took place, names or witnesses and their accounts of the accident/incident, injured person ' s account of the accident/incident, time injured person attending physician was notified, as well as time physician responded and his/her instructions, dated and time injured person family was notified and by whom, condition of the injured person to include vital signs, disposition of the injured (transferred to hospital, put to bed, etc.), any corrective action taken, follow up information, signature of person completing the report. According to the policy: The Accident/Incident report and the Accident Investigation Report Form was to be submitted to the administrator no later than 24 hours after the occurrence of the accident/incident. Since the Risk Manager/DON did not complete the Investigative Report Form, which was the investigative component of the process, the Incident Reports and nurse's notes lacked crucial information pertaining to the circumstances surrounding the incidents, names or witnesses's of the incidents and their accounts of the accident/incident, details involving the injured person's account of the incident, details of the physicians response to the incident and his/her instructions, details of the family member contacted (name/relationship), and details related to the disposition of the injured. There were no corrective actions noted or any follow up information provided. Review of the policy on Managing the Risk and Liability of Falls, indicated that Fall Risk Evaluations should be completed on all residents within the first 3 hours of admission, with any change of condition, and after a fall. Once a resident has been identified as " at risk for fall " there should be documented evidence of intervention to reduce the risk of fall from occurring. If the resident repeats fall, the care plan should reflect goal changes or approach changes. All new fall prevention measures should be introduced to current employees through an in-service and incorporated into new employee orientation. Review of the facility policy for Fall Risk Evaluations revealed that they were initiated upon admission, but only updated on a quarterly basis. None of the assessments indicated that they were updated after a fall. The only evidence of intervention was documented orders for bed and chair alarms recommended by hospice nursing to be put in place for the hospice residents. Repeat falls were not reflected or updated with goal changes or approach changes on the care plans or fall risk evaluations. On 5/16/13 at 2:45 p.m. an interview with the Administrator and the DON was conducted. Additional investigative information according to the facility policy and procedure was requested, but not provided for all 5 residents who sustained multiple falls. On 5/16/13 at 4:00 p.m. during an interview with the UM, she explained that there was no written protocol or training tools related to fall precautions/prevention. She said that nursing was responsible for completing the Admission Assessment information and the Interim Care Plans. She said once they initiate the care plans common interventions included bed in lowest position, mats, chair alarms, and bed alarms. She stated if the resident falls again, it was the responsibility of the MDS Coordinator to update the care plan. She said the Fall Risk Assessment was completed initially by nursing and then updated on a quarterly basis. She stated the MDS Coordinator sends out dates on when to complete the quarterly assessments. She said the unit nurses do not update the care plans. The MDS Coordinator prints them off and places them in the charts. She explained that there were no markers on the doorways or rooms to reflect that the resident was a fall risk. She said the nurses pass on information verbally to the CNAs during report. When asked how the MDS Coordinator knew when to update the care plan, she explained that the MDS Coordinator attends the morning meetings, and the information was verbally passed on to her. She said she does not receive a copy of the Incident Report. She stated the Incident Reports go to the DON and the Director of Therapy. She said they do not have a fall precaution program in place (like Falling Stars or Starlight). She said she thought she remembered that in-service for fall precautions were conducted in December of 2012 for CNAs. No in-service was done for nursing that she was aware of for this year. She clarified that the nurse who was first in the room completed the Incident Report and notified the first contact for family member. The Fall Risk Evaluation Form was to be completed by nursing upon admission and quarterly. Instructions included to "evaluate the resident ' s condition and determine the most appropriate response. When resident ' s total score is 10 or more, interventions should promptly be put in place. If resident scored a 10 or above, interventions should be initiated. Document interventions below and on the resident ' s care plan. Resident should be informed of the risk/benefits associated with each intervention." Twenty six Incident Reports were reviewed for residents #6, #31, #38, #41 and #52. It was determined that the staff did not follow the facility ' s policy for completing the form. In 18 of 26 reports it could not be determined if the staff completing the form, was the first person to respond to the resident or just summarized the occurrence. The facility neglected to get staff statements and perform an in-depth investigation on how the each resident fell . Resident #52 is an cognitively alert resident. In two of the three falls that resident #52 had, staff neglected to interview the resident to determine why she fell and why she did not call for assistance. Staff neglected to document the condition of the resident in 12 of 26 reports. Corrective actions were not seen in 24 of 26 incident reports. The facility neglected to develop a staff education plan. On 5/18/13 at 1:35 p.m. the Human Resource Coordinator stated that nursing does

