Every finding on record at Arbor Lake Skilled Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility failed to 1) disinfect whirlpool A and whirlpool B per Manufacturer's Instructions for Use, and 2) implement standard precautions for proper storage of a non-invasive urine collection system, and administration of medications. Findings: Review of the facility's undated Whirlpool/Shower Cleaning and Disinfecting policy revealed the following: Purpose: To ensure that whirlpool/showers are cleaned and disinfected according to disinfectant manufacturer guidelines. General Guidelines: Whirlpool/shower shall be cleaned and disinfected between each use. Remove any visible soil before disinfecting. Apply Non-Acid Disinfectant Bathroom Cleaner (NABC) with a cloth, mop, sponge, or coarse sprayer. All surface areas and each individual jet shall be treated with disinfectant. Treated surfaces shall remain wet for 10 minutes then rinse thoroughly with water. On 09/30/2025 at 11:05 a.m., an interview was conducted with S18Certified Nursing Assistant (CNA) related to the process for cleaning and disinfecting the whirlpool. S18CNA reported that she cleans the whirlpool at the beginning of the day by spraying down the whirlpool with tile and grout cleaner and lets the solution sit for 5 minutes and rinses the whirlpool. S18CNA further reported that she then presses the disinfectant button for approximately 10 seconds, allows the disinfectant to sit for about 30 seconds, and finally rinses the whirlpool thoroughly. S18CNA also reported that, between residents, she sprays down the whirlpool with tile and grout cleaner and allows it to sit for about 30 seconds followed by a rinse. After this, the disinfectant button is pressed for 10-15 seconds and allowed to sit for about 1-2 minutes followed by a thorough rinse. On follow-up inquiry, S18CNA reported that the maintenance department refills the disinfectant and she did not know who cleaned the whirlpool jets. On 09/30/2025 at 11:16 a.m., an interview with S10CNA reported that, prior to beginning baths, she sprays the whirlpool down with tile and grout cleaner, lets the solution sit for about 5 minutes, then rinses the whirlpool thoroughly. S10CNA reported that between residents the whirlpool is sprayed down with tile and grout cleaner with is allowed to sit for 2 minutes followed by a thorough rinse. S10CNA reported that she did not use the disinfectant button because there is no disinfectant in the whirlpool. S10CNA further stated that there had not been disinfectant in the whirlpool since May of 2025. S10CNA reported that she did not know who cleaned the whirlpool jets. On 09/30/2025 at 11:18 a.m., an interview was conducted with S19Maintenance who reported that neither the housekeeping or maintenance departments replace the disinfectant solution in the whirlpools. Interview with S25Housekeeping Supervisor at this time revealed their department has never been instructed to clean and disinfect the whirlpool. On 09/30/2025 at 11:20 a.m., S20CNA Supervisor reported that residents received whirlpool baths on 09/30/2025. The surveyor and S20CNA observed the whirlpool and the hose labeled disinfectant was not connected to a supply bottle. On 09/30/2025 at 11:25 a.m., S1Administrator was notified of findings in the whirlpool. S1Administrator was unable to confirm that the instructions posted near the whirlpool were the manufacturer's instructions for use. Review of the whirlpool's manufacturer's instructions for use, after every bath, the whirlpool should be cleaned and disinfected. The steps included: heating the disinfectant solution via the temperature control knob, removing visible tissue, residue or fluids with the shower sprayer, draining/plugging the tub, and holding the disinfectant button until the solution is coming out of the air jets and there is 1 to 1 1/2 gallons of disinfectant solution in the tub. This is to be followed by a thorough scrub of all interior surfaces of the tub and allowing the disinfectant to stay on the surface for 10 minutes, or, as recommended by the instructions on the disinfectant concentrate container. Per manufacturer's instructions for use, the whirlpool is then to be rinsed thoroughly and the air blower run to push the rinse water out of the air injection system. On 10/01/2025 at 11:20 a.m., an interview with S21CNA revealed the whirlpool tub is sprayed down after each use, including the jets. The solution sits for 5-10 minutes and is then rinsed thoroughly. S21CNA confirmed that the whirlpool jets and bubbles are used for residents. On 10/01/2025 at 2:35 p.m., S2Director of Nursing (DON) confirmed that 58 residents received whirlpool baths. S2DON was informed of whirlpool findings and agreed that the whirlpool was not disinfected per manufacturer's instructions for use. Resident #90 Review of the medical record for Resident #90 revealed diagnoses that included personal history of urinary tract infections, and overactive bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. On 09/29/2025 at 9:15 a.m. and 10/01/2025 at 8:22 a.m., observations revealed Resident #90 was in her recliner in her room. Further observations revealed her non-invasive urine collection system tubing was not covered and was clipped to the upper drawer of her plastic storage bin. The resident's snacks, chocolate candy and cheese nips) were stored in the top drawer near the uncovered tubing. On 10/01/2025 at 1:15 p.m., the surveyor and S3Assistant Director of Nursing (ADON) made an observation in Resident #90's room. The resident was in her recliner and the urine collection system tubing was uncovered and was clipped to the upper drawer of her plastic storage bin. The resident's snacks (chocolate candy and cheese nips) were stored in the top drawer near the uncovered tubing. S3ADON confirmed the tubing should be in a bag and not kept near food items. On 10/01/2025 at 2:30 p.m., an interview with S23Certified Nursing Assistant (CNA) revealed the tubing (urine collection system) should be stored in a bag and kept in the bathroom. She stated the resident wanted it by her bedside. S23CNA confirmed the tubing should not be kept near the resident's food. On 10/01/2025 at 2:35 p.m., an interview with S24LPN confirmed the tubing should not be kept near the resident's snacks. On 10/01/2025 at 3:18 p.m., an interview with S2Director of Nursing (DON) confirmed the urine collection system tubing should be stored in a bag and not near food items. Resident #4 On 09/30/2025 at 10:10 a.m., during medication pass S26Licensed Practical Nurse (LPN) dropped 2 pills on top of the medication cart. The pills were Neurontin 600mg and Zyrtec 10mg, S26LPN picked them up with her ungloved hand and put them back into the medication cup with the other pills and administered them to Resident #4. On 09/30/2025 at 2:40 p.m., S26LPN confirmed she picked up Resident #4's Neurontin and Zyrtec pills and placed them in the medication cup and administered them to the resident after dropping them on the medication cart. On 10/01/2025 at 3:18 p.m., S2Director of Nursing (DON) confirmed S26LPN should not have picked up the dropped pills and administered them to Resident #4.

Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings and failed to demonstrate the facility's response for such grievances. Findings:Review of the facility's policy, Resident Council undated, revealed in part:6. All resident concerns will the addressed and revisited at the resident council meeting the following month. Review of the facility's policy, Filing Grievances/Complaints dated 1/22/2025 revealed in part: Policy Statement - Our facility will assist residents or his/her responsible party in filing grievances or complaints when such requests are made 3. Grievances and/or complaints may be submitted orally or in writing. 4. The administrator had delegated the responsibility of grievance and/or complaint investigation to the social services director. 7. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Review of the facility's Resident Council Minutes Form for the time period of 10/23/2024 - 09/25/2025 revealed a section titled: Old Business (List follow-up on last month's minutes and identify staff person responsible). Further review revealed there was no documented response or follow up to issues concerning care and life at the facility. Review of the facility's Resident Council meeting held on 02/28/2025 revealed in part: Resident #60 looking for missing wheelchair (w/c) with no written response or follow up. Review of the facility's monthly grievance logs provided by S7SSD (Social Services Director) for November 2024 to September 2025 revealed one grievance dated 05/28/2025 for the 11 month period of grievance logs. During the resident council meeting held on 09/29/2025 at 2:30 p.m., residents reported not receiving any follow up on issues/complaints reported during resident council meetings. During the same meeting, Resident #60 revealed she made a verbal report that her personal wheelchair was missing during a past resident council meeting. During an interview on 10/01/2025 at 9:50 a.m., Resident #25 reported not receiving feedback or follow up for verbalized complaints in resident council. During an interview on 09/30/2025 at 10:48 a.m., S7SSD revealed she was the grievance official and had never seen the resident council meeting minutes during her tenure at the facility. During an interview on 09/30/2025 at 11:00 a.m., S6Administrative Assistant confirmed the identified issues in the resident council meeting notes should have been followed up on. During an interview on 10/01/2025 at 9:31 a.m., S1Administrator reported he received the minutes after each resident council meeting and followed up on them; however, was unable to provide any written documentation for follow up of individual or group issues reported in the monthly resident council meetings.

Based on observations and interviews the facility failed to ensure all mechanical equipment was maintained in safe operating condition by having a pipe leaking water under the 3-compartment sink and the deep fryer with grease buildup on the internal compartment. This deficient practice had the potential to affect 93 residents that received meals from the kitchen. Findings:On 09/29/2025 at 8:30 a.m. observation of the kitchen revealed a polyvinyl chloride (PVC) pipe under the 3 - compartment sink was leaking water. The water was being captured in a large tin can and when the can was full the dietary workers would discard the water in the sink. Further observation of the kitchen revealed the deep fryer contained a buildup of grease on the internal compartment. On 09/29/2025 at 8:45 a.m. an interview with S8Dietary Manager confirmed the PVC pipe was in need of repair and the deep fryer needed to be cleaned. On 09/30/2025 at 1:30 p.m. S1Administator was notified of the above issues.

Based on record reviews and interviews, the facility failed to ensure residents that received psychotropic drugs were not subjected to chemical restraints for 4 (#2, #11, #25, #37) of 5 (#2, #11, #25, #37, #65) residents reviewed for unnecessary medications. The facility failed to ensure:1). as needed (PRN) orders for psychotropic drugs were limited to 14 days (#2, #11, #37),2). a gradual dose reduction was attempted (#25, #37), and3). a physician addressed pharmacist recommendations (#25)Findings: Resident #11 Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with behaviors/agitation, major depressive disorder, and anxiety disorder. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a brief mental status score (BIMS) of 3 which indicated severe cognitive impairment. Further review revealed she required substantial/maximal assistance for most activities of daily living (ADL). Review of Resident #11's September 2025 physician orders revealed an order dated 03/18/2024 for Lorazepam 0.5 milligrams (mg), give 1 tablet by mouth (po) every 6 hours PRN (as needed). Review of the Resident's September 2025 Medication Administration Record (MAR) revealed documentation the resident had received Lorazepam 0.5mg on 09/05/2025 and 09/29/2025. Review of the Pharmaceutical Consultant Report dated 07/24/2025 revealed the following recommendation for Lorazepam 0.5 mg, give 1 tablet po every 6 hours PRN. Psychotropic PRN medications are limited to an initial 14 days and requires prescriber to evaluate the resident prior to extending the order. If extending, document the rationale for the extended time period in the medical record. Further review revealed there was no documentation the resident's physician addressed the above recommendation. On 10/01/2025 at 3:18 p.m., S2Director of Nursing (DON) confirmed the above recommendation from the consultant pharmacist was not addressed by the physician in a timely manner and Resident #11 continued to receive the Lorazepam 0.5 mg 1 tablet po every 6 hours PRN. Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, dementia, and chronic pain. Record review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS of 3 which indicated severe cognitive impairment. Further review revealed he required substantial/maximal assistance and was dependent for most ADLs. Review of Resident #2's September 2025 physician orders revealed an order dated 04/10/2025 for Lorazepam oral concentrate 2mg/milliliter (ml) give 1 ml by mouth every 4 hours as needed for agitation. Review of the Resident #2's September 2025 MAR revealed documentation the resident had received Lorazepam 1 ml on 09/04/2025. Review of the Pharmaceutical Consultant Report dated 07/24/2025 revealed the following recommendation for Lorazepam 2mg/ml, give 1 ml by mouth every 4 hours as needed: Psychotropic PRN medications are limited to an initial 14 days and requires prescriber to evaluate the resident prior to extending the order. If extending, document the rationale for the extended time period in the medical record. Further review revealed there was no documentation the resident's physician addressed the above recommendation. On 10/01/2025 at 3:18 p.m., S2DON confirmed the physician did not provide a specific duration or stop date for the medication as recommended by the consultant pharmacist. Resident #25 Review of the medical record for Resident #25 revealed diagnoses that included major depressive disorder, hypertension, personal history of venous thrombosis, and chronic congestive heart failure. Review of the Quarterly MDS assessment dated [DATE] revealed, in part, a BIMS score of 10 which indicated that Resident #25 had moderate cognitive impairment. Further review revealed that the resident received high risk drugs which included antidepressant medication. Review of the September 2025 electronic physician's orders revealed an order for Zoloft oral tablet 50 mg: give 1 tablet by mouth one time a day and Doxepin Hydrochloride (HCl) oral tablet 10 mg: give 10 mg by mouth at bedtime. Review of the September 2025 MAR revealed that Resident #25 received Zoloft 50 mg and Doxepin HCl 10 mg as ordered. Review of the Pharmaceutical Consultant Report/Psychoactive Gradual Dose Reduction dated 07/24/2025 revealed that the pharmacist's recommendations for dose reduction of Zoloft 50 mg by mouth at bedtime and Doxepin HCl 10 mg by mouth at bedtime were not addressed by the physician. On 10/01/2025 at 3:18 p.m., S2DON confirmed that the recommendations from the consultant pharmacist were not addressed by the physician and Resident #25 continued to receive the Zoloft 50 mg and Doxepin HCl 10 mg as ordered. Resident #37 Review of the medical record for Resident #37 revealed diagnoses that included cerebral infarction, hemiplegia affective right dominant side, nicotine dependence, anxiety disorder, hypertension, dysphagia, and other depressive episodes. Review of the Annual MDS assessment dated [DATE] revealed a BIMS score of 10 which indicated that Resident #37 had moderate cognitive impairment. Further review revealed that Resident #37 received high risk drugs that included antipsychotic, anxiolytic, and antidepressant medications. Review of the September 2025 electronic physician's orders revealed an order for Ambien tablet 10 mg: give 10 mg by mouth every 24 hours as needed for sleeplessness, Buspirone HCl oral tablet 7.5 mg: give 1 tablet orally two times a day, Diazepam 2 mg tab: give 2 mg by mouth one time a day, Duloxetine HCl capsule delayed release sprinkle 30 mg: give 30 mg by mouth one time a day, and Seroquel oral tablet 25 mg: give 25 by mouth two times a day related to depression, unspecified. Review of the September 2025 MAR revealed Resident #37 was administered Ambien 10 mg as ordered on 09/09/2025. Further review revealed that Buspirone HCl 7.5 mg, Diazepam 2 mg, Duloxetine HCl 30 mg, and Seroquel 25 mg were administered as ordered. Review of the Pharmaceutical Consultant Report/Psychoactive Gradual Dose Reduction dated 07/24/2025 revealed that the pharmacist requested dose reductions for Buspirone Hcl 7.5 mg, Diazepam 2 mg, and Duloxetine HCl 30 mg. Additionally, the pharmacist requested that the physician provide a specific duration with stop date for Ambien 10 mg as well as a Centers for Medicare and Medicaid Services (CMS) approved diagnosis for the use of Seroquel 25 mg. The recommendations and requests from the pharmacist were not addressed by the physician. On 10/01/2025 at 3:18 p.m., S2DON confirmed the above requests and recommendations from the consultant pharmacist were not addressed by the physician and Resident #37 received the medications as ordered.