Based on observation, record review and interview the facility's Quality Assurance (QA) Committee did not evaluate and identify deficits in the facility's fall/accident prevention program in order to identify and correct quality deficiencies to ensure the safety and wellness of residents residing in the facility for 5 of 5 residents (#6, 31, 38, 41 & 52) reviewed for falls out of 25 sampled residents. Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on 5/11/13 and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from 3/02/13 to 5/09/13. The resident hit her head on 3/02/13. Injuries occurred on 3/30/13 and 5/04/13 in the form of skin tears. The resident also sustained swelling to the left side of her forehead on 5/04/13. Resident #6 fell 4 times from 4/09/13 to 4/28/13. On 5/13/13 he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from 3/07/13 to 5/04/13. She sustained skin tears on 3/07/13 and received a large bruise to the right side of her face and a skin tear to her right arm on 5/04/13. Resident #38 fell 11 times from 1/17/13 to 5/15/13. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on December 21, 2012. As of the exit date of the survey on 5/18/13, the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a [MEDICAL CONDITION] and 3 fractured bones respectively. The facility failed to evaluate each fall and failed to modify and implement individualized interventions to reduce avoidable falls and prevent injury when necessary after successive falls as of the exit date of the survey on 5/18/13. These practices resulted in immediate jeopardy starting on 12/21/12 and it was determined to be ongoing as of the exit date of 5/18/13. Findings: Cross reference F323. 1. Resident #31 readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. This tool indicated the scored a 24 out of possible 38 possible points. A score of 10 or higher indicates a risk for falls. Review of the annual Minimum (MDS) data set [DATE] revealed that the resident is cognitively impaired and was dependent of staff for bed mobility, transfer, dressing personal hygiene, locomotion and bathing. The resident fell in the shower room on 12/21/12 and sustained 3 skin tears to the right arm. The resident's fall care plan was not updated with new goals or interventions to prevent falls. The quarterly minimum data set ((MDS) dated [DATE] indicated that the resident's cognition remained the same and the resident was still dependent on staff to meet all care needs. The resident fell again on 5/11/13 in the TV room and sustained a fractured nose, fractured wrist and fractured bones around the right eye. Upon return from the hospital on [DATE], the resident's fall care plan remained the same since the time of admission. On 5/18/13 at 11:20 am the Unit Manager (UM) was interviewed. She confirmed that staff was not in the TV room when resident #31 fell on [DATE]. She also stated, "We do not have staff in the TV room to supervise residents." 2. Resident #41 was observed on 5/17/13 at 9:20 am at the nurses' station, in a straight back wheelchair. The resident was leaning forward with her head almost parallel to her lap. There was a pillow on her lap and a doll on top of the pillow. The pillow was slipping off the resident's lap. At that time, an alarm was attached to the wheelchair. No staff were at the nurse's station at this time. Several minutes later at 9:35 a.m., the resident was still leaning forward, but the cord/string from the chair alarm was now not attached to the resident. At this time the UM came out of the office, located behind the nurses' station, looked at the resident, but did not intervene. Several seconds later, a Certified Nursing Assistant (CNA) arrived in the area, cued, and repositioned the resident, the pillow, and placed the doll under the resident's right arm. The CNA reattached the cord from the alarm to the resident. Then the CNA wheeled the resident toward her room. Record review revealed the resident fell 8 times in a 2 month period from 3/2/13 to 5/9/13. The resident fell 5 of 8 times in her room and 2 of 8 times in the Activity/Day/TV Room. The TV room is approximately 6 feet across form the nurse's station. It was determined that if staff were sitting behind the nurse's station the entire TV room could not been seen. Review of the resident's Minimum Data Set ((MDS) dated [DATE] indicated that the resident was totally dependent on staff for bed mobility, transfer, dressing, personal hygiene and locomotion. The resident's current fall care plan was initiated on 2/2013. Since that time, the care plan was updated on 5/04/13 to indicate the resident had a fall. However, the care plan goals and fall interventions remained the same since the care plans inception of 2/2013. 3. Resident #6 is cognitively impaired with a BIMS score of 3 out of 15 which means the resident is cognitively impaired. On the day of admission, 4/09/13, the resident fell out of his wheelchair twice at 7:40 p.m. and 8:10 p.m., respectively. The resident's fall care plan was initiated on 4/10/10. The resident fell 2 more times on 4/18/13 and 4/28/13 for a total of 4 falls in less that 1 month. On 5/14/13 at 12:06 p.m. the resident's POA was interviewed via phone. The POA stated that she was not satisfied with the care in the facility and did not think there was enough staff to properly take care of her father-in-law. On 5/15/13 at 11:50 am the resident's direct care CNA #I was interviewed. She described the resident as being very demanding. She indicated the resident always wanted to get up first. The CNA said that the resident required a lot of assistance and was capable of using the call bell, but he usually calls out for help. CNA #I was not aware of any procedures or protocols for fall precaution/prevention. She said the nurses tell her at report if someone is a fall risk. Staff I added, "After you been here awhile, you figure it out." Later that day at 2:50 p.m., the resident's direct care nurse #D was interviewed. Nurse #D stated that when a resident falls, she completes an Incident Report. She was asked what new fall interventions are put in place and she said the resident is brought to the nurse's station so that staff can keep a closer eye on the resident. Review of the MDS dated [DATE] indicated the resident required extensive assistance from staff for bed mobility, transfer, walking in corridor, and dressing. The resident was totally dependent of staff for locomotion both on and off the unit and for personal hygiene. Further review of the resident's care plan revealed that the fall preventions interventions remained the same since 4/10/13. The care plans were not evaluated after falls on 4/18/13 and 4/28/13. 4. Resident #38 is a cognitively impaired resident receiving hospice services. The resident fell 11 times between 1/27/13 to 5/15/13. The resident's third fall at the facility was on 3/13/13 and he was sent to the hospital for a laceration to his forehead. The resident returned to the facility and fell another 8 times. The fall risk evaluation scored the resident a 26. A score of 10 or higher indicates at risk for falls. The resident's recent MDS indicated that he was rarely understood and his cognition was severely impaired. The resident required extensive assistance from staff for bed mobility, transfer and dressing. The resident was totally dependent on staff for personal hygiene, bathing and locomotion. The resident's active [DIAGNOSES REDACTED]. The residents fall care plan was dated 3/29/13 and was not evaluated or updated after subsequent falls and not after the other 8 falls. On 5/16/13 at 11:10 am resident 38's hospice nurse was interviewed. She stated the resident was at risk for falls based upon her assessment. Hospice fall intervention tool dated 3/21/13 indicated the hospice nurse recommend an alarm to both wheelchair and bed. She also recommended mats on the floor at bedside. On 4/30/13 the physician wrote an order for [REDACTED]. The first reference to mats in the Incident Reports was on 4/13/13. The note read 'Observed on mat on floor by his bed. Therefore, it could not be determined when mats were initiated by staff. On 5/15/13 at 6:15 p.m. resident #38's direct care nurse # G stated she has worked in the facility for about a year and that she's usually on the 3-11 shift. She stated she was not aware of any protocol for fall precautions and had not had any in-services this year related to fall prevention. She stated when a resident falls, she completes and Incident report that is turned into the Director of Nursing (DON). During the interview resident #38's alarm was sounding and nurse G left the interview to respond to the alarm. When she returned, approximately 10 minutes later, she explained that the resident was found on the floor by the Unit Manager. She stated, "I will probably have to complete the Incident Report and I did not even witness the incident." Further review of the resident's fall care plan revealed that the goals and fall interventions remained the same since 3/29/13. The care plan was not updated with the latest interventions of the call bell and mats on the floor in room. 5. Resident #52 is an alert and cognitively aware resident. She had 3 falls from 3/07/13 to 5/4/13. The resident attempts to transfer herself without staff assistance. On 5/14/13, the resident stated she fell in the bathroom attempting to transfer herself form the chair to the toilet. She also stated there is not always enough staff to help her get on the toilet. The resident's fall care plan was updated to reflect that the resident fell on [DATE] and sustained a bruise on her right cheek and a skin tear to her right arm due to the fall. The fall interventions were never changed or modified on the plan of care. 6. Review of the fall care plans for resident #6, #31, #38, #41 and #52 revealed that these residents all had the same fall interventions: A. Educated resident in safety awareness B. Remind resident to call when needing assistance C. Keep call light and most frequent used personal items within reach D. Assess medication for contributing factors E. Move room closer to the nurse's station if necessary F. Shoes well fitting with non-slip soles G. Gripper Socks H. PT/OT evaluation for strength training and gait I. Assist res. To and from toilet J. Maintain room and pathway free of clutter, from furniture, tables etc. On 5/17/13 at 1:30 p.m. the MDS/Care Plan coordinator (CPC) stated she creates all care plans except for Dietary and Social Services. In regards to falls she stated the floor nurse' are responsible for the interventions. She explained that if a resident falls the floor nurse will decide if the resident needs an alarm. The CPC stated the fall is discussed in morning meeting and she will update the care plan with the new intervention. When asked how direct care is staff informed about new interventions, the she stated, "They can read the care plans." On 5/17/13 at 5:00 p.m. the Administrator and DON were interviewed about the Facility's QA program. There was no evidence the QA committee identified that all 5 residents had the same fall interventions and that the care plans were not individualized for each resident or evaluated. Also, the QA committee failed to ensure the that the Care Plan staff were reviewing the fall interventions to determine the effectiveness of each of the approaches. Based on the amount of falls for the cognitively impaired residents, #6, #31, #38, #41, the QA Committee failed to demonstrate the effectiveness of how "Re-Educating Resident on Safety Awareness" was still effective. The DON stated that they track falls each month. They considered having more than 5 falls in a month as a high amount of fall incidences. They stated that when a resident falls, the nurse documents on the Incidence Report form. Therapy screens the resident to determine if the resident should receive therapy services. If therapy does not pick up the resident, Therapy will in-service the nursing staff, on repositioning the resident. In comparing falls for February, March and April 2013, the DON stated they had more falls in March and that the facility census was higher in March in comparison to February and April. The DON could not explain the low fall rate in February. The DON stated she noticed a trend in March that the frequency of falls occurred on the weekend between 7 a.m. and 11 a.m. The QA committed did not trend falls for their location i.e. resident room verses common areas such has hallways and TV room. She attributed the increase in falls on the weekends due a decrease in activities on the weekends in comparison to the work week. However, activities are only one aspect of the resident's life from 7 a.m. to 11 a.m.. In that time period, staff are performing activities of daily living (ADLs) with the residents and breakfast is also served within that time frame. The QA committee did not analyze falls during before or after ADL Care and before or after breakfast. During morning ADL Care, if all CNAs are providing individual care, the QA committee should determine if there are enough staff available to provide the level of supervision to prevent falls that are not directly working with a CNA. It was not apparent the QA committee reviewed falls in the context with staffing patterns. The DON stated they staff according to the census. There was no indication that staffing was being done with the consideration of resident care needs, especially safety. 7. The QA committee failed to ensure that each falls/accidents were investigated in accordance with facility policy. On 5/15/13 at 8:45 a.m. during an interview with the DON, she revealed that she was also the Risk Manager and stated that she did not keep an Incident Log with names/dates/incidents/ or follow-up information. She stated when a resident has a fall; the assigned nurse completes an Incident Report and sends to her. She then makes a copy of the Incident Report for Therapy Department and keeps the original. She stated that falls are discussed in the morning meetings and the MDS Coordinator updates the care plans. She stated examples of interventions included mats at bedside, non-skid socks, bed in low position, move resident rooms closer to the nurse's station if they can, and if they absolutely have too, use alarms on bed and chair. When asked why the investigative portion of the incident reports had not been completed, she stated, " I use to fill out the information on the form, but I don ' t anymore. You can find the information in the nurse ' s notes; I don ' t have an additional investigative form. " When asked why she was not following the "Accident and Incidents-Investigating and Reporting" policy and procedures, she did not