Based on record reviews and interviews the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#40) of 1 residents reviewed for pressure ulcers. The facility failed to 1) have documented evidence of weekly body audits, 2) have documented evidence of wound treatments performed as ordered, and 3) failed to have an accurate pressure ulcer assessment. Findings: Review of the medical record for sampled resident #40 revealed an admission date of 03/05/2024 with diagnoses of somatoform disorder, hyperlipidemia, anxiety, major depression, transient ischemic attack, and pressure ulcer on the back. Review of the quarterly Minimum Data Set (MDS) dated [DATE] assessment revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognition for daily decision making and was dependent on staff for toileting, bathing and personal hygiene. Further review of the MDS revealed Resident #40 has one or more unhealed pressure injuries and was at risk for developing pressure ulcers. Review of the careplan revealed Resident #40 had the potential for impaired skin integrity. Resident #40 was total bowel and bladder incontinent and had a presence of feeding tube. Further review of the care plan revealed interventions were to administer medications as ordered for wound healing, apply barrier cream as needed, low air loss mattress to the bed, apply heel protectors to bilateral heels, and to turn/reposition every 2 hours. Review of the September 2025 physician orders revealed an order dated 09/17/2025 to clean left ankle with wound cleanser, apply collagen, alginate and cover with a foam dressing every other day and as needed. Review of the September 2025 Treatment Administration Record (TAR) revealed no documented evidence that the treatment was done on 09/21/2025, 09/23/2025, 09/25/2025, and 09/29/2025.Review of the September 2025 physician orders revealed an order dated 09/17/2025 to paint left back with betadine, apply alginate, and cover with silicone dressing every day and as needed. Review of the September 2025 TAR revealed no documented evidence that the treatment was done on 09/20/2025, 09/21/2025, 09/23/2025, 09/24/2025, 09/25/2025, 09/26/2025, 09/29/2025 and 09/30/2025.Review of the September 2025 physician orders dated 08/20/2025 to clean wound to back with skin prep, apply Santyl, Hydrofera Blue Foam, absorbent pad, abdominal pad, and secure with tape, change dressing every day, and as needed. Review of the September 2025 TAR revealed no documented evidence that the treatment was done on 09/20/2025, 09/21/2025, 09/23/2025, 09/24/2025, 09/25/2025, 09/26/2025, 09/29/2025 and 09/30/2025.Review of the record revealed no documented evidence of weekly body audits performed for Resident #40 who was at risk for developing pressure ulcers.On 09/30/2025 at 2:30 p.m. interview with S11Wound Care Nurse (WCN) confirmed she did not have documentation of weekly body audits for Resident #40. On 10/01/2025 at 9:30 a.m. interview with S4Assistant Director of Nursing (ADON) confirmed the pressure ulcer assessment dated [DATE] for Resident #40 was inaccurate. Further interview with S4ADON confirmed Resident #40 was at risk for pressure ulcers and weekly body audits should have been performed. On 10/01/2025 at 11:40 a.m. interview with S11WCN confirmed there was no documented evidence on the September 2025 TAR that wound care was performed for Resident #40 on the dates listed above.On 10/01/2025 at 3:15 p.m. interview with S2Director of Nursing (DON) confirmed the pressure ulcer assessment for Resident #40 was inaccurate and she was at risk for developing pressure ulcers. Further interview with S2DON confirmed there was missing documentation of treatments in September 2025 and confirmed weekly body audits should have been performed and documented for Resident #40.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure laboratory tests were collected as ordered for 1 (#11) of 5 (#2, #11, #25, #37, #65) residents reviewed for unnecessary medications. Findings:Record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, dementia, major depressive disorder, and anxiety disorder. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a brief mental status score (BIMS) of 3 which indicated severe cognitive impairment. Further review revealed Resident #11 required substantial/maximal assistance for most activities of daily living (ADL). Review of Resident #11's September 2025 physician orders revealed an order dated 04/22/2025 for Levothyroxine Sodium 125 micrograms (mcg) 1 by mouth (po) one time a day. Further review revealed an ordered dated 07/12/2023 for Ferrous Sulfate 325 milligrams (mg) 1 po one time a day. There was also an order dated 04/30/2025 to obtain Thyroid Stimulating Hormone (TSH) and Iron laboratory levels every 6 months. Review of Resident #11's September 2025 Medication Administration Record (MAR) revealed documentation she received Levothyroxine Sodium 125 mcg 1 po one time a day from 09/01/2025 - 09/30/2025. Further review revealed documentation she received Ferrous Sulfate 325mg 1 po one time a day from 09/01/2025 - 09/30/2025. Review of the medical record for Resident #11 revealed no documented evidence that the TSH and Iron levels were obtained as ordered. On 10/01/2025 at 1:15 p.m., an interview with S3Assistant Director of Nursing (ADON) confirmed the facility failed to obtain Resident #11's TSH and Iron levels as ordered. On 10/01/2025 at 3:18 p.m., an interview with S2Director of Nursing (DON) confirmed the facility had not obtained TSH and Iron levels for Resident #11 as ordered.

Based on observations, record reviews and interviews, the facility failed to develop and implement a comprehensive care plan for 1 (#90) of 1 (#90) resident reviewed for care of a urinary collection system.FindingsReview of the medical record for Resident #90 revealed diagnoses that included personal history of urinary tract infections, and overactive bladder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. On 09/29/2025 at 9:15 a.m. and 10/01/2025 at 8:22 a.m., observations revealed Resident #90 was in her recliner in her room. Further observations revealed her urine collection system tubing was not covered and was clipped to the upper drawer of her plastic storage bin. The resident's snacks, chocolate candy and cheese nips) were stored in the top drawer near the uncovered tubing. On 10/01/2025 at 1:15 p.m., the surveyor and S3Assistant Director of Nursing (ADON) made an observation in Resident #90's room. The resident was in her recliner and the urine collection system tubing was uncovered and was clipped to the upper drawer of her plastic storage bin. The resident's snacks (chocolate candy and cheese nips) were stored in the top drawer near the uncovered tubing. Review of Resident #90's current care plan revealed the facility failed to identify the urine collection system and the proper storage of supplies in Resident #90's plan of care. On 10/01/2025 at 1:00 p.m., an interview with S3ADON confirmed Resident #90's urine collection system was not identified on her careplan and there were no approaches regarding how to store and care for the supplies. On 10/01/2025 at 3:18 p.m., an interview with S2Director of Nursing (DON) confirmed Resident #90's urine collection system should have been identified on her current care plan.

Based on observation, record review and interview the facility failed to ensure each resident was treated with dignity and respect in an environment that promotes maintenance and enhancement of his or her quality of life for 1 (#77) of 1 resident reviewed for dignity. Findings: Review of facility's policy Assistance with Meals dated 07/2017 revealed in part: 3.a. not standing over residents while assisting with meals. Review of facility's policy Quality of Life-Dignity dated 01/10/2025 revealed in part: 1. Residents shall be treated with dignity and respect at all times. Review of Resident #77's clinical record revealed an admit date of 02/14/2025 with diagnoses that included: Parkinson's disease, dysphagia following cerebral infarction and gastro-esophageal reflux disease without esophagitis.Review of Resident #77's Quarterly Minimum Data Set (MDS) dated [DATE] indicated substantial/maximal assistance while eating. Observation on 09/30/2025 at 7:48 a.m. revealed Resident #77 seated in a geri chair with a lap tray in the dining room. Further observation revealed S10Certified Nursing Assistant (CNA) was standing up while assisting the resident with the meal. During an interview on 09/30/2025 at 7:53 a.m. with S10CNA in the dining room, S10CNA confirmed she was standing over Resident #77 while assisting him with his meal. During an interview on 10/01/2025 at 3:00 p.m., S3Assistant Director of Nursing (ADON) confirmed staff should not stand over residents while assisting them with their meals. During an interview on 10/01/2025 at 3:12 p.m., S2Director of Nursing confirmed staff should not stand over the residents while assisting them with meals.

Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#42, #64, and #92) of 8 (#10, #18, #20, #27, #42, #64, #68, and #92) residents reviewed for restraints. The facility failed to ensure: 1). restraint consents were obtained which included risks and benefits of the restraint use for residents #42, #64, and #92; 2). physician orders were obtained for the lap trays for residents #64, and #92; and 3). monitoring was conducted for the release of the lap trays for residents #42, #64, and #92. Findings: Review of the facility Use of Restraints policy dated 01/12/2024 revealed the following, in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the least restrictive will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative has consented to the treatment or procedure and the use of treatment restraints. 12. The following safety guidelines shall be implemented and documented while a resident is in restraints. a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. c. A resident placed in a restraint will be observed at least every 30 minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each 2 hours in which restraints are employed. e. Restrained residents must be repositioned at least every 2 hours on all shifts 14. Residents shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 19. Documentation regarding the use of restraints shall include: a. full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode; b. description of the resident's medical symptoms that warranted the use of restraints; c. how the restraint use benefits the resident by addressing the medical symptoms; d. the type of the physical restraint used; e. the length of effectiveness of the restraint time; and f. observation, range of motion and repositioning flow sheets. Resident #42 Review of the record revealed resident #42 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and muscle wasting and atrophy. Review of resident #42's October 2024 Physicians Orders revealed an order dated 07/14/2023 resident may be up in gerichair with lap tray when out of bed to promote mobility and socialization and an order dated 10/28/2024 to release laptray every 2 hours for 15 minutes and then reapply. Review of resident #42's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed no use of restraints and resident required partial/moderate assistance with activities of daily living. Review of resident #42's careplan dated 07/11/2023 with revision date of 09/17/2024 revealed potential for falls, required limited 2 person assist with transfers, wheelchair locomotion- resident may be up in gerichair with lap tray when out of bed to promote mobility. The interventions included: release lap tray every 2 hours for 15 minutes then reapply. Observations on 10/28/2024 at 10:04 a.m., 10/29/2024 at 9:30 a.m., and 10/31/2024 at 8:35 a.m. of resident #42 revealed resident was up in a gerichair with a lap tray in her room. Review of the Pre-Restraining assessment dated [DATE] revealed resident #42 may be up in gerichair for positioning and socialization. Further review of the record revealed no documented pre-restraining assessment prior to 07/14/2023 when a gerichair with lap tray was implemented for resident #42. Review of the Physical Restraint Elimination assessment dated [DATE] revealed a score of 35, indicating poor candidate for restraint reduction, less restrictive restraining measures, or total restraint elimination. Gerichair with lap tray, less restrictive measures to be used- no, additional comments- this device is not considered to be a restraint but to promote mobilization and socialization per Director of Nursing (DON). Review of the Consent for Assistive Devices for resident #42 dated 07/11/2023 revealed resident was at risk for injury. Further review revealed the consent did not specify specific restraint to be implemented (lap tray) and did not identify the risks/benefits for having a restraint. Review of the record for resident #42 revealed there was no documented evidence of the release of the lap tray every 2 hours prior to 10/28/2024. An interview on 10/30/2024 at 9:30 a.m. with S4Assistant Director of Nursing (ADON) revealed the facility did not have an order in place prior to 10/28/2024 for the release of the lap tray every 2 hours and confirmed resident #42 has had a gerichair with a lap tray since 07/14/2023. S4ADON further confirmed that resident #42 unable to release her lap tray. An interview on 10/31/2024 at 10:00 a.m. with S5ADON revealed the pre- restraining assessment for resident #42 was not completed prior to the implementation of the gerichair with lap tray on 07/14/2023. An interview on 10/31/2024 at 10:55 a.m. with S3Director of Nursing (DON) confirmed resident #42 has had a gerichair with lap tray since 07/14/2023. S3DON further confirmed the facility failed to have documentation of the release of the lap tray for resident #42 prior to 10/28/2024. S3DON confirmed the Pre-Restraining Assessment was not completed prior to implementing the gerichair with lap tray on 07/14/2023 for resident #42. S3DON confirmed the consent dated 07/11/2023 for use of assistive devices (which they use for restraints) does not identify the risks/benefits associated with the use of a restraint (gerichair with lap tray). 22575 Resident #64 Review of the medical record for resident #64 revealed she was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hypertensive heart disease, dementia in other diseases (mild with behavioral disturbance), and other lack of coordination. Review of the quarterly MDS assessment dated [DATE] revealed resident #64 had a BIMS score of 3 which indicated severe cognitive impairment for daily decision making and the resident required extensive to total assistance for most activities of daily living. Further review revealed a trunk restraint was not used. Review of resident #64's October 2024 physician's orders revealed no order for the use of a gerichair with a lap tray. On 10/28/2024 at 9:55 a.m., an observation of resident #64 revealed she was in her room sitting in a gerichair with a lap tray with her feet reclined. An interview with S7Certified Nursing Aide (CNA) at this time revealed the resident was unable to remove lap tray by herself. On 10/30/2024 at 8:55 a.m. and 10/30/2024 at 1:24 p.m., observations of resident #64 revealed she was sitting in a gerichair with a lap tray by the nurses' station. On 10/30/2024 at 1:50 p.m., an interview with S8CNA revealed she had not observed resident #64 take off her lap tray since she has worked with her. Review of the Pre-Restraining assessment dated [DATE] for resident #64 revealed she may be up in the gerichair with a lap tray for positioning and socialization. Further review revealed the lap tray was not identified as a restraint in the assessment. Review of resident #64's medical record revealed there was no documentation that a consent was obtained for the use of a gerichair with a lap tray. Further review revealed no documented evidence the resident and/or responsible party were informed of the potential risk and benefits of the use of lap tray per the facility policy. Further review of resident #64's medical record revealed no documented evidence of monitoring for the release of the lap tray at least every 2 hours. On 10/31/2024 at 3:00 p.m., an interview with S4ADON confirmed resident #64 did not have a physician's order or a consent for a gerichair with a lap tray. She also confirmed there was no documentation of monitoring for the release of the lap tray for resident #64. On 10/31/2024 at 12:45 p.m., an interview with S3DON confirmed resident #64 did not have a physician's order for a gerichair with lap tray. She also confirmed there was no documentation of monitoring for the release of the lap tray for resident #64. 19121 Resident #92 Review of the medical record revealed sample resident #92 was admitted to the facility on [DATE] with diagnosis that include diabetes mellitus, Psychotic disturbance, mood disturbance and anxiety, major depressive disorder, anxiety disorder, Parkinson's disease, hypertension, muscle spasm and aftercare following joint replacement surgery prior to admission. Further review of the medical record revealed the Significant change MDS dated [DATE] revealed the resident had a BIMS score of 3 which indicated the resident is cognitively impaired and needs assistance with all activities of daily living. Further review of the medical record revealed a pre-restraining assessment dated [DATE] which included a recommendation to use a gerichair with lap tray to promote mobility and socialization. Further review revealed, the lap tray was not identified as a restraint in the assessment. Review of resident #92's October 2024 physician's orders revealed no order for the use of a gerichair with a lap tray. On 10/28/2024 at 7:45 a.m., an observation of resident #92 revealed he was in the locked unit day room sitting in a gerichair with a lap tray. On 10/30/2024 at 8:55 a.m. and 10/30/2024 at 1:24 p.m., observations of resident #92 revealed he was sitting in a gerichair with a lap tray in the locked unit day room. Review of resident #92's medical record revealed there was no documentation that a consent was obtained for the use of a gerichair with a lap tray. Further review revealed no documented evidence the resident and/or responsible party were informed of the potential risk and benefits of the use of lap tray per the facility policy. Further review of resident #92's medical record revealed no documented evidence of monitoring for the release of the lap tray at least every 2 hours. On 10/31/2024 at 9:40 a.m., an interview with S4ADON confirmed resident #92 did not have a physician's order or a consent for a gerichair with lap tray. She also confirmed there was no documentation of monitoring for the release of the lap tray for resident #92. On 10/31/2024 at 11:15 a.m., an interview with S3DON confirmed resident #92 did not have a physician's order for a gerichair with lap tray. She also confirmed there was no documentation of a consent and monitoring for the release of the lap tray for resident #92.

Based on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director, and the director of nursing. The pharmacist failed to identify the nurses' incomplete medication administration documentation for 4 (#50, #59, #68, and #93) of 5 (#50, #59, #68, #92, and #93) sampled residents reviewed for unnecessary medications, 1 (#17) of 1 sampled resident reviewed for an antibiotic medication, and 1 (#83) of 1 sampled resident reviewed for an anticoagulant medication. Findings: Resident #68 Review of the record for resident #68 revealed diagnoses of type 2 diabetes, dementia with other behavioral disturbances, depression, anxiety, congestive heart failure, and edema. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #68 had a Brief Interview Mental Status (BIMS) of 3 indicating the resident had severe cognitive impairment. Review of the September 2024 and October 2024 Physician orders revealed: Anti-anxiety medication side effects include drowsiness, confusion, nausea, weakness, delirium, disorientation, dizziness, impaired thinking, crying every shift. Anti-depressant side effects include: blurred vision, sedation, weight gain, gastrointestinal disturbance, dry mouth, constipation, urinary retention, headache, nausea, diarrhea, sleep disturbance every shift. Assess pain every shift using pain scale 0-10 every shift. Behavior/Mood monitoring every shift. Observe psychotropic medication side effects every shift. Apixaban 5mg (milligrams) by mouth twice a day. Atorvastatin Calcium 5mg by mouth every day. Cardizem CD extended release 24 hour 180 mg by mouth every day Doxazosin Mesylate 4mg by mouth at bedtime. Famotidine 20mg by mouth twice a day. Ferrous Sulfate 325mg by mouth every day. Flomax 0.4mg by mouth every day. Folic Acid 1mg by mouth every day. Insulin Lispro inject 10 units two times a day Klonopin 0.5 mg by mouth twice a day. Lasix 20mg by mouth every morning. Metformin HCL (Hydrochloride) 850 mg by mouth two times on 10/11/2024 the order was changed to Metformin 1000 mg by mouth twice a day. Namenda 10mg by mouth every day at bedtime. Polyethylene Glycol 17gm (gram) by mouth every day. Sennosides-Ducosate Sodium 8.6-50mg by mouth every day. Tradjenta 5mg by mouth every day. Tylenol 325mg give 2 tablets by mouth two times a day Vitamin C 250mg by mouth three times per day. Zoloft 50mg by mouth at bedtime. Review of the September 2024 Medication Administration Record (MAR) revealed no documentation of medication administration for the following medications to resident #68 during September: Atorvastatin Calcium 5 times. Cardizem CD extended release 24 hour 180 mg 3 times. Doxazosin Mesylate 4mg 5 times. Ferrous Sulfate 325mg 3 times. Flomax 0.4mg 5 times. Folic Acid 1mg 3 times. Lasix 20mg 3 times. Namenda 10mg 5 times. Polyethylene Glycol 17gm 3 times. Sennosides-Ducosate Sodium 8.6-50 mg 3 times. Tradjenta 5mg 3 times Zoloft 50mg 5 times. Apixaban 5mg by mouth twice a day at 8:00 a.m. 3 times and at 6:00 p.m. 5 times. Famotidine 20mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Insulin Lispro inject 10 units two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Klonopin 0.5 mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Metformin HCL 850 mg by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Tylenol 325 mg give 2 tablets by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Vitamin C 250 mg by mouth three times per day at 8:00 a.m. 3 times, 12:00 p.m. 3 times and 6:00 p.m. 3 times. Assess pain every shift using the pain scale 0-10 every shift 4 times on day shift. Behavior/Mood monitoring to be monitored every shift 4 times on day shift. Anti-anxiety medication side effects monitoring 4 times on day shift. Antidepressant side effects monitoring 4 times on day shift. Bleeding precautions- assess for bleeding 4 times on day shift. Review of the October 2024 Pharmacy Consultant report revealed the pharmacist did not identify/address the incomplete documentation by the nurses on the September 2024 MAR. On 10/31/2024 at 2:45 p.m., S3Director of Nursing (DON) confirmed the above incomplete documentation was inadequate for resident #68's September 2024 MAR. S3DON further confirmed the Pharmacy Consultant did not address the missing documentation in the October 2024 drug regimen review. 22575 Resident #17 Review of the medical record for resident #17 revealed he was admitted to the facility on [DATE] with diagnoses including enlarged prostate with lower urinary tract symptoms, overactive bladder, history of urinary tract infections, and long term use of antibiotics. Review of the quarterly MDS assessment dated [DATE] revealed resident #17 had a BIMS score of 9 which indicated he was moderately cognitively impaired for daily decision making and the resident required supervision with 1 person assistance for most activities of daily living (ADLs). Review of resident #17's October 2024 Physician's Orders revealed an order dated 05/20/2024 for Macrobid 100mg 1 by mouth daily. Review of resident #17's September 2024 MAR revealed the nurses failed to document 3 times that the resident's Macrobid 100mg was administered. Review of the Medication Regimen Review (MRR) dated 10/10/2024 (review was for previous month, September 2024) for resident # 17 revealed the pharmacy consultant failed to identify the nurses above incomplete documentation of the administration of Macrobid 100mg on the September 2024 MAR. On 10/31/2024 at 2:45 PM, S3DON confirmed the pharmacy consultant failed to address the above missed documentation of Macrobid on the September 2024 MAR for resident #17. Resident #83 Review of the medical record for resident #83 revealed an admitted [DATE] with diagnoses including paroxysmal atrial fibrillation and essential primary hypertension. Review of the quarterly MDS assessment dated [DATE] revealed resident #83 had a BIMS score of 8 which indicated she was moderately cognitively impaired for daily decision making and the resident required supervision with limited 1 person assistance for most ADLs. Review of resident #83's October 2024 Physician's Orders revealed an order dated 02/26/2024 for Eliquis 2.5mg 1 po twice a day. Further review revealed an order dated 05/28/2024 for bleeding precautions/monitoring every shift. Review of resident #83's September MAR revealed the nurses failed to document 5 times that the resident's Eliquis 2.5mg was administered. Further review revealed the nurses failed to consistently document monitoring for bleeding precautions. There was a total of 5 times missed for September 2024. On 10/31/2024 at 2:45 PM, S3DON confirmed the pharmacy consultant failed to address the above missed documentation for Eliquis administration and monitoring for bleeding for resident #83 on the September 2024 MAR. 43405 Resident #50 Review of the record for resident #50 revealed an admitted [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, hypertension, edema, hyperlipidemia, neuralgia and neuritis, hypokalemia, other pulmonary embolism without acute cor pulmonale, Parkinson's disease with dyskinesia with fluctuations, anxiety disorder, Alzheimer's disease, and vascular dementia unspecified severity with mood disturbance. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Review of resident #50's current Physician's Orders revealed the following orders: 07/13/2024- Lasix oral tablet 20 milligrams (mg) give 1 tablet 1 time a day; 03/13/2024- Losartan Potassium oral tablet 25 mg give 1 tablet by mouth (po) in the morning; 04/25/2024- Metoprolol Tartrate oral tablet 25 mg give 1 tablet po 2 times a day; 03/13/2024 Atorvastatin Calcium oral tablet 40 mg give 1 tablet po in the evening, Eliquis oral tablet 5 mg give 1 tab po 2 times a day, Gabapentin oral capsule 100 mg give 1 capsule po in the evening, Thiamine Hydrochloride (HCL) oral tablet 100 mg give 1 tab po in the morning, Potassium Chloride ER oral tablet extended release give 20 millequivalents (meq) po 1 time a day; 04/25/2024- Bumetanide oral tablet 1 mg give 1 tablet po 2 times a day; 05/22/2024- Celexa oral tablet give 20 mg po 1 time per day; 09/12/2024- Geodon oral capsule 20 mg give 20 mg po 1 time a day for combative behavior for 4 days; 09/16/2024- Geodon oral capsule 20 mg give 1 cap po in the morning; 05/26/2024- Risperidone oral tablet 1 mg give 1 tab po in the morning; 03/13/2024- Multivitamin oral tablet give 1 tablet po in the morning; 03/13/2024- Namenda oral tablet 5 mg give 1 tablet po 2 times a day; 03/13/2024- Vitamin C oral tablet give 1 tablet po 2 times a day; 03/13/2024- Nuplazid oral capsule 34 mg give 1 capsule po in the morning; 04/25/2024- Wellbutrin XL oral tablet extended release 24 hr 300 mg give 1 tablet po 1 time a day; 09/27/2024- Levofloxacin oral tablet 750 mg give 1 tablet po in the morning for 10 days; 07/17/2024- Nystatin External Powder 100000 unit/gram topical- apply to under breast and lower abdomen topically every day shift. Review of the September 2024 Medication Administration Record (MAR) revealed no documentation of medication administration for the following medications to resident #50: Atorvastatin Calcium- 4 times Celexa- 11 times Gabapentin- 4 times Geodon- 5 times Lasix- 11 times Levofloxacin- 1 time Losartan Potassium- 11 times Multivitamin- 11 times Nuplazid- 11 times Nystatin External powder- 1 time Thiamine- 11 times Potassium Chloride- 11 times Risperidone- 11 times Wellbutrin XL- 11 times Bumetanide - 15 times Eliquis- 15 times Vitamin C- 15 times Metoprolol Tartrate- 15 times Namenda- 15 times Review of the Pharmaceutical Consultant Report dated 10/10/2024 revealed no documented evidence that the pharmacist identified the irregularities regarding the September 2024 MAR having multiple medications not documented as administered for resident #50. An interview with S3Director of Nursing (DON) on 10/30/2024 at 2:56 p.m. confirmed no documentation of administration of multiple medications listed above for resident #50 on the September 2024 MAR. An interview on 10/30/2024 at 3:41 p.m. with S4Assistant Director of Nursing (ADON) revealed there was missing documentation of medication administration for resident #50 on the September MAR for multiple medications. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #50 on the September MAR. S3DON confirmed the pharmacist failed to notify the DON/Physician/facility regarding irregularities from the September 2024 MAR for resident #50. Resident #59 Review of resident #59's record revealed an admitted [DATE] with diagnoses including type 2 diabetes mellitus with unspecified complications, chronic obstructive pulmonary disease, chronic bronchitis, hypertension, hyperlipidemia, anemia, depression, cellulitis, dementia in other diseases classified elsewhere unspecified severity with agitation, generalized anxiety disorder, bipolar disorder, Alzheimer's disease, and peripheral vascular disease. Review of resident #59's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Review of resident #59's current Physician's Orders revealed the following: 03/14/2023- Aricept oral tablet 10 milligrams (mg) give 1 tablet by mouth (po) 1 time a day, Melatonin tablet 3 mg give 3 mg po at bedtime. 05/26/2022- Atorvastatin Calcium tablet 40 milligrams (mg) give 1 tablet at hour of sleep (hs) 04/10/2023- Dulera Aerosol 100-5 micrograms (mcg)/ACT 2 puffs inhale orally 2 times a day 04/24/2022- Eliquis tablet 2.5 mg give 1 tab po 2 times a day 12/22/2021- Metformin Hydrochloride (HCL) 500 mg give 500 mg po 2 times a day 10/12/2022- Quetiapine Fumarate (Seroquel) tablet 50 mg give 50 mg po 4 times a day 10/12/2022- Zyprexa tablet 2.5 mg give 2.5 mg po 2 times a day (bipolar disorder) 08/31/2022- Lubricant eye drops solution instill 1 drop in both eyes 3 times a day Review of the September 2024 Medication Administration Record (MAR) revealed no documentation for medication administration for the following medications on resident #59 in September: Aricept- 3 times Atorvastatin Calcium-2 times Melatonin (3 mg - give 3 mg po at hs) - 2 times Dulera Aerosol- 2 times Eliquis- 2 times Iron tablet 325 mg (65 Fe, Ferrous Sulfate give 1 tab po 2 times a day- 04/27/22)- 2 times Metformin HCL- 2 times; Vitamin C (500 mg po 2 times a day- 08/09/23)- 2 times; Zyprexa- 2 times; Quetiapine Fumarate- 9 times; Lubricant eye drops solution (1 gtt in both eyes 3 times daily- 08/31/22)- 9 times; Review of the Pharmaceutical Consultant Report dated 10/10/2024 revealed no documented evidence that the pharmacist identified the irregularities regarding the September 2024 MAR having multiple medications not documented as administered for resident #59. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #59 on the September MAR. S3DON confirmed the pharmacist failed to notify her/the facility/physician regarding the irregularities from the September 2024 MAR for resident #59. Resident #93 Review of resident #93's record revealed an admitted [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, pain in unspecified joint, depression, hypothyroidism, edema, overactive bladder, hyperlipidemia, and unspecified insomnia. Review of resident #93's current Physician's Orders revealed the following orders dated 09/04/2024: Citalopram Hydrobromide oral tablet 20 milligrams (mg) give 1 tablet by mouth (po) in the morning, Lasix oral tablet 40 mg give 1 tablet po in the morning, Levothyroxine Sodium tablet 50 micrograms (mcg) give 1 tablet po in the morning, Seroquel oral tablet 25 mg give 1 tablet po at hour of sleep (hs), Simvastatin oral tablet 40 mg give 1 tablet po in the evening, Trazodone Hydrochloride (HCL) oral tablet 100 mg give 1 tablet po at hs, Oxybutynin chloride oral tablet 5 mg give 1 tablet po 2 times a day, Meloxicam oral tablet 15 mg give 1 po in the morning, Colace oral capsule 100 mg give 1 capsule po in the morning, and Donepezil Hydrochloride (HCL) oral tablet 5 mg give 1 tablet po at bedtime. Review of the September 2024 MAR revealed no documentation of medication administration for the following: Lasix- 13 times; Levothyroxine- 9 times; Meloxicam- 9 times; Seroquel- 4 times; Simvastatin- 4 times; Trazodone - 4 times; Oxybutynin Chloride- 13 times; Citalopram- 9 times; Colace- 9 times; Donepezil HCL- 4 times Review of the Pharmaceutical Consultant Report dated 10/10/2024 revealed no documented evidence that the pharmacist identified the irregularities regarding the September 2024 MAR having multiple medications not documented as administered for resident #93. An interview on 10/31/2024 at 11:55 a.m. with S5ADON confirmed nurses failed to document administration of multiple medications to resident #93 for September 2024. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #93 on the September MAR. S3DON confirmed the pharmacist failed to notify her/the facility/physician regarding irregularities from the September 2024 MAR for resident #93.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' informed consent included the potential benefits and risks of the side rail use prior to installation for 2 (#18 and #22) of 2 (#18 and #22) residents identified for having side rails in use. Findings: Review of the facility's policy titled Physical Restraints, Side Rails dated 01/15/2024 revealed the following, in part: Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 4. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 8. The risk and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. Resident #22 Review of resident #22's medical record revealed an admitted [DATE] with diagnosis of cardiac arrhythmia, heart disease, edema, osteoporosis, hypertension, dysphagia, and hearing loss. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicates the resident is cognitively aware and able to make daily decisions. Further review revealed the resident needs minimal assistance with activities of daily living. Observation of resident #22 on 10/28/2024 at 2:42 p.m. revealed she was lying in bed with bilateral quarter side rails raised. Observations of resident #22 on 10/29/2024 at 9:15 a.m. and 3:30 p.m. revealed she was lying in bed on her right side with the bilateral quarter side rails raised. Review of resident #22's Consent for Assistive Devices revealed the facility failed to identify the assistive device implemented for the resident which was bilateral quarter side rails. Further review revealed the facility failed to inform the resident and/or the responsible party regarding the potential benefits and risks of the side rail use per the facility policy. Interview on 10/30/2024 at 11:55 a.m. with S3Assistant Director of Nurses (ADON) confirmed resident #22 did not have a consent for the use of the side rails. Interview on 10/30/2024 at 12:00 p.m. with the S3Director of Nursing (DON) confirmed resident #22 did not have a consent for the use of the side rails. 22575 Resident #18 Review of resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including heart failure, Alzheimer's disease, and anxiety disorder. Review of resident #18's MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated the resident was unable to complete the test. Further review revealed she required extensive assistance with bed mobility. An observation of resident #18 on 10/28/2024 at 9:11a.m. revealed she was lying in bed with a right quarter side rail that was raised. Observations of resident #18 on 10/29/2024 at 9:15 a.m. and 1:48 p.m. revealed she was lying in bed on her right side with the right quarter side rail raised. Review of resident #18's Consent for Assistive Devices revealed the facility failed to identify the assistive device implemented for the resident which was a right quarter side rail. Further review revealed the facility failed to inform the resident and/or the responsible party regarding the potential benefits and risks of the side rail use per the facility policy. An interview on 10/30/2024 at 3:00 p.m. with S4ADON confirmed the above consent for assistive devices did not identify the right quarter side rail use for resident #18. S4ADON also confirmed the potential risk and benefits of the side rail use were not included in the consent.