respond. Review of the policy, "Accidents and Incidents-Investigating and Reporting" revealed that all accidents or incidents involving residents, employees, visitors, etc. occurring on the premises must be investigated and reported to the administrator. An incident report form must be completed for all reported incidents. The nurse supervisor/charge nurse must be immediately informed so that medical attention can be provided. The nurse supervisor/charge nurse and or the department director or supervisor must conduct an immediate investigation of the incident including the date and time incident took place, the nature of injury, circumstances surrounding the incident, where the incident took place, names or witnesses and their accounts of the accident/incident, injured person ' s account of the accident/incident, time injured person attending physician was notified, as well as time physician responded and his/her instructions, dated and time injured person family was notified and by whom, condition of the injured person to include vital signs, disposition of the injured (transferred to hospital, put to bed, etc.), any corrective action taken, follow up information, signature of person completing the report. According to the policy, "The Accident/Incident report and the Accident Investigation Report Form" was to be submitted to the administrator no later than 24 hours after the occurrence of the accident/incident. Since the Risk Manager/DON did not complete the Investigative Report Form, which was the investigative component of the process, the Incident Reports and nurse's notes lacked crucial information pertaining to the circumstances surrounding the incidents, names or witnesses's of the incidents and their accounts of the accident/incident, details involving the injured person's account of the incident, details of the physicians response to the incident and his/her instructions, details of the family member contacted (name/relationship), and details related to the disposition of the injured. There was evidence of corrective action or follow up information regarding their investigations Review of the Managing the Risk and Liability of Falls documentation given for review by the DON, indicated that Fall Risk Evaluations should be completed on all residents within the first 3 hours of Admission, with any change of condition, and after a fall. Once a resident has been identified as " at risk for fall " there should be documented evidence of intervention to reduce the risk of fall from occurring. If the resident continues to fall, the care plan should reflect goal changes or approach changes. All new fall prevention measures should be introduced to current employees through an in-service and incorporated into new employee orientation. Review of the facility Fall Risk Evaluations revealed that they were initiated upon admission, but only updated on a quarterly basis. None of the assessments indicated that they were updated after each fall. The only evidence of intervention was documented orders for bed and chair alarms recommended by hospice nursing to be put in place for the hospice residents. Repeat falls were not reflected or updated with goal changes or approach changes on the care plans or fall risk evaluations. On 6/07/13, the facility implemented sufficient measures to decrease the severity/scope to E, but the facility remains out of compliance with F520.

Based on observation, interview, and record review the facility failed to review and revise care plans for falls for 5 of 5 (#6, 31, 38, 41 & 52) residents out of 25 sampled residents. All 5 residents have a history of multiple falls and falls with injuries. They all have conditions that put them at risk for continued avoidable falls and potential for serious injury. The facility also failed to notify families of care conferences (#6) and failed to update the care plan for hospice care (#38). Resident #31 fell on [DATE] and sustained 3 skin tears to her arm. She fell again on 5/11/13 and sustained a fractured right wrist, fractured nose and fractured bones around the right eye and forehead abrasions. Resident #41 fell 8 times from 3/02/13 to 5/09/13. The resident hit her head on 3/02/13. Injuries occurred on 3/30/13 and 5/04/13 in the form of skin tears. The resident also sustained swelling to the left side of her forehead on 5/04/13. Resident #6 fell 4 times from 4/09/13 to 4/28/13. On 5/13/13 he fell again and sustained a bruise to the leg. Resident #52 fell 3 times from 3/07/13 to 5/04/13. She sustained skin tears on 3/07/13 and received a large bruise to the right side of her face on 5/04/13. Resident #38 fell 11 times from 1/17/13 to 5/15/13. The resident sustained [REDACTED]. Residents #6, #31, #38, #41, #52 had multiple avoidable falls in the facility beginning on December 21, 2012. As of the exit date of the survey on 5/18/13, the facility neglected to provide care and services to prevent accidents. All 5 residents sustained injuries extending from bruises, skin tears, lacerations, to fractured bones. Residents #38 and #31 were sent to the hospital to receive a higher level of care, for a [MEDICAL CONDITION] and 3 fractured bones respectively. Failure to revise the plan of care for falls placed residents at risk for continued avoidable falls with injury. These practices resulted in immediate jeopardy starting on 12/21/12 and it was determined to be ongoing as of the exit date of 5/18/13. Findings: 1. Resident #6 was admitted to the facility on [DATE] following an acute care stay. His most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that he was severely cognitively impaired with a cognitive summary score on his Brief Interview for Mental Status (BIMS) of 3/15 on a scale of 00-15. (00-07 = severe impairment, 08-12 = moderate impairment, and 13-15 =cognitively intact). The MDS Assessment indicated that he was exhibiting verbal behavior directed toward others, and rejection of care. His functional status indicated that he needed extensive assistance with bed mobility, transfers, and dressing (with a 1-2 person assist), and he was totally dependent on assist with toilet use and personal hygiene (with 1-2 person assist). His Active [DIAGNOSES REDACTED]., anxiety disorder, and depression. His care plan dated 4/10/13 indicated the potential for injury related to falls due to cognitive deficits, impaired safety awareness, weakness, dizziness, polypharmacy, use of [MEDICAL CONDITION] medications, impaired mobility, balance problem: as evidenced by history of falls, unable to transfer without assistance. The Goal was that the resident would remain free from injuries. Interventions included educate the resident in safety awareness, remind resident to call when needing assistance, keep call light and most frequently used personal items in reach, assess medications from contributing factors, make sure all staff aware that resident was at high risk for falls, move to room closer to nurse ' s station, shoes well-fitting with non-slip soles, gripper socks, PT/OT evaluation for strength training and gait. Assist resident to and from the toilet, maintain room and pathways free of clutter from furniture, tables, etc. The falls listed on the care plan were dated 4/09/13 times two at 7:40 a.m. and 8:10 a.m., continue therapy. Additional falls were not updated on the care plan and no new interventions were put in place. Review of the record for information from nurse's notes and/or Incident Reports revealed that the resident had additional falls that were not updated on the care plans and no new interventions were determined: 4/9/13 fell from wheelchair trying to stand x 2 4/13/13 Attempted to transfer and fell to the floor 4/18/13 Found on floor in front of wheelchair (No incident report found) 4/28/13 Found on floor next to elevator door. Care plans should include measurable objectives and timetables to meet each resident ' s specific medical, nursing, and mental and psychosocial needs. On 5/13/13 at 7:35 a.m. an observation revealed the resident attempting to get out of bed. When asked resident if he was okay, he stated, " No come help me. " Instructed resident to use his call bell, but he got up anyway and transferred to the chair beside the bed. His gait/balance was very unsteady. The resident was wearing a brief and had a large reddened area to his right upper thigh. CNA L entered the room and stated that the resident had fallen earlier and that ' s why he had a bruise on his leg. Did not observe any alarms on the bed or wheelchair and there were no mats beside the bed. On 5/14/13 at 12:06 p.m. during a telephone interview with the resident ' s daughter in law, who was the Power of Attorney (POA), she revealed that she was not satisfied with the care in the facility, and did not think there was enough staff to properly take care of her father-in-law. She stated that she had requested a conference to discuss her father-in-law's care with the Social Services Coordinator, and that a care conference was suppose to be conducted within 21 days of resident's admission. She said, "No one has contacted me." On 5/15/13 at 3:30 p.m. during an interview with the Social Services Coordinator, she explained that it was the responsibility of the MDS Coordinator to notify the family and set up the care conference. She said once the meeting was set-up by the MDS Coordinator, she would be notified when to attend. She said that she attempts to attend all care conferences for residents/family and usually representatives for activities, dietary, and nursing would attend. She stated that she gave information related to the care conference in the Admissions Packet informing the resident/family that a care plan meeting would be held during the first 30 days and quarterly thereafter. Review of the notice in the care packet indicated, 'The members of the interdisciplinary team meet to review and update the plan of care established for the resident. 'We do call or send notices to the family or the responsible party prior to the meeting.' On 5/15/13 at 5:20 p.m. during an interview with the MDS Coordinator, she explained that she notifies family members for care conferences via a letter sent through the mail. She stated she does not make telephone calls to the family prior to the care conference or notifies them via telephone. She stated she does not send the letter certified or registered mail. When asked how she knew if the family was notified, she responded, "If I don't receive the letter back, then I assume they got it." She provided a copy of the letter she said she mailed to the resident dated 4/29/13. She stated once the conference was conducted, she places the care conference attendance sheet in the resident's medical record. Upon review of the record, there was no care conference attendance sheet for resident #6. She returned to her office and approximately 10 minutes later, she found an attendance sheet for the care conference dated 5/2/13. The 2 members of the interdisciplinary team in attendance included the MDS Coordinator and the Activities Coordinator. The summary noted, 'care conference held, plan of care discussed, no family attended. On 5/18/13 at 4:15 p.m. during an interview with the MDS Coordinator, when asked if the care conference for resident #6 was held on 5/2/12 and the letter was not mailed until 4/29/13, how was that enough time for the family to receive notification of the care conference, she responded, "This may have been the letter I gave to the sitter." 2. Resident #38 was re-admitted to the facility on [DATE] following an acute care stay. His Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated that he had a significant decline and was now under the care of Hospice for Failure to Thrive. The assessment revealed that he was rarely understood and cognitive skills severely impaired. Signs of [MEDICAL CONDITION], disorganized thinking. Functional status indicated extensive assistance with bed mobility, transfers, dressing, total dependence with toilet use, personal hygiene. Balance not steady. Functional status indicated that resident was an extensive assist (1 person) with bed mobility, transfer, dressing, and was totally dependent (1 person physical assist) on staff for toileting, personal hygiene, bathing, and locomotion off the unit. Active [DIAGNOSES REDACTED]. Health Conditions indicated fall history since admission reentry and fall with minor injury. Skin conditions indicated skin tears, Medications included insulin, and Hospice Care was initiated. His care plan dated 4/4/13 indicated the potential for injury related to falls due to cognitive deficits, impaired safety awareness, weakness, dizziness, polypharmacy, use of [MEDICAL CONDITION] medications, impaired mobility, balance problem: as evidenced by history of falls, unable to transfer without assistance. The goal was that the resident would remain free from injuries. Interventions included educate the resident in safety awareness, remind resident to call when needing assistance, keep call light and most frequently used personal items in reach, assess medications from contributing factors, make sure all staff aware that resident was at high risk for falls, move to room closer to nurse ' s station, shoes well-fitting with non-slip soles, gripper socks, PT/OT evaluation for strength training and gait. Assist resident to and from the toilet, maintain room and pathways free of clutter from furniture, tables, etc. Review of the record revealed that the Fall Risk Assessment was dated 3/20/13, but the physician's order [REDACTED]. Bed in low position with side mats. ' She stated that she assesses the resident and makes recommendations and documents the information. She then relays the information to the facility nursing staff to coordinate care with the attending physician. She stated