Based on record review and interview, the facility failed to ensure that nursing staff were able to demonstrate competencies and skills necessary to care for residents needs for 6 (#17, #50, #59, #68,#83, #93) of 6 (#17, #50, #59, #68,#83, #93) residents. The facility failed by not having documentation of medication administration daily. Resident #68 Review of the record for resident #68 revealed diagnoses of type 2 diabetes, dementia with other behavioral disturbances, depression, anxiety, congestive heart failure, and edema. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #68 had a Brief Interview Mental Status (BIMS) of 3 indicating the resident had severe cognitive impairment. Review of the September 2024 and October 2024 Physician orders revealed: Anti-anxiety medication side effects include drowsiness, confusion, nausea, weakness, delirium, disorientation, dizziness, impaired thinking, crying every shift. Anti-depressant side effects include: blurred vision, sedation, weight gain, gastrointestinal disturbance, dry mouth, constipation, urinary retention, headache, nausea, diarrhea, sleep disturbance every shift. Assess pain every shift using pain scale 0-10 every shift. Behavior/Mood monitoring every shift. Observe psychotropic medication side effects every shift. Apixaban 5mg (milligrams) by mouth twice a day. Atorvastatin Calcium 5mg by mouth every day. Cardizem CD extended release 24 hour 180 mg by mouth every day Doxazosin Mesylate 4mg by mouth at bedtime. Famotidine 20mg by mouth twice a day. Ferrous Sulfate 325mg by mouth every day. Flomax 0.4mg by mouth every day. Folic Acid 1mg by mouth every day. Insulin Lispro inject 10 units two times a day Klonopin 0.5 mg by mouth twice a day. Lasix 20mg by mouth every morning. Metformin HCL (Hydrochloride) 850 mg by mouth two times on 10/11/2024 the order was changed to Metformin 1000 mg by mouth twice a day. Namenda 10mg by mouth every day at bedtime. Polyethylene Glycol 17gm (gram) by mouth every day. Sennosides-Ducosate Sodium 8.6-50mg by mouth every day. Tradjenta 5mg by mouth every day. Tylenol 325mg give 2 tablets by mouth two times a day Vitamin C 250mg by mouth three times per day. Zoloft 50mg by mouth at bedtime. Review of the September 2024 Medication Administration Record (MAR) revealed no documentation of medication administration for the following medications to resident #68: Atorvastatin Calcium 5 times. Cardizem CD extended release 24 hour 180 mg 3 times. Doxazosin Mesylate 4mg 5 times. Ferrous Sulfate 325mg 3 times. Flomax 0.4mg 5 times. Folic Acid 1mg 3 times. Lasix 20mg 3 times. Namenda 10mg 5 times. Polyethylene Glycol 17gm 3 times. Sennosides-Ducosate Sodium 8.6-50 mg 3 times. Tradjenta 5mg 3 times Zoloft 50mg 5 times. Apixaban 5mg by mouth twice a day at 8:00 a.m. 3 times and at 6:00 p.m. 5 times. Famotidine 20mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Insulin Lispro inject 10 units two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Klonopin 0.5 mg by mouth twice a day at 8:00 a.m. 3 times and 6:00 p.m. 5 times. Metformin HCL 850 mg by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Tylenol 325 mg give 2 tablets by mouth two times a day at 8:00 a.m.3 times and 6:00 p.m. 5 times. Vitamin C 250 mg by mouth three times per day at 8:00 a.m. 3 times, 12:00 p.m. 3 times and 6:00 p.m. 3 times. Assess pain every shift using the pain scale 0-10 every shift 4 times on day shift. Behavior/Mood monitoring to be monitored every shift 4 times on day shift. Anti-anxiety medication side effects monitoring 4 times on day shift. Antidepressant side effects monitoring 4 times on day shift. Bleeding precautions- assess for bleeding 4 times on day shift. Review of the October 2024 MAR from October 1- October 30, 2024 revealed: Atorvastatin Calcium 5mg 9 times; Cardizem CD extended release 24 hour 180 mg 8 times; Doxazosin Mesylate 4mg 10 times; Ferrous Sulfate 325mg 7 times; Flomax 0.4mg 9 times; Folic Acid 1mg 7 times; Lasix 20mg 7 times; Namenda 10mg 9 times; Polyethylene Glycol 17gm 7 times; Sennosides-Ducosate Sodium 8.6-50 mg 7 times; Tradjenta 5mg 7 times; Zoloft 50mg 9 times; Apixaban 5mg by mouth twice a day at 8:00 a.m. 8 times and 6:00 p.m. 9 times; Famotidine 20mg by mouth twice a day at 8:00 a.m. 7 times and 6:00 p.m. 7 times; Insulin Lispro inject 10 units two times a day at 8:00 a.m. 9 times and 6:00 p.m. 10 times; Klonopin 0.5mg by mouth twice a day at 8:00 a.m. 8 times and 6:00 p.m. 9 times; Metformin HCL 850 mg by mouth two times a day at 8:00 a.m. 3 times and 6:00 p.m. 2 times; Metformin HCL 1000 mg by mouth two times a day with a start date of 10/11/2024 6 of 19 days at 6:00 p.m.; Tylenol 325 mg 2 tablets two times a day 8:00 a.m. 7 times and 6:00 p.m. 9 times; Vitamin C 250 mg by mouth three times per day at 8:00 a.m. 7 times, 12:00 p.m. 7 times and 6:00 p.m. 9 times. Assess pain every shift using the pain scale 0-10 every shift 11 times on day shift; Behavior/Mood monitoring to be monitored every shift revealed 11 times on day shift; Anti-anxiety medication side effects monitoring twice a day 10 times on day shift; Antidepressant side effects monitoring twice a day 10 times on day shift; Bleeding precautions- assess for bleeding on the day shift and night shift. 10 times on day shift. On 10/31/2024 at 2:45 p.m., S3Director of Nursing (DON) confirmed the above documentation was inadequate on the September and October 2024 MAR for resident #68. 22575 Resident #17 Review of the medical record for resident #17 revealed he was admitted to the facility on [DATE] with diagnoses including enlarged prostate with lower urinary tract symptoms, overactive bladder, history of urinary tract infections, and long term use of antibiotics. Review of the quarterly MDS assessment dated [DATE] revealed resident #17 had a BIMS score of 9 which indicated he was moderately cognitively impaired for daily decision making and the resident required supervision with 1 person assistance for most activities of daily living (ADLs). Review of resident #17's October 2024 Physician's Orders revealed an order dated 05/20/2024 for Macrobid 100mg 1 by mouth daily. Review of resident #17's September 2024 and October 2024 MARs revealed the nurses failed to document multiple times that the resident's Macrobid 100mg was administered. Further review revealed a total of 3 times missed in September 2024 and 6 times missed in October 2024. On 10/31/2024 at 2:00 p.m., an interview with S4ADON revealed resident #17 received his Macrobid as ordered but they have had issues with some of the nurses not consistently documenting medications for the resident. The surveyor reviewed resident #17's September 2024 and October 2024 MARs with S4ADON. She confirmed the nurses failed to document the resident's Macrobid 100mg - 3 times in Sept. 2024 and 6 times in October 2024. On 10/31/2024 at 2:45 PM, S3DON confirmed resident #17's Macrobid documentation was inadequate for September 2024 and October 2024. S3DON revealed she recently had issues with some of the nurses not consistently documenting on the resident's MARs. Resident #83 Review of the medical record for resident #83 revealed she was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation and essential primary hypertension, Review of the quarterly MDS assessment dated [DATE] revealed resident #83 had a BIMS score of 8 which indicated she was moderately cognitively impaired for daily decision making and the resident required supervision with limited1 person assistance for most ADLs. Review of resident #83's October 2024 Physician's Orders revealed an order dated 02/26/2024 for Eliquis 2.5mg 1 po twice a day (BID). Further review revealed an order dated 05/28/2024 for bleeding precautions/monitoring every shift. Review of resident #83's September and October 2024 MARs revealed the nurses failed to document multiple times that the resident's Eliquis 2.5mg was administered. There was a total of 5 times missed for September 2024 and 12 times missed for October 2024. Further review revealed the nurses failed to consistently document monitoring for bleeding precautions. There was a total of 5 times missed for September 2024 and 7 times missed for October 2024. On 10/31/2024 at 2:00 p.m., an interview with S4ADON revealed resident #83 received her Eliquis 2.5mg po bid as ordered but they have had issues with some of the nurses not documenting medications for the resident. The surveyor reviewed resident #83's September 2024 and October 2024 MARs with S4ADON and she confirmed the nurses failed to document the above Eliquis administration and monitoring for bleeding as ordered. On 10/31/2024 at 2:45 PM, S3DON confirmed resident #83's Eliquis administration and monitoring for bleeding documentation was inadequate for September 2024 and October 2024. S3DON confirmed the nurses failed to document the above Eliquis administration and monitoring for bleeding as ordered. 43405 Resident #50 Review of the record for resident #50 revealed an admitted [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, hypertension, edema, hyperlipidemia, neuralgia and neuritis, hypokalemia, other pulmonary embolism without acute cor pulmonale, Parkinson's disease with dyskinesia with fluctuations, anxiety disorder, Alzheimer's disease, and vascular dementia unspecified severity with mood disturbance. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Review of resident #50's current Physician's Orders revealed the following orders: 07/13/2024- Lasix oral tablet 20 milligrams (mg) give 1 tablet 1 time a day; 03/13/2024- Losartan Potassium oral tablet 25 mg give 1 tablet by mouth (po) in the morning; 04/25/2024- Metoprolol Tartrate oral tablet 25 mg give 1 tablet po 2 times a day; 03/13/2024 Atorvastatin Calcium oral tablet 40 mg give 1 tablet po in the evening, Eliquis oral tablet 5 mg give 1 tab po 2 times a day, Gabapentin oral capsule 100 mg give 1 capsule po in the evening, Thiamine Hydrochloride (HCL) oral tablet 100 mg give 1 tab po in the morning, Potassium Chloride ER oral tablet extended release give 20 millequivalents (meq) po 1 time a day; 04/25/2024- Bumetanide oral tablet 1 mg give 1 tablet po 2 times a day; 05/22/2024- Celexa oral tablet give 20 mg po 1 time per day; 09/12/2024- Geodon oral capsule 20 mg give 20 mg po 1 time a day for combative behavior for 4 days; 09/16/2024- Geodon oral capsule 20 mg give 1 cap po in the morning; 05/26/2024- Risperidone oral tablet 1 mg give 1 tab po in the morning; 03/13/2024- Multivitamin oral tablet giv e 1 tablet po in the morning; 03/13/2024- Namenda oral tablet 5 mg give 1 tablet po 2 times a day; 03/13/2024- Vitamin C oral tablet give 1 tablet po 2 times a day; 03/13/2024- Nuplazid oral capsule 34 mg give 1 capsule po in the morning; 04/25/2024- Wellbutrin XL oral tablet extended release 24 hr 300 mg give 1 tablet po 1 time a day; 09/27/2024- Levofloxacin oral tablet 750 mg give 1 tablet po in the morning for 10 days; 07/17/2024- Nystatin External Powder 100000 unit/gram topical- apply to under breast and lower abdomen topically every day shift; 10/24/2024- Lasix oral tablet 20 mg give 1 tablet orally 2 times a day for edema to BLE 10/24/2024- Clindamycin Hydrochloride (HCL) oral capsule 300 mg give 300 mg po 3 times per day for 10 days Review of the September 2024 MAR revealed no documentation of medication administration for the following medications to resident #50: Atorvastatin Calcium- 4 times Celexa- 11 times Gabapentin- 4 times Geodon- 5 times Lasix- 11 times Levofloxacin- 1 time Losartan Potassium- 11 times Multivitamin- 11 times Nuplazid- 11 times Nystatin External powder- 1 time Thiamine- 11 times Potassium Chloride- 11 times Risperidone- 11 times Wellbutrin XL- 11 times Bumetanide - 15 times Eliquis- 15 times Vitamin C- 15 times Metoprolol Tartrate- 15 times Namenda- 15 times Review of the October 2024 MAR revealed no documentation of medication administration for the following medications to resident #50: Atorvastatin Calcium- 8 times Celexa- 5 times Gabapentin- 8 times Geodon- 5 times Lasix- 4 times Levofloxacin- 1 time Losartan Potassium-5 times MVI- 3 times Nuplazid- 3 times Nystatin External powder-3 times Thiamine- 3 times Potassium Chloride- 3 times Risperidone- 3 times Wellbutrin XL- 3 times Bumetanide - 8 times Eliquis- 8 times Vitamin C- 7 times Metoprolol Tartrate- 8 times Namenda- 7 times Lasix 20 mg bid- started 10/24/24- 3 times Clindamycin HCL started 10/24/2024- 3 times An interview on 10/30/2024 at 3:41 p.m. with S4Assistant Director of Nursing (ADON) revealed there was missing documentation of medication administration for resident #50 on the September and October 2024 MAR for multiple medications. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #50 on the September and October 2024 MAR. Resident #59 Review of resident #59's record revealed an admitted [DATE] with diagnoses including type 2 diabetes mellitus with unspecified complications, chronic obstructive pulmonary disease, chronic bronchitis, hypertension, hyperlipidemia, anemia, depression, cellulitis, dementia in other diseases classified elsewhere unspecified severity with agitation, generalized anxiety disorder, bipolar disorder, Alzheimer's disease, and peripheral vascular disease. Review of resident #59's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, which indicated severe cognitive impairment. Review of resident #59's current Physician's Orders revealed the following: 03/14/2023- Aricept oral tablet 10 milligrams (mg) give 1 tablet by mouth (po) 1 time a day, Melatonin tablet 3 mg give 3 m po at bedtime. 05/26/2022- Atorvastatin Calcium tablet 40 milligrams (mg) give 1 tablet at hour of sleep (hs) 04/10/2023- Dulera Aerosol 100-5 micrograms (mcg)/ACT 2 puffs inhale orally 2 times a day 04/24/2022- Eliquis tablet 2.5 mg give 1 tab po 2 times a day 12/22/2021- Metformin Hydrochloride (HCL) 500 mg give 500 mg po 2 times a day 10/12/2022- Quetiapine Fumarate (Seroquel) tablet 50 mg give 50 mg po 4 times a day 10/12/2022- Zyprexa tablet 2.5 mg give 2.5 mg po 2 times a day (bipolar disorder) 08/31/2022- Lubricant eye drops solution instill 1 drop in both eyes 3 times a day to right eye Review of the September 2024 MAR revealed no documentation for medication administration for the following medications on resident #59: Aricept- 3 times Atorvastatin Calcium-2 times Melatonin (3 mg - give 3 mg po at hs) - 2 times Dulera Aerosol- 2 times Eliquis- 2 times Iron tablet 325 mg (65 Fe, Ferrous Sulfate give 1 tab po 2 times a day- 04/27/22)- 2 times Metformin HCL- 2 times; Vitamin C (500 mg po 2 times a day- 08/09/23)- 2 times; Zyprexa- 2 times; Quetiapine Fumarate- 9 times; Lubricant eye drops solution (1 gtt en both eyes 3 times daily- 08/31/22)- 9 times; Review of the October 2024 MAR revealed no documentation for medication administration for the following medications on resident #59: Aricept- 3 times Atorvastatin Calcium- 3 times Melatonin (3 mg - give 3 mg po at hs) -3 times Dulera Aerosol- 3 times Eliquis- 2 times- 3 times Iron tablet 325 mg (65 Fe, Ferrous Sulfate give 1 tab po 2 times a day- 04/27/22)-3 times Metformin HCL-3 times Vitamin C (500 mg po 2 times a day- 3 times Zyprexa- 3 times Quetiapine Fumarate- 2 times Lubricant eye drops solution (1 drop in both eyes 3 times daily- 08/31/22)- 1 time An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #59 on the September and October 2024 MAR. Resident #93 Review of resident #93's record revealed an admitted [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, pain in unspecified joint, depression, hypothyroidism, edema, overactive bladder, hyperlipidemia, and unspecified insomnia. Review of resident #93's current Physician's Orders revealed the following orders dated 09/04/2024: Citalopram Hydrobromide oral tablet 20 milligrams (mg) give 1 tablet by mouth (po) in the morning, Lasix oral tablet 40 mg give 1 tablet po in the morning, Levothyroxine Sodium tablet 50 micrograms (mcg) give 1 tablet po in the morning, Seroquel oral tablet 25 mg give 1 tablet po at hour of sleep (hs), Simvastatin oral tablet 40 mg give 1 tablet po in the evening, Trazodone Hydrochloride (HCL) oral tablet 100 mg give 1 tablet po at hs, Oxybutynin chloride oral tablet 5 mg give 1 tablet po 2 times a day, Meloxicam oral tablet 15 mg give 1 po in the morning, Colace oral capsule 100 mg give 1 capsule po in the morning, and Donepezil Hydrochloride (HCL) oral tablet 5 mg give 1 tablet po at bedtime. Review of the September 2024 MAR revealed no documentation of medication administration for resident #93 for the following medications: Lasix- 13 times; Levothyroxine- 9 times; Meloxicam- 9 times; Seroquel- 4 times; Simvastatin- 4 times; Trazodone - 4 times; Oxybutynin Chloride- 13 times; Citalopram- 9 times; Colace- 9 times; Donepezil HCL- 4 times Review of the October 2024 MAR revealed no documentation of medication administration for resident #93 for the following medications: Lasix- 2 times Levothyroxine- 2 times Meloxicam- 2 times Seroquel- 5 times Simvastatin- 5 times Trazodone - 5 times Oxybutynin Chloride- 7 times Citalopram- 1 time Colace- 1 time Donepezil HCL- 5 times An interview on 10/31/2024 at 11:55 a.m. with S5Assistant Director of Nursing (ADON) confirmed the nurses failed to document administration of multiple medications to resident #93 on the September and October 2024 MAR. An interview on 10/31/2024 at 10:55 a.m. with S3DON confirmed the nurses failed to document medication administration for the medications listed above for resident #93 on the September and October 2024 MAR.