at most facilities she attends the care conferences for her residents, but here, " I am not invited -am not notified to attend. " The only fall listed on the care plan was dated 4/13/13 fell out of bed with no injury noted. Interventions were not updated to reflect falls. physician progress notes [REDACTED]. Bed in low position with mats. There was no update to the care plan to reflect the addition of chair and bed alarms. Review of the nurse's notes and incident reports revealed that the resident fell 11 times from 1/27/13 to 5/15/13 with no update to the care plan and no new interventions listed on the care plan. The resident was actually transferred from his room to a new room equally far from the nurse's station down a different hallway: 1/27/13 Resident was in wheelchair and slipped onto floor with skin tear to right hand. 2/25/13 Resident was observed sitting on the floor by his bed asking " can somebody help me? " 3/13/13 Resident observed on floor right laceration to forehead with bump -sent to hospital 3/17/13 CNA heard resident saying " somebody help me " as she entered room-found on floor on his buttocks. 3/18/13 Resident observed lying down on the floor by his bed. 3/31/13 Nurse observed resident yelling out and on floor. 4/2/13 Found on floor in his old room. 4/13/13 Observed on mat on floor by his bed. 4/23/13 CNA called nurse and resident noted on floor with wound to back of head. 4/27/13 On floor in his room with wheelchair on top of him. 5/15/13 Nurse found resident lying on his back beside the bed. Care plans should include measurable objectives and timetables to meet each resident ' s specific medical, nursing, and mental and psychosocial needs. On 5/13/13 at 7:45 a.m. an observation revealed the resident resting in bed. His bed was in low position, there were no mats on floor, and the room was dark with the blinds closed, half side rails were up. Resident was unable to respond to questions-stated repeatedly " What can I do? " On 5/16/13 at 11:10 a.m. during a telephone interview with the hospice nurse assigned to the resident, she revealed that if a resident has a fall the facility was to call and notify them immediately. When asked if she was aware #38 ' s fall on 5/15/13, she responded, " No, no one called me. " She explained that she ordered bed and chair alarms for the resident because he was having multiple falls. Review of the facility care plan for hospice dated 4/04/13 indicated that the resident had potential for further decline related to [DIAGNOSES REDACTED]. Approaches included: assist to wheelchair as able, provide incontinent care after each episode, resident likes to be called "his first name", pain management as needed, encourage socialization, notify hospice of any change in condition, and allow family to visit. There was no update of the care plan related to the interventions put in place by the hospice nurse related to the resident's multiple falls and approaches impacting resident safety. Based on hospice nurse interview, she recommended orders for bed and chair alarms, and mats at bedside, and to be notified when resident had a fall. On 5/16/13 at 1:45 p.m. during an interview with the MDS Coordinator, she validated that she does not invite the hospice nurses to the care planning conference. She stated, " I have been doing this for [AGE] years, and we have never had hospice nurses coming to the care conferences. " On 5/16/13 at 11:10 a.m. during an interview with resident #38 ' s hospice Nurse X, she revealed that she visits the resident on a weekly basis and coordinates his care with the facility nursing staff. She explained that she places her notes in the resident ' s medical record, but stated that his chart was not available last week, so she did not add it at that time. All hospice notes from nursing and aides as well as the care plans are part of the resident ' s record. She said that the resident was a fall risk and upon her Fall Risk Assessment she ordered a bed and chair alarm for his wheelchair. On 5/16/13 at 11:30 a.m. during an interview with the Unit Manager, she validated that she neglected to call the hospice nurse to report that the resident had fallen. She stated that she knew to call hospice when the resident had a significant change, but was not aware that she was supposed to call them when the resident had a fall. She explained that it was the responsibility of the hospice nurse to make recommendations related to care and services and the facility nurses were responsible for coordinating the orders with the physician. 3. Resident #52 was admitted to the facility on [DATE] following an acute care stay. Her most recent MDS assessment dated [DATE] indicated a she was cognitively intact with a cognitive summary score of 15/15 on the BIMS. Her functional status indicated that she required (1 person) extensive assistance with bed mobility, walking in corridor, locomotion on unit, dressing, toilet use, and personal hygiene. Her balance was not steady. Her Active [DIAGNOSES REDACTED]. Her medications included an antidepressant and a diuretic. She was receiving therapy with speech therapy (ST) started 3/05/13 to 4/21/13, occupational therapy (OT) started 3/1/13 and ongoing, and physical therapy (PT) started 3/04/13 and was ongoing. Care plan dated 4/04/13 indicated the potential for injury related to falls due to cognitive deficits, impaired safety awareness, weakness, dizziness, polypharmacy, use of [MEDICAL CONDITION] medications, impaired mobility, balance problem: as evidenced by history of falls, unable to transfer without assistance. The Goal was that the resident would remain free from injuries. Interventions included educate the resident in safety awareness, remind resident to call when needing assistance, keep call light and most frequently used personal items in reach, assess medications from contributing factors, make sure all staff aware that resident was at high risk for falls, move to room closer to nurse ' s station, shoes well-fitting with non-slip soles, gripper socks, PT/OT evaluation for strength training and gait. Assist resident to and from the toilet, maintain room and pathways free of clutter from furniture, tables, etc. The only fall listed on the care plan was dated 3/2/13 -found on floor bruise on right cheek skin tear to right arm. Additional falls were not included and interventions were not updated to reflect falls: 3/7/13 Found on floor skin tear to left and right elbow 3/24/13 Found on floor by chair in room; attempted to transfer without assistance. 