Based on record review and interview, the facility failed to have documentation in the medical record regarding the need for a resident to be transferred to the hospital for 1 (#61) of 3 (#45, #61, #99) residents reviewed for hospitalization . Findings: Review of the Change in Condition policy and procedure dated 01/15/2024 in part revealed: 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the record for resident #61 revealed an original admitted [DATE] and a readmitted [DATE]. Further review of the record for resident #61 revealed diagnoses of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery dated 03/05/2024, hypertension, somatoform disorder, gastrostomy, bladder disorder, anxiety disorder, dementia, chronic pain, sepsis, disorder of the adrenal, urinary tract infection, spinal stenosis, delusional disorders, and delirium. Review of the record revealed a discharge Minimum Data Set (MDS) assessment dated [DATE] and a return MDS assessment dated [DATE]. Review of the record for resident #61 revealed there was no documentation in the nurses' notes why resident #61 was discharged to the hospital on 05/31/2024. On 10/31/2024 at 8:30 a.m., an interview with S9Licensed Practical Nurse (LPN) revealed they do not document on anything to give to the family regarding transfers. S9LPN further revealed the only thing they do is call the family, send the medication list, Louisiana Physician Order for Scope of Treatment (LaPost) and face sheet with the resident. On 10/31/2024 at 8:34 a.m., an interview with S4Assistant Director of Nursing (ADON) confirmed there was no documentation in the record why resident #61 was sent to the hospital on 05/31/2024. S4ADON revealed the only notification the family received was a phone call and she confirmed there was no documentation in the record of resident #61's family being notified of the transfer to the hospital on 05/31/2024.

Based on observations, record review, and interviews, the facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan and the preference of each resident to support residents in their choice of activities for 1 (#97) of 3 (#32, #42, and #97) residents reviewed for activities. Findings: Review of the record for resident #97 revealed an admitted [DATE] with diagnoses of hypertensive chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes. Review of the admission MDS (minimum data set) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Review of the activity assessment dated [DATE] for resident #97 revealed in part: C. When would you prefer to participate in scheduled activities? Any. 42C. Preferred activity setting- Any. The reason I am here- due to health issues. I am most happy when . I can get around/go to church. Review of the plan of care related to activities for resident #97 revealed in part: Cognitive impairment- ability to focus attention fluctuates. I need encouragement to attend activities- I am frequently tired with little energy. Will attend activities of my choice during the next review date. Allow me to express my feelings and desires. Encourage me to become involved in activities. Inform me of upcoming activities by: provide activity calendar, verbal reminders, escort, and encouragement. Praise involvement in activities. Review of the activity calendar for October 2024 for the week of 10/28/2024-10/31/2024 revealed: 10/28/2024- hand bells, bingo, coffee and chat 10/29/2024- pretty nails, bingo 10/30/2024- Bible Study with Mr. Porter, Bingo, Go Fish On 10/28/2024 at 2:27 p.m., observation of resident #97 throughout the day revealed the resident sat at a table with staff most of day. During the observations, staff were not interacting with resident #97 and there were no activities provided to resident #97. On 10/29/2024 at 1:45 p.m., observation of resident #97 revealed he was again sitting at the same table with no activities being provided. Review of the activity calendar revealed bingo was being played at 1:30 p.m. Further observation at that same time revealed S10Certified Nursing Aid (CNA) was sitting at the table eating food in front of the resident #97 and S11 CNA was standing at the table and food was noted to be in front of where she was standing. On 10/30/2024 at 8:30 a.m. and 10:00 a.m., observation of resident #97 revealed he was sitting at the same table in with no interaction. Review of the activity calendar for 10/30/2024 at 10:00 a.m. revealed Bible study was happening. On 10/30/2024 at 11:04 a.m., an interview with S12Activity revealed resident #97 liked to sit out on the hall, listen to music and will sometimes go to bingo and staff have to do the card for the resident at bingo. Further interview with S12Activity revealed she did not have any documentation of the specific activities that have been done with the resident #97. Review of the activity note in the computer dated 07/22/2024 by S12Activity revealed resident was an [AGE] year old widowed male that was admitted from home due to health issues. Resident Activity Director (RAD) goal is to offer in room/daily activities to help reduce any loneliness or boredom that may occur. Review of the activity note from 10/30/2024 at 7:58 a.m. revealed resident enjoys sitting in lobby, listening to music and getting visits from family. RAD goal is to continue to offer in room/daily activities to help reduce any loneliness or boredom that may occur. On 10/30/2024 at 11:34 a.m., an interview with resident #97 revealed he was very soft spoken but did say he would have liked to have gone to Bible study on 10/30/2024 at 10:00 a.m.

Based on observation, record review and interview, the facility failed to ensure the resident received adequate supervision to remain as free of accident hazards as possible for 1 (#1) of 1 (#1) residents investigated for smoking. Findings: Review of the smoking policy with a date of 03/04/2024 revealed in part: Policy: It is the policy of this facility to enforce a smoke free environment within the facility for both residents and staff. As well as, to ensure the rights, safety, and well-being of all residents and staff are being respected. Procedure: Smoking procedures will be established and enforced for residents as a fire safety factor. The following guidelines include conditions under which smoking is permitted. 2. Residents may smoke only in designated areas so supervision of smoking may be enforced. 4. Residents who smoke will be assessed on admit, quarterly, and when there is a significant change in the resident's ability to handle their smoking products. 6. Assistance for smoking residents will be encouraged and provided based on the resident's needs and wishes. 8. Residents are not allowed to keep cigarettes, cigars, vape pens, vape chargers, nor lighters in their rooms. These items are to be kept at the nurses' station. Review of the record for resident #1 revealed diagnoses of diabetes, borderline intellectual functioning, tremor, unspecified dementia, psychotic disturbance, mood disturbance and anxiety, undifferentiated schizophrenia, and Parkinsonism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a Brief Interview Mental Status (BIMS) of 5 indicating resident #1 had severe cognitive impairment. Further review revealed resident #1 had problems with inattention and required substantial/maximal assistance with shower/bathing. Review of October 2024 Physician orders in part revealed resident #1 was prescribed: Abilify 10 milligrams (mg) every morning- for schizophrenia. Sinemet 10-100 mg, give 2 tabs twice a day for Parkinson's. Depakote 500 mg every morning and 250 mg every evening for bipolar disorder. Ativan 0.5 mg three times a day for anxiety. Chlorpromazine Hydrochloride (HCL)100 mg every evening for schizophrenia. Ingrezza 80 mg every evening for schizophrenia. Review of the current care plan revealed resident #1 was at risk for injury related to smoking. Further review revealed the resident digs in the ashtray for cigarette butts and picks up butts off ground. He constantly asked other residents/staff for cigarettes. The goal was for the resident to safely smoke in designated smoking areas. Further review of the resident's care plan revealed the following interventions: counsel on hazards of smoking in non-designated smoking areas, counsel resident on designated smoking areas and observe resident during smoking every shift. On 10/28/2024 9:05 a.m., observation of resident #1 revealed he was sitting outside in the smoking area. Resident #1 did not have a lit cigarette at that time. Surveyor walked in parking lot and returned to smoking area. At this time, resident #1 had a lit cigarette and the only staff in the area was the Environmental Supervisor, the laundry worker and the Maintenance Director. Interview with S13Maintenance Director stated that each resident is given 2 cigarettes and whatever staff is outside in the smoking area will light the cigarette for the resident. On 10/29/2024 at 2:45 p.m., observation of resident #1 revealed he was sitting in the smoking building by himself. Resident #1 said he had not smoked his cigarettes yet. An interview with S14Housekeeper who was outside near the smoking building said that any staff will light the cigarettes for resident #1. On 10/30/2024 at 2:21 p.m., an interview with S15Ward Clerk revealed S16Activity bags up the number of cigarettes for each resident per day and the bags of cigarettes were kept at the front desk. S15Ward Clerk further said that residents go to smoke at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., and 6:00 p.m. S15Ward Clerk said she will go outside with the resident and light the cigarette and any staff that is out near the smoking area can light the resident's cigarette. On 10/30/2024 at 3:13 p.m., review of the smoking assessment dated [DATE] revealed S4ADON completed the smoking assessment and scored resident #1 as a safe smoker. On 10/30/2024 at 3:18 p.m., an interview with S4ADON confirmed the assessment was not accurate, resident #1 should have been deemed an unsafe smoker and that resident #1 should have been monitored while smoking. At the same time, S2Corporate Director also said that if resident #1 was digging in the trash for cigarettes, picking butts off ground, or not extinguishing the cigarette correctly the resident is an unsafe smoker.

Based on record review and interview, the facility failed to ensure resident's drug regimens were free from unnecessary psychotropic medications for 1 (#93) of 5 (#50, #59, #68, #92, and #93) residents reviewed for unnecessary medications. The facility failed to ensure a psychotropic medication was used only when there was an acceptable diagnosis documented in the medical record for resident #93. Findings: Review of resident #93's record revealed an admitted [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral/psychotic/mood disturbance, and anxiety, pain in unspecified joint, depression, hypothyroidism, edema, hyperlipidemia, and unspecified insomnia. Review of resident #93's October 2024 Physician's Orders revealed an order dated 09/04/2024 for Seroquel oral tablet 25 milligrams (mg) give 1 tablet by mouth (po) at hour of sleep (hs) with associated diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotropic disturbance, mood disturbance, psychotic disturbance, and anxiety. Review of the Pharmaceutical Consultant Report (Psychoactive Gradual Dose Reduction) for resident #93 dated 10/10/2024 revealed the pharmacist recommended the following -please provide an appropriate diagnosis for the use of Seroquel. Further review revealed the physician only addressed the request for the Gradual Dose Reduction (GDR) on 10/30/2024, but did not address the appropriate diagnosis for the use of Seroquel. Review of the record revealed resident #93 does not have an acceptable diagnosis for the use of Seroquel (psychotropic). An interview on 10/31/2024 at 10:55 a.m. with S3Director of Nursing (DON) confirmed the physician failed to document an acceptable diagnosis for the use of Seroquel.

Based on observations, record review, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (#152) of 1 sampled residents. Findings: Review of Self-Administration of medication policy and procedure with a revised date of 01/15/2024 revealed in part: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. For self-administering resident, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken. Self-administered medications must be stored in a safe and secure place, which is not accessible by other resident. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medications to the resident when the resident requests them. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the medication administration record kept at the nurse's station, appropriately noting that the doses were self-administered. Review of the record for resident #152 revealed an admitted [DATE] with diagnoses of amyotrophic lateral sclerosis (ALS) , depressive episodes, heart disease, type 2 diabetes, hypertension, sequelae of unspecified cerebrovascular diseases, and anxiety disorder. Review of the October 2024 Physician orders revealed: B complex vitamin 1 by mouth QD (every day), Fish oil 1 by mouth QD, Hydralazine HCL (Hydro Chloride) 25 milligrams (mg) by mouth BID (twice a day), Hydrochlorothiazide (HCTZ) 25mg by mouth QD, Hydrocodone-Tylenol 10-325mg 1 by mouth QD, Miralax 17grams (gm) powder by mouth QD, Novolog insulin per sliding scale before meals and bedtime, Radicava ORS oral suspension 105 mg/5milliliters (ml) 1 application by mouth every Monday, Rilutek 50mg (Riluzole) by mouth BID, Calcium 40mg by mouth at bedtime, Zoloft 50mg by mouth QD, Tamsulosin 0.4mg by mouth at bedtime, Toprol XL 50mg by mouth QD, Verapamil HCL ER (extended release) 120mg by mouth at bedtime, Vitamin C 1000mg by mouth QD, Vitamin D3 25microgram (mcg) by mouth QD, Coumadin 2.5mg give 3.75mg by mouth on Tuesday, Thursday and Saturday and 4.5 mg by mouth on Monday, Wednesday, Friday, and Sunday. Further review of the record and Physician orders revealed there were no orders for Fluticasone nasal spray 50mcg or Albuterol 90 mcg inhaler. On 10/28/2024 at 3:27 p.m., observation of a table at resident #152's bedside revealed a box of Fluticasone nasal spray 50 mcg with a label that read 2 sprays each nares every 12 hours as needed and an Albuterol 90 mcg inhaler without labeled instructions. Interview with resident #152 at this time revealed he does give himself these 2 medications. On 10/29/2024 at 2:04 p.m., observation again of resident #152's room revealed the same medications were still noted on the table at the resident's bedside. On 10/30/2024 at 2:01 p.m., an interview with S6Licensed Practical Nurse (LPN) revealed she removed the medications from resident #152's room this morning. S6 LPN confirmed resident #152 should not have had the medication at the bedside and should not have been taking the medications on his own.

Based on record reviews and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's need by not having: 1) Documented evidence of wound care completed for resident #83 as ordered; and 2) Documented evidence of medications administered to resident #100 on 11/13/2023 as ordered. Findings: Resident #83 Review of the facility's current Charting and Documentation Policy and Procedure revealed in part the following: Rules for Charting and Documentation 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medications, etc., as well as routine observations. 2. Be concise, accurate, complete and use objective terms. 5. Document daily treatments, vital signs, etc. Review of the record for resident #83 revealed an admitted [DATE] with diagnoses including acute post hemorrhagic anemia, idiopathic peripheral autoimmune neuropathy, periapical abscess without sinus, and nontraumatic subarachnoid hemorrhage, and tinea unguium. Review of Physician's Progress Notes revealed the following orders: -09/25/2023- discontinue Fluorouracil for now, restart twice a day (bid) applications in 2 weeks (10/09/2023); and -11/06/2023- discontinue Fluorouracil, continue Vaseline applications at nighttime, gently wash scalp with dove soap nightly. Review of resident #83's October 2023 Treatment Administration Record (TAR) revealed no documented evidence that the Flourouracil cream treatment to the scalp bid was completed 30 times from 10/09/2023-10/31/2023. Review of resident #83's November 2023 TAR revealed no documented evidence that the Flourouracil cream treatment to the scalp bid was completed 7 times from 11/01/2023-11/07/2023. Further review of the TAR revealed no documentation of washing the scalp with Dove soap nightly and applying Vaseline to the scalp every night 4 times from 11/07/2023-11/15/2023. An interview on 11/15/2023 at 11:25 a.m. with S3Licensed Practical Nurse (LPN)/Treatment Nurse revealed no documented evidence treatments were completed as ordered bid and nightly for resident #83 for October and November 2023. An interview on 11/15/2023 at 3:15 p.m. with S2DON confirmed no documented evidence that the treatments were completed as ordered for resident #83. S2DON further confirmed there was no documented evidence of Flourouracil treatments 30 times in October 2023, and 7 times in November 2023. S2DON confirmed no documentation of nightly Dove soap and Vaseline 4 times in November 2023. 18118 Resident #100 Review of the medical record for resident #100 revealed diagnoses of Non-Hodgkin's Lymphoma, reflux, seizure disorder, hypokalemia, hypertension, depression, constipation, polycythemia, and obesity. Review of the care plan revealed the resident was at risk for the following: abnormal labs, injury related to seizures, hypertension and resident #100 had the potential for excessive weakness and fatigue. Review of the approaches were to administer medication as ordered. Review of the November 2023 Medication Administration Record (MAR) revealed no documented evidence the evening medications were administered on November 13, 2023. On 11/15/2023 at 3:20 p.m. interview with S7Licensed Practical Nurse (LPN) that worked 11/13/2023 revealed the computers were not working and she was unable to sign the electronic Medication Administration Record and she did not use a paper MAR. On 11/14/2023 at 4:10 p.m. an interview with S6Assistant Director of Nursing (ADON) revealed when the computer electronic MAR is not working the LPNs are to use a paper MAR. S6ADON confirmed there was no documentation that S7LPN administered medications to resident #100 on 11/13/2023.

Based on record review and interview, the pharmacist failed to report any irregularities to the attending physician, facility's medical director, and director of nursing by failing to report lab not obtained as ordered for 1 (#68) of 5 (#47, #63, #68, #100, and #259) sampled residents reviewed for unnecessary medications. The pharmacist failed to identify that the facility failed to obtain a Fasting Lipid Panel (FLP) for resident #[AGE] yearly. Findings: Resident #68 Review of the medical record revealed resident #68 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, depression, anxiety, hypothyroidism, and hypertension. Review of the current care plan revealed the resident was at risk for abnormal labs and to draw labs as ordered. Review of the physician's orders dated 05/04/2022 revealed an order to obtain a FLP yearly. Review of the medical record revealed no documented evidence of a FLP drawn yearly as ordered. Review of the Medication Regimen Review dated 07/05/2023, 08/03/2023, 09/06/2023, and 10/10/2023 revealed the pharmacist did not address the FLP was not drawn yearly in May 2023 as ordered. On 11/15/2023 at 2:20 p.m. interview with S2Director of Nursing (DON) revealed the pharmacist did not inform her that resident #68's FLP had not be drawn in May 2023.

Based on observation, record review and interview the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were trimmed and cleaned in a timely manner for 1 (#49) of 2 (#49, #54) residents reviewed for activities of daily living. Findings: Review of Resident #49's medical record revealed an admitted [DATE] with diagnosis of heart disease with heart failure, depression, chronic obstructive pulmonary disease, anxiety, fluid overload, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has a BIMS (Brief Interview for Mental Status) score of 5 which indicated the resident was cognitively impaired and unable to make daily decisions. Further review revealed the resident required physical assistance with all activities of daily living. Review of the residents current care plan revealed the Certified Nursing Assistants (CNAs) are responsible for cleaning and cutting resident #49's fingernails. Observation on 11/13/2023 at 11:05 a.m., 11/14/2023 at 10:50 a.m., 11/14/2023 at 3:30 p.m. and 11/15/2023 at 8:15 a.m. revealed resident #49 had long dirty unkept fingernails. Interview on 11/15/2023 at 8:30 a.m., with S5CNA stated the nurses cut and clean the resident's nails when they are in need of cutting and cleaning. Interview on 11/15/2023 at 1:22 p.m., with the S4Licensed Practical Nurse (LPN) stated sample resident #49 is not a diabetic and the CNAs are responsible for cutting and cleaning the residents nails as long as they are not diabetic. Interview on 11/15/2023 at 2:30 p.m. with S2Director of Nursing (DON) confirmed the CNAs are responsible for cutting and cleaning the residents nails as long as they don't have a diagnosis of diabetes and Resident #49 doesn't have diabetes.