5/4/13 Resident attempted to transfer without assistance found on bathroom floor. Right forearm and elbow contusion to right cheek. Care plans should include measurable objectives and timetables to meet each resident ' s specific medical, nursing, and mental and psychosocial needs. On 5/14/13 at 9:35 a.m. an observation revealed the resident sitting in her wheelchair in her room. She had a large bruise to right side of her face below her eye. During an interview with the resident at that time, she explained that she fell in the bathroom while trying to transfer from chair to toilet. She said there was not always enough staff to help her get on the toilet. On 5/16/13 at 6:15 p.m. during an interview with the Rehab Therapy Director, she revealed that the therapy department receives a copy of the Incident Report related to falls and the discuss falls in the morning meetings. She explained that the Therapy Department updates care plans in the resident ' s charts, but she could not explain why resident #52's care plans were not updated to reflect current physical therapy (PT) and occupational therapy (OT) status with proper target dates. On 5/16/13 at 4:00 p.m. during an interview with the Unit Manager, she said that nursing was responsible for completing the Admission Assessment information and the Interim Care Plans. She said once they initiate the care plans common interventions included bed in lowest position, mats, chair alarms, and bed alarms. She stated if the resident falls again, it was the responsibility of the MDS Coordinator to update the care plan. She said the Fall Risk Assessment was completed initially and then updated on a quarterly basis. She stated the MDS Coordinator sends out dates on when to complete the quarterly assessments. She said the unit nurses do not update the care plans. The MDS Coordinator prints them off and places them in the charts. When asked how the MDS Coordinator knew when to update the care plan, she explained that the MDS Coordinator attends the morning meetings and the information was verbally passed on to her. She said she does not receive a copy of the Incident Report. She stated the Incident Reports go to the DON and the Director of Therapy. On 5/17/13 at 1:45 p.m. during an interview with the MDS Coordinator, she stated that it was the responsibility of the Risk Manager/DON to update the care plans related to falls, but lately "they were trying to push it on her and she had a million other jobs already." She stated that she was responsible for updating the care plans related to antibiotics and treatments. 4. Resident #41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's previous living arrangement was assisted living facility (ALF). She had history of multiple falls. She was sent to a hospital in January 2012 with right [MEDICAL CONDITION] with open reduction internal fixation (ORIF). She then was admitted to skilled nursing facility (SNF) for rehabilitation and returned to ALF. She was readmitted to SNF with [DIAGNOSES REDACTED]. The resident has been under hospice care since March 2013. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/2013 assessed the resident ' s speech clarity as ' no speech-absence of spoken words ' (B0600=2); ability to understand others as ' rarely/never understands ' (Section B0800=3). Under Cognitive Patterns, Section C, the MDS showed that Brief Interview for Mental Status (BIMS) should not be conducted with the resident because the resident is rarely/never understood. The resident has short-term and long-term problem. The resident ' s cognitive skills for daily decision making is severely impaired - never/rarely made decisions (C1000=3). Under Functional Status (Section G), the resident is assessed as total dependence with 2 plus persons physical assist for bed mobility, total dependence with one person physical assist for transfer, locomotion on unit and off unit, dressing, toilet use, and personal hygiene. Fall history on admission (J1700) indicated the resident did not have a fall any time in the last month and 2-6 months prior to admission. The resident did not have any fracture related to a fall in the 6 months prior to admission. Fall Risk Evaluations were done on 2/04/13 and 5/17/13 with a total score of 16 and 22 respectively. The Fall Risk Evaluation indicated a resident who scores a 10 or higher is at risk, consider environmental risk factors in resident ' s interventions. A review of nurse ' s notes revealed that the resident had fallen on the following dates: 3/02/13, time 2:35 p.m. A housekeeper saw the resident climbed out of bed and walked towards wheelchair and fell on floor. The resident stated she hit her head. Physician and resident ' s daughter were informed. Physician ordered to send the resident to a hospital, but the daughter refused. 3/08/13, time 12:15 a.m. Bed alarm sounded, resident was found on floor sitting beside bed. Resident denied pain. 3/23/13, time 10:30 p.m. The resident was found on floor in room. 3/30/13, time 10:40 a.m. The resident found on floor lying on right arm. Skin tears noted to right arm. Order received for X-ray of Right shoulder and bilateral hips. 4/5/13 time 10:15 p.m. Resident alarm sounded. CNA (certified nursing assistant) found resident lying on the floor next to her bed. No apparent injuries noted. 4/26/13 time 2:00 p.m. Resident observed sitting on the floor by her wheelchair. Denied pain, no injuries noted. 5/04/13 time 1:30 p.m. Resident observed lying on the floor in the TV room at front of her wheelchair. Skin tear and bump left side of forehead. Alert and responsive. Daughter refused to have her sent to hospital, on neurochecks. 5/09/13 time 11:25 p.m. Resident observed in room sitting on floor beside roommate's bed. No injury noted. No s/s (sign/symptom) pain noted. On 5/15/13 at about 11:00 a.m., the resident was observed sitting in a wheelchair at nurse ' s station. There were staff at the nurse's station. The resident then was standing up and leaning forward with hands on the armrest of the wheelchair. Nobody observed/supervised the resident. With the surveyor ' s intervention that a staff got up and went to the resident to sit her down. Observation at 9:20 a.m. on 5/17/13 found the resident at nurses' station in wheelchair with straight back, leaning forward. No nursing staff were at the station. The chair alarm was on her. At 9:35 a.m., she was still leaning forward and the chair alarm was not attached to her clothing. The Unit Manager saw her, but did not intervene at that time. A CNA came over, spoke with her, and took her back to her room. No support for positioning was observed for this resident. A care plan was initiated on 2/20/13 for potential for injury r/t (related to) falls d/t (due to) cognitive deficits, impaired safety awareness, weakness, polypharmacy, use of [MEDICAL CONDITION] medications, impair mobility, and balance problem, as evidenced by: history of falls, unable to transfer without assistance. Interventions included but were not limited to educate resident in safety awareness, remind resident to call when needing assistance, make sure that all staff members are aware that resident is at high risk for falls, move to room closer to nurse ' s station if necessary, PT/OT (physical therapy/occupational therapy) evaluation for strength training, gait, or assist resident to and from toilet. The care plan was revised on 5/04/13. It indicated that the resident was found lying on floor TV room, skin tear to forehead. This was the only revision noted after the resident ' s falls. The care plan was not evaluated and revised to prevent additional avoidable falls. Care plans should include measurable objectives and timetables to meet each resident ' s specific medical, nursing, and mental and psychosocial needs. On 5/16/13 at about 4:30 p.m. an interview was conducted with the unit manager licensed practical nurse. She stated resident care plans would be evaluated and updated by MDS (Minimum Data Set) coordinator who would get resident information from CNAs and nurses staff at the daily morning meeting when staff discussed resident falls. 