Based on record review and interview, the facility failed to develop a fall prevention care plan on admission for 2 sampled residents with a history of falls (#4, #6) in a total sample of 6 in a facility with 61 residents. Sampled resident #4 was placed in immediate jeopardy when she was admitted to the facility and the facility failed to implement measures to prevent falls. On [DATE] sample #4 had 4 falls, sustained a head injury and was transferred to the hospital and died that day of her injuries. The facility failed to increase supervision to prevent further falls. The immediate jeopardy for sample #4 was removed when she was transferred to the hospital. The deficient practice continues at a level H. Sampled resident #6 was placed in immediate jeopardy when he was admitted to the facility and the facility failed to implement measures to prevent falls. On [DATE] sample #6 had a fall, sustained a head injury and was transferred to the hospital. The immediate jeopardy remained in effect for this resident when he returned to the facility due to the facility's failure to provide additional supervision and failure to implement interventions to prevent future falls. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. Findings: Sample #4 1. Sample #4 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Sample #4 was admitted from another nursing home with documentation that she had a history of [REDACTED]. On [DATE] at 1:20pm interview with staff #S4LPN, ADON, confirmed that sample #4 was admitted with a history of falls and head injuries. She stated the resident was admitted from another nursing home. Record review of the Interim Care Plan dated [DATE] revealed the resident was not identified as a fall risk and the plan included no approaches for fall prevention measures. On [DATE] at 11:00am, S1DON confirmed sample #4 had not been identified as high risk for falls and there was no fall prevention care plan developed prior to the falls experienced by sample resident #4 on [DATE]. Record review of the incident and accident reports revealed that on [DATE] sample #4 had 4 falls as follows: 1. On [DATE] at 12:15am the resident was found laying on her back on the floor beside her bed. The nursing intervention initiated was "encourage resident to call for assistance when ambulating". Record review of the nurses notes dated [DATE] at 6:15am revealed the resident's daughter was notified at that time and the daughter stated "I'm not surprised, this is what was happening at the other nursing home". 2. On [DATE] at 6:30am the resident was found sitting on the floor against the bed. The nursing intervention initiated was "bed alarm placed on bed, and the resident requested to take it off the bed , it made her nervous and she did not want it." The alarm was not placed on the bed. 3. On [DATE] at 3:00pm blood was found on the floor in front of the recliner in her room, the Fall Investigation Report stated the resident had fell and got herself back up without telling staff. The nursing intervention initiated was to "move her to a room close to the nurses station and the resident refused to change rooms, make a physician appointment on [DATE]". 4. On [DATE] at 3:40pm the resident was found on the floor in her bathroom. The Incident & Accident report stated the resident had a contusion to the back of the head on the left side. The nursing interventions initiated was to "send the resident to the local hospital emergency room ". Record review of the Incident and Accident reports and the nurses notes, all dated [DATE], revealed no monitoring of the resident's condition, no ongoing neurological assessments and no increased supervision was done after any of the 4 falls that day. On [DATE] at 11:00am, interview with S1DON and S5Administrator confirmed sample #4 was admitted with a history of falls and had no fall risk assessment done on admission as required by the facility policies. They also confirmed that no fall prevention measures were initiated or care planned. They confirmed that after each of the resident's 4 falls on [DATE] there were no fall interventions initiated or care planned to prevent further falls. Sample #6 2. Review of the medical record for sample #6 revealed he was an [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the Certification and Plan of Care obtained from the home health agency dated [DATE] revealed the resident also had arthropathy, low vision, and abnormality of gait. The reason for home health services included increased mental status changes with frequent falls and increased immobility. Review of the admission physician orders [REDACTED]. The therapy evaluation dated [DATE] revealed the resident had a decline in function and mobility transferring requiring skilled services to increase strength and minimize falls. The physical and occupational assessment summaries revealed resident #6 was a fall risk. On [DATE] at 11:00am, an interview with S1DON confirmed resident #6 should have been considered high risk for falls because he was admitted with a history of falls in the last 3 months. Review of the interim care plan completed [DATE] revealed the resident was not identified as a fall risk and the plan included no approaches for fall prevention measures. On [DATE] at 11:00am, S1DON confirmed there was no fall prevention care plan developed prior to the fall experienced by sample resident #6 on [DATE], and no preventive measures were implemented to protect sample #6 from falls. Review of the nurse notes dated [DATE] at 7:30am revealed the nurse was called to the room of resident #6 to find the resident lying face down on the floor with blood everywhere. Vital signs were taken as follows: blood pressure ,[DATE], pulse 66, respirations 18, temperature 98. The resident was noted to have a contusion to his forehead and pressure was held by the nurse to stop the bleeding. Resident #6 was sent to the hospital for evaluation and treatment and returned to the facility on [DATE] at 11:10pm. Review of the Fall Investigation Report dated [DATE] at 7:30am revealed resident #6 was reaching for something on the floor and lost his balance. The resident was encouraged to call for assistance for reaching for things on the floor. Review of the care plan was developed after the actual fall experienced by resident #6 on [DATE] revealed the resident was placed on fall prevention program. On [DATE] at 11:00am, S1DON stated staff would know that the fall prevention program was implemented for a resident because the resident would have a yellow star beside the name plate on his door. On [DATE] at 11:05am, observation of the nameplate on the door of sample resident #6 revealed no star on it to identify to staff that the fall prevention program was in place. On [DATE] at 11:08am, S1DON confirmed there should be a yellow star on the name plate of resident #6 to alert staff that fall prevention measures should be implemented. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. The plan of removal read as follows; 1. The fall risk assessment was completed for resident #6. The DON/ADON will review fall risk assessments for all residents to ensure that they are completed. The DON/ADON will complete fall risk assessments for any residents not having a fall risk assessment. The DON will inservice nursing staff on completion of fall risk assessments for all residents upon admission and quarterly. The DON will monitor fall risk assessments for all new admits and residents due for quarterly staffing weekly x4 then monthly thereafter to ensure that fall risk assessments are completed for all residents upon admission and on a quarterly basis and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 2. The care plan for resident #6 was updated to include fall risk interventions. The DON/ADON will review the care plans for all residents at high risk for falls to ensure that risk for falls/fall prevention measures are addressed in the careplan. The care plan will be updated for each resident following a fall by the ADON and new measures implemented with each fall as needed by the ADON. The DON will inservice nursing staff on proper completion of care plans to include risk for falls/fall prevention measures. The DON will monitor the careplan for all new admits and residents due for quarterly staffing weekly x 4 then monthly thereafter to ensure that risk for falls/fall prevention measures are addressed in the careplan and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] 3. Fall prevention measures were implemented for resident #6. The DON/ADON will review all residents at high risk for falls to ensure that appropriate fall prevention measures are implemented. The DON/ADON will implement any additional fall prevention measures for residents at high risk for falls as needed. The DON will inservice nursing staff on proper implementation of fall prevention measures for all residents at high risk for falls. The DON will monitor all residents deemed to be high risk for falls weekly x4 then monthly thereafter to ensure that all residents at high risk for falls have appropriate fall prevention measures implemented and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 4. Resident #6 will be monitored/assessed thoroughly after any fall. The Administrator/DON will update/enforce the Fall Prevention Policy to include appropriate assessment/monitoring/fall prevention for all residents following a fall and residents at risk for falls. The DON/ADON will monitor all residents with falls weekly x4 then monthly thereafter to ensure that appropriate assessment/monitoring is completed and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 5. A fall risk symbol was placed on resident #6's room name plate. The DON/ADON will review all residents at high risk for falls to ensure that fall risk symbols are posted on their room name plate to alert nursing staff that resident is high risk for falls. The DON/ADON will place fall risk symbol on the resident's name plate if needed for any resident at high risk for falls. The DON will monitor weekly x4 then monthly thereafter all residents at high risk for falls to ensure that they have a fall risk symbol on their name plate and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE]

I. Based on record review and interview, the facility failed to: 1) complete fall risk assessments on admission for 2 sampled residents that were admitted with a history of falls (#4, #6); 2) assess on an ongoing basis, 2 sampled residents with unwitnessed falls involving head injury (#4, #6); and 3) reassess 2 sampled residents following falls to determine how the residents fell (#4, #6). The extent is 2 residents with falls in a total sample of 6 residents in a facility with 61 residents. Sampled resident #4 was placed in immediate jeopardy on [DATE] when she was admitted to the facility and the facility failed to assess her as being at high risk for falls. On [DATE] sample #4 had 4 falls, sustained a head injury and was transferred to the hospital and died that day of her injuries. The facility failed assess the resident after each fall to determine how the resident fell . The facility failed to assess the resident for injury including on-going neuro checks. The immediate jeopardy for sample #4 was removed when she was transferred to the hospital. Sampled resident #6 was placed in immediate jeopardy on [DATE] when he was admitted to the facility and the facility failed to assess him as being at high risk for falls and failed to implement measures to prevent falls. On [DATE] sample #6 had a fall, sustained a head injury and was transferred to the hospital. The resident returned to the nursing home on [DATE]. The immediate jeopardy continued for this resident due to the facility's continued failure to conduct a fall risk assessment after the resident's fall and identify the resident to the staff as a fall risk. The deficient practice continues at a level H for this resident On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. Findings: Sample #4 1. Sample #4 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Sample #4 was admitted from another nursing home with documentation that she had a history of [REDACTED]. On [DATE] at 1:20pm interview with staff #S4LPN, ADON, confirmed that sample #4 was admitted with a history of falls and head injuries. She stated the resident was admitted from another nursing home. Review of the Admission Nurse Documentation dated [DATE] at 4:40pm for sample #4 revealed that falls was not identified as a care issue. Review of the Psychological Functioning area scored sample #4 as disoriented to time, place and person. Record review revealed there was no fall risk assessment done on admission or at any time after admission. Review of the facility policies for Fall Prevention Program revealed that "A Fall Risk Assessment will be completed on all residents upon admission, quarterly and with a significant change in condition". Record review of the incident and accident reports revealed that on [DATE] sample #4 had falls as follows: 1. On [DATE] at 12:15am the resident was found laying on her back on the floor beside her bed. The nursing intervention initiated was "encourage resident to call for assistance when ambulating". Review of the resident's record revealed no monitoring of the resident's physical condition after the fall. 2. On [DATE] at 6:30am the resident was found sitting on the floor against the bed. The nursing intervention initiated was "bed alarm placed on bed, and the resident requested to take it off the bed , it made her nervous and she did not want it." The alarm was not placed on the bed. Review of the resident's record revealed no monitoring of the resident's condition after the fall. 3. On [DATE] at 3:00pm blood was found on the floor in front of the recliner in her room, the Fall Investigation Report stated the resident had fell and got herself back up without telling staff. The nursing intervention initiated was to "move her to a room close to the nurses station and the resident refused to change rooms, make a physician appointment on [DATE]". Review of the resident's record revealed no monitoring of the resident's physical condition after the fall. 4. On [DATE] at 3:40pm the resident was found on the floor in her bathroom. The Incident & Accident report stated the resident had a contusion to the back of the head on the left side. The nursing interventions initiated was to "send the resident to the local hospital emergency room ". Record review of the Incident and Accident reports and the nurses notes, all dated [DATE], revealed no monitoring of the resident's condition, no ongoing neurological assessments and no increased supervision was done after any of the 4 falls that day. Review of the local hospital records of a Cat Scan dated [DATE] at 5:35pm revealed sample #4 had a large subdural hematoma involving the right hemisphere with marked shift of the midline structures from right-to-left. The resident progressed to a coma state, was transferred to a higher level of care hospital where she died that day. On [DATE] at 11:00am, interview with S1DON and S5Administrator confirmed sample #4 was admitted with a history of falls and had no fall risk assessment done on admission as required by the facility policies. They also confirmed that no fall prevention measures were initiated or care planned. They confirmed that after each of the resident's 4 falls on [DATE] there was no monitoring or ongoing assessments done of the resident's physical condition. Review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition, Chapter 63, pages 1913 - 1920, "The importance of ongoing assessment and monitoring of the brain-injured patient cannot be overstated. As soon as the initial assessment is made, the use of a neurologic flow chart is started and maintained. Changes in a brain-injured patient can occur minutes, hours or days after the head injury. Elderly patients must be assessed very carefully. Even given similar mechanisms of injury, an elderly person will often suffer more severe injury than a young person and will often recover more slowly and with more complications." 2. Review of the medical record for sample #6 revealed he was an [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the Certification and Plan of Care obtained from the home health agency dated [DATE] revealed the resident also had arthropathy, low vision, and abnormality of gait. The reason for home health services included increased mental status changes with frequent falls and increased immobility. Review of the admission physician orders [REDACTED]. The therapy evaluation dated [DATE] revealed the resident had a decline in function and mobility transferring requiring skilled services to increase strength and minimize falls. The physical and occupational assessment summaries revealed resident #6 was a fall risk. Review of the medical record for client #6 revealed no fall risk assessment was completed upon admission to the facility. An undated and unsigned fall risk assessment was presented to the surveyors on [DATE] at 11:00AM, at which time an interview with S1DON confirmed the fall risk assessment was not completed for sample #6 when he was admitted on [DATE], but was still in the process of being completed. She confirmed sample #6 should have been considered high risk for falls because he was admitted with a history of falls in the last 3 months. Review of the nurse notes dated [DATE] at 7:30AM revealed the nurse was called to the room of resident #6 to find the resident lying face down on the floor with blood everywhere. Vital signs were taken as follows: blood pressure ,[DATE], pulse 66, respirations 18, temperature 98. The resident was noted to have a contusion to his forehead and pressure was held by the nurse to stop the bleeding. Resident #6 was sent to the hospital for evaluation and treatment and returned to the facility on [DATE] at 11:00PM. Further review of the nurse notes revealed no other documented assessments since his return from the hospital. Review of the facility's Incident/Accident Follow-up Policy revealed the resident should be monitored by the licensed nurse following all incidents and accidents every shift for 72 hours and document in the resident record vital signs and monitoring of any injury sustained, any complaints, or changes in condition. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. The plan of removal read as follows; 1. The fall risk assessment was completed for resident #6. The DON/ADON will review fall risk assessments for all residents to ensure that they are completed. The DON/ADON will complete fall risk assessments for any residents not having a fall risk assessment. The DON will inservice nursing staff on completion of fall risk assessments for all residents upon admission and quarterly. The DON will monitor fall risk assessments for all new admits and residents due for quarterly staffing weekly x4 then monthly thereafter to ensure that fall risk assessments are completed for all residents upon admission and on a quarterly basis and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 2. The care plan for resident #6 was updated to include fall risk interventions. The DON/ADON will review the care plans for all residents at high risk for falls to ensure that risk for falls/fall prevention measures are addressed in the careplan. The care plan will be updated for each resident following a fall by the ADON and new measures implemented with each fall as needed by the ADON. The DON will inservice nursing staff on proper completion of care plans to include risk for falls/fall prevention measures. The DON will monitor the careplan for all new admits and residents due for quarterly staffing weekly x 4 then monthly thereafter to ensure that risk for falls/fall prevention measures are addressed in the careplan and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] 3. Fall prevention measures were implemented for resident #6. The DON/ADON will review all residents at high risk for falls to ensure that appropriate fall prevention measures are implemented. The DON/ADON will implement any additional fall prevention measures for residents at high risk for falls as needed. The DON will inservice nursing staff on proper implementation of fall prevention measures for all residents at high risk for falls. The DON will monitor all residents deemed to be high risk for falls weekly x4 then monthly thereafter to ensure that all residents at high risk for falls have appropriate fall prevention measures implemented and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 4. Resident #6 will be monitored/assessed thoroughly after any fall. The Administrator/DON will update/enforce the Fall Prevention Policy to include appropriate assessment/monitoring/fall prevention for all residents following a fall and residents at risk for falls. The DON/ADON will monitor all residents with falls weekly x4 then monthly thereafter to ensure that appropriate assessment/monitoring is completed and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 5. A fall risk symbol was placed on resident #6's room name plate. The DON/ADON will review all residents at high risk for falls to ensure that fall risk symbols are posted on their room name plate to alert nursing staff that resident is high risk for falls. The DON/ADON will place fall risk symbol on the resident's name plate if needed for any resident at high risk for falls. The DON will monitor weekly x4 then monthly thereafter all residents at high risk for falls to ensure that they have a fall risk symbol on their name plate and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] II. Based on interview and record review, the facility failed to conduct ongoing assessments to provide the appropriate care and services for each resident by failing to ensure staff checked on residents as needed for each resident during the night shift for 1 of 6 sampled resident in a facility with 61 residents. (Sample #3) Findings: Review of the medical record of resident #3 revealed she was found dead in her room by a housekeeper on [DATE] at 8:05am. Staff #S1DON conducted an investigation of the incident and it was determined that neither #S2LPN nor #S3CNA had checked on resident #3 throughout the entire night shift. On [DATE] at 10:45am, staff #S1DON stated the night nurse should have checked on the resident within an hour of starting her shift at 11:00pm.