5. A review of the medical record was conducted 5/16/13 which revealed resident #31 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The fall risk evaluation tool evaluates: History of falls, Cognitive status/behavioral symptoms, vision status, balance, systolic blood pressure and vitals, age, health conditions/risk factors and medications. The form instructs a resident who scores a 10 or higher is at risk. Resident #31's score was 24. The facility provided a policy "Managing the Risk and Liability of Falls which directed staff that risk evaluations should be completed on all residents within the first 3 hours of admission, with any change of conditions and after a fall. Review of the Minimum Data Set ((MDS) dated [DATE] documented the resident was not able to repeat 3 words, not able to answer the correct month or year; and resident was not able to be interviewed for mental status. It was documented the resident was easily distracted, out of touch and disorganized. In Section G- Activities of Daily Living (ADLs) it was documented the resident needed extensive assist of two persons for bed mobility, transfer, walking in corridor and was totally dependent for locomotion on unit. Section G- Balance during transitions documented the resident was not steady, only able to stabilized with human assistance. On 2/28/13 a quarterly review using MDS, Section J1800, documented the resident had not had any falls since admission or prior to assessment, whichever is more recent. It was documented in the resident's medical record she had sustained a fall on 12/21/12. Review of nursing documentation, dated 12/21/12 at 2:00 p.m. revealed resident #31 fell in the shower room and sustained three skin tears to her right arm. There was no further nursing documentation found in the medical record regarding the fall or reassessment. A care plan for skin tears was not initiated after the fall with injury on 12/21/12. An interview was conducted with UM 5/18/12 at 11:20 a.m. regarding the resident's fall on 12/21/12 and she said, " The resident lost her balance and slid to the floor hitting her arm on the shower chair. The CNA was drying the resident's peri area after her shower, so the resident was standing while in the shower room." The UM said the CNA who was assisting the resident on 12/21/12 was no longer employed by the facility. Review of the nursing care plan dated 12/13/12 did show any evidence interventions or goals had been modified as necessary to prevent accidents, falls and/or injuries after the resident had sustained a fall with injury on 12/21/12. Care plans should include measurable objectives and timetables to meet each resident ' s specific medical, nursing, and mental and psychosocial needs. On 5/16/13 at 4:00 p.m. resident #31 was observed in her wheel chair in the hallway, unattended. It was observed she had a cast on her right arm and bruising to the right side of her face. Review of nursing documentation revealed the resident sustained [REDACTED]. The resident was found face down in the television room on the nursing unit. An interview was conducted with RN #E on 5/17/13 at 1:35 p.m. and she said "Residents are normally taken to the TV room after meals. The resident must have tried to get out of her chair and fell . A resident saw the incident and got the attention of a CNA and nurse. I went to the TV room and saw resident on the floor. The resident was face down on the floor and there was blood on the carpet." Review of the nursing note dated 5/11/13 at 11:00 a.m. documented "the resident was out of bed in wheelchair for breakfast and was put in TV room after breakfast. Around 9:45 a.m. nurse's attention was called to TV room. Resident found on floor face down and blood noted on floor. Resident was assessed and 911 initiated. Laceration noted to lower forehead. Resident was transported to hospital around 10:00 a.m." An interview was conducted with the administrator on 5/17/13 at 5:30 p.m. She said neurological (neuro) checks are performed on any resident who sustains an unwitnessed fall. There was no evidence of neuro checks being completed or documented on resident #31 on 5/11/13 after an unwitnessed fall. The resident was transferred to an acute care hospital for evaluation on 5/11/12 at 10:00 a.m. An interview was conducted with CNA #K on 5/17/13 at 1:30 p.m. She was not the CNA assisting the resident on 12/21/12, but she indicated resident #31 likes to have her feet up. She is always trying to get out of her wheel chair into a recliner chair when in the TV room. When asked when she assists the resident to the TV room why she did not put the resident into the recliner chair, she said, "She would try to get out of that chair too." She was not aware of any chair or bed alarms being used for this resident. She said "There are no mats on the floor that I know of." An interview was conducted with the UM 5/18/13 at 11:20 a.m. She confirmed the resident fell on [DATE] and there were no staff members in the TV room supervising the resident at the time of the fall. She also stated, "We do not assign staff to the TV room to supervise residents." Observation of the TV room [ROOM NUMBER]/18/13 at 11:25 a.m. from the nursing station revealed there were several residents in the TV room, there was no staff observed in the TV room and all the residents could not be visualized from the nursing station. Review of the physician's history and physical dated 5/11/12 at 5:13 p.m., revealed the resident had sustained a fracture to the right distal radius and a right orbital floor fracture, as well as nasal fracture and forehead abrasions. The resident was readmitted to the facility on [DATE] at 1:45 p.m. with bruising to left arm, bilateral knee abrasions, bruising to right eye and forehead and a cast on her right arm. Her mental status was assessed as confusion, dementia and unable to orient. Review of the fall assessment tool dated 5/14/13 did not document any change in resident ' s fall status. The total score was 24, the same as the resident ' s score before the second fall on 5/11/13. Rev