Based on record review and interview, the facility failed to complete fall risk assessments on admission for 2 sampled residents (#4 and #6) that were admitted with a history of falls in a total sample of 6 in a facility with 61 residents. Sampled resident #4 was placed in immediate jeopardy on [DATE] when she was admitted to the facility and the facility failed to assess her as being at high risk for falls and failed to implement measures to prevent falls. On [DATE] sample #4 had 4 falls, sustained a head injury and was transferred to the hospital and died that day of her injuries. After each fall the facility failed to increase supervision to prevent further falls and failed to assess the resident for injury including on-going neuro checks. The immediate jeopardy for sample #4 was removed when she was transferred to the hospital. Sampled resident #6 was placed in immediate jeopardy on [DATE] when he was admitted to the facility and the facility failed to assess him as being at high risk for falls and failed to implement measures to prevent falls. On [DATE] sample #6 had a fall, sustained a head injury and was transferred to the hospital. The immediate jeopardy remained in effect for this resident due to the facility's failure to provide additional supervision and failure to implement interventions to prevent future falls. The deficient practice continued at a level H for this resident. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. Findings: 1. Resident #4 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Sample #4 was admitted from another nursing home with documentation that she had a history of [REDACTED]. On [DATE] at 1:20pm interview with staff #S4LPN, ADON, confirmed that sample #4 was admitted with a history of falls and head injuries. She stated the resident was admitted from another nursing home. Record review of the Admission Nurse Documentation dated [DATE] at 4:40pm for sample #4 revealed that falls was not identified. Review of the Psychological Functioning area scored sample #4 as disoriented to time, place and person. Record review revealed there was no fall risk assessment done on admission or at any time after admission. Review of the facility policies for Fall Prevention Program revealed that "A Fall Risk Assessment will be completed on all residents upon admission, quarterly and with a significant change in condition". Record review of the incident and accident reports revealed that on [DATE] sample #4 had falls as follows: 1. On [DATE] at 12:15am the resident was found laying on her back on the floor beside her bed. The nursing intervention initiated was "encourage resident to call for assistance when ambulating". 2. On [DATE] at 6:30am the resident was found sitting on the floor against the bed. The nursing intervention initiated was "bed alarm placed on bed, and the resident requested to take it off the bed , it made her nervous and she did not want it." The alarm was not placed on the bed. 3. On [DATE] at 3:00pm blood was found on the floor in front of the recliner in her room, the Fall Investigation Report stated the resident had fell and got herself back up without telling staff. The nursing intervention initiated was to "move her to a room close to the nurses station and the resident refused to change rooms, make a physician appointment on [DATE]". 4. On [DATE] at 3:40pm the resident was found on the floor in her bathroom. The Incident & Accident report stated the resident had a contusion to the back of the head on the left side. The nursing interventions initiated was to "send the resident to the local hospital emergency room ". Review of the Incident and Accident reports and the nurses notes, all dated [DATE], revealed no monitoring of the resident's condition, no ongoing neurological assessments and no increased supervision was done after any of the 4 falls that day. Review of the local hospital records of a Cat Scan dated [DATE] at 5:35pm revealed sample #4 had a large subdural hematoma involving the right hemisphere with marked shift of the midline structures from right-to-left. The resident progressed to a coma state, was transferred to a higher level of care hospital where she died that day. Review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition, Chapter 63, pages 1913 - 1920, "The importance of ongoing assessment and monitoring of the brain-injured patient cannot be overstated. As soon as the initial assessment is made, the use of a neurologic flow chart is started and maintained. Changes in a brain-injured patient can occur minutes, hours or days after the head injury. Elderly patients must be assessed very carefully. Even given similar mechanisms of injury, an elderly person will often suffer more severe injury than a young person and will often recover more slowly and with more complications." On [DATE] at 11:00am, interview with S1DON and S5Administrator confirmed sample #4 was admitted with a history of falls and had no fall risk assessment done on admission as required by the facility policies. They also confirmed that no fall prevention measures were initiated or care planned. They confirmed that after each of the resident's 4 falls on [DATE] there were no fall interventions initiated or care planned to prevent further falls. 2. Review of the medical record for resident #6 revealed he was an [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the Certification and Plan of Care obtained from the home health agency dated [DATE] revealed the resident also had arthropathy, low vision, and abnormality of gait. The reason for home health services included increased mental status changes with frequent falls and increased immobility. Review of the admission physician orders [REDACTED]. The therapy evaluation dated [DATE] revealed the resident had a decline in function and mobility transferring requiring skilled services to increase strength and minimize falls. The physical and occupational assessment summaries revealed resident #6 was a fall risk. Review of the medical record for client #6 revealed no fall risk assessment was completed upon admission to the facility. An undated and unsigned fall risk assessment was presented to the surveyors on [DATE] at 11:00am, at which time an interview with S1DON confirmed the fall risk assessment was not completed for sample #6 when he was admitted on [DATE], but was still in the process of being completed. She confirmed sample #6 should have been considered high risk for falls because he was admitted with a history of falls in the last 3 months. Review of the interim care plan completed [DATE] revealed the resident was not identified as a fall risk and the plan included no approaches for fall prevention measures. On [DATE] at 11:00am, S1DON confirmed there was no fall prevention care plan developed prior to the fall experienced by sample resident #6 on [DATE], and no preventive measures were implemented to protect sample #6 from falls. Review of the nurse notes dated [DATE] at 7:30am revealed the nurse was called to the room of resident #6 to find the resident lying face down on the floor with blood everywhere. Vital signs were taken as follows: blood pressure ,[DATE], pulse 66, respirations 18, temperature 98. The resident was noted to have a contusion to his forehead and pressure was held by the nurse to stop the bleeding. Resident #6 was sent to the hospital for evaluation and treatment and returned to the facility on [DATE] at 11:10pm. Further review of the nurse notes revealed no other documented assessments since his return from the hospital. Review of the facility's Incident/Accident Follow-up Policy revealed the resident should be monitored by the licensed nurse following all incidents and accidents every shift for 72 hours and document in the resident record vital signs and monitoring of any injury sustained, any complaints, or changes in condition. Review of the Fall Investigation Report dated [DATE] at 7:30am revealed resident #6 was reaching for something off floor and lost his balance. The resident was encouraged to call for assistance for reaching for things off floor. Review of the medical record revealed a care plan was developed after the actual fall experienced by resident #6 on [DATE]. Interventions included: monitor every 2 hours, keep call light in reach at all times, provide assist with transfers, place frequently used items in reach, PT/OT as ordered, and to place on fall prevention program. On [DATE] at 11:00am, S1DON stated the staff would know which residents were on the fall prevention program because the residents would have a yellow star beside the name plate on their door. On [DATE] at 11:05am, observation of the nameplate on the door of sample #6 revealed no star on it to identify to staff that he was at high risk for falls. On [DATE] at 11:08am, S1DON confirmed there should be a yellow star on the nameplate of resident #6 to identify him to staff as high risk for falls. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. The plan of removal read as follows; 1. The fall risk assessment was completed for resident #6. The DON/ADON will review fall risk assessments for all residents to ensure that they are completed. The DON/ADON will complete fall risk assessments for any residents not having a fall risk assessment. The DON will inservice nursing staff on completion of fall risk assessments for all residents upon admission and quarterly. The DON will monitor fall risk assessments for all new admits and residents due for quarterly staffing weekly x4 then monthly thereafter to ensure that fall risk assessments are completed for all residents upon admission and on a quarterly basis and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 2. The care plan for resident #6 was updated to include fall risk interventions. The DON/ADON will review the care plans for all residents at high risk for falls to ensure that risk for falls/fall prevention measures are addressed in the careplan. The care plan will be updated for each resident following a fall by the ADON and new measures implemented with each fall as needed by the ADON. The DON will inservice nursing staff on proper completion of care plans to include risk for falls/fall prevention measures. The DON will monitor the careplan for all new admits and residents due for quarterly staffing weekly x 4 then monthly thereafter to ensure that risk for falls/fall prevention measures are addressed in the careplan and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] 3. Fall prevention measures were implemented for resident #6. The DON/ADON will review all residents at high risk for falls to ensure that appropriate fall prevention measures are implemented. The DON/ADON will implement any additional fall prevention measures for residents at high risk for falls as needed. The DON will inservice nursing staff on proper implementation of fall prevention measures for all residents at high risk for falls. The DON will monitor all residents deemed to be high risk for falls weekly x4 then monthly thereafter to ensure that all residents at high risk for falls have appropriate fall prevention measures implemented and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 4. Resident #6 will be monitored/assessed thoroughly after any fall. The Administrator/DON will update/enforce the Fall Prevention Policy to include appropriate assessment/monitoring/fall prevention for all residents following a fall and residents at risk for falls. The DON/ADON will monitor all residents with falls weekly x4 then monthly thereafter to ensure that appropriate assessment/monitoring is completed and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 5. A fall risk symbol was placed on resident #6's room name plate. The DON/ADON will review all residents at high risk for falls to ensure that fall risk symbols are posted on their room name plate to alert nursing staff that resident is high risk for falls. The DON/ADON will place fall risk symbol on the resident's name plate if needed for any resident at high risk for falls. The DON will monitor weekly x4 then monthly thereafter all residents at high risk for falls to ensure that they have a fall risk symbol on their name plate and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE]

I. Based on record review and interview, the facility failed to be administered in a manner that enabled it to utilize it's resources effectively and efficiently by failing to implement policies on the completion of fall risk assessments on admission of all residents and failure to develop policies with parameters for assessing and providing increased supervision for residents after a fall. Two of 6 sampled residents, with a recent history of falls, were placed in immidiate jeopardy upon admission to the facility due to the failure of the facility to implement policies. On [DATE] sample #4 had 4 falls, sustained a head injury and was transferred to the hospital and died that day of her injuries. The facility failed to increase supervision to prevent further falls and failed to assess the resident for injury including on-going neuro checks after the falls. The immediate jeopardy for sample #4 was removed when she was transferred to the hospital. The deficient practice continues at a level H. Sampled resident #6 was placed in immediate jeopardy on [DATE] when he was admitted to the facility and the facility failed to assess him as being at high risk for falls and failed to implement measures to prevent falls. On [DATE] sample #6 had a fall, sustained a head injury and was transferred to the hospital. The immediate jeopardy remained in effect for this resident due to the facility's failure to provide additional supervision and failure to implement interventions to prevent future falls. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. Findings: 1. Sample #4 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Sample #4 was admitted from another nursing home with documentation that she had a history of [REDACTED]. Record review of the Admission Nurse Documentation dated [DATE] at 4:40pm for sample #4 revealed that falls was not identified. Review of the Psychological Functioning area scored sample #4 as disoriented to time, place and person. Record review revealed there was no fall risk assessment done on admission or at any time after admission. Review of the facility policies for Fall Prevention Program revealed that "A Fall Risk Assessment will be completed on all residents upon admission, quarterly and with a significant change in condition". Record review of the incident and accident reports revealed that on [DATE] sample #4 had 4 falls as follows: 1. On [DATE] at 12:15am the resident was found laying on her back on the floor beside her bed. The nursing intervention initiated was "encourage resident to call for assistance when ambulating". Review of the resident's record revealed no monitoring of the resident's condition after the fall 2. On [DATE] at 6:30am the resident was found sitting on the floor against the bed. The nursing intervention initiated was "bed alarm placed on bed, and the resident requested to take it off the bed , it made her nervous and she did not want it." The alarm was not placed on the bed. Review of the resident's record revealed no monitoring of the resident's condition after the fall 3. On [DATE] at 3:00pm blood was found on the floor in front of the recliner in her room, the Fall Investigation Report stated the resident had fell and got herself back up without telling staff. The nursing intervention initiated was to "move her to a room close to the nurses station and the resident refused to change rooms, make a physician appointment on [DATE]". Review of the resident's record revealed no monitoring of the resident's condition after the fall 4. On [DATE] at 3:40pm the resident was found on the floor in her bathroom. The Incident and Accident report stated the resident had a contusion to the back of the head on the left side. The nursing interventions initiated was to "send the resident to the local hospital emergency room ". Record review of the Incident and Accident reports and the nurses notes, all dated [DATE], revealed that after each fall there was no monitoring of the resident's condition, no ongoing neurological assessments and no increased supervision to prevent further falls. Review of the local hospital records of a Cat Scan dated [DATE] at 5:35pm revealed sample #4 had a large subdural hematoma involving the right hemisphere with marked shift of the midline structures from right-to-left. The resident progressed to a coma state, was transferred to a higher level of care hospital where she died that day. On [DATE] at 11:00am, interview with S1DON and S5Administrator confirmed sample #4 was admitted with a history of falls and had no fall risk assessment done on admission as required by the facility policies. They also confirmed that no fall prevention measures were initiated or care planned. They confirmed that after each of the resident's 4 falls on [DATE] there were no fall interventions initiated or care planned to prevent further falls. On [DATE] at 1:20pm interview with staff #S4LPN, ADON, confirmed that sample #4 was admitted with a history of falls and head injuries. She stated the resident was admitted from another nursing home. Review of the facility policy revealed fall risk assessments were to be completed at the time of admission. The facility incident/accident follow-up policy only stated the resident would be monitored each shift for the next 72 hours and it should be documented in the resident's record. On [DATE] at 11:00am, interview with #S1DON and #S2Administrator confirmed there was no other policy requireing frequent assessment and closer supervision after a fall. Review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition, Chapter 63, pages 1913 - 1920, "The importance of ongoing assessment and monitoring of the brain-injured patient cannot be overstated. As soon as the initial assessment is made, the use of a neurologic flow chart is started and maintained. Changes in a brain-injured patient can occur minutes, hours or days after the head injury. Elderly patients must be assessed very carefully. Even given similar mechanisms of injury, an elderly person will often suffer more severe injury than a young person and will often recover more slowly and with more complications." 2. Review of the medical record for sample #6 revealed he was an [AGE] year old male admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the Certification and Plan of Care obtained from the home health agency dated [DATE] revealed the resident also had arthropathy, low vision, and abnormality of gait. The reason for home health services included increased mental status changes with frequent falls and increased immobility. Review of the admission physician orders revealed physical and occupational therapy was started on [DATE]. The therapy evaluation dated [DATE] revealed the resident had a decline in function and mobility transferring requiring skilled services to increase strength and minimize falls. The physical and occupational assessment summaries revealed resident #6 was a fall risk. Review of the medical record for client #6 revealed no fall risk assessment was completed upon admission to the facility. An undated and unsigned fall risk assessment was presented to the surveyors on [DATE] at 11:00am, at which time an interview with S1DON confirmed the fall risk assessment was not completed for sample #6 when he was admitted on [DATE], but was still in the process of being completed. She confirmed sample #6 should have been considered high risk for falls because he was admitted with a history of falls in the last 3 months. Review of the interim care plan completed [DATE] revealed the resident was not identified as a fall risk and the plan included no approaches for fall prevention measures. On [DATE] at 11:00am, S1DON confirmed there was no fall prevention care plan developed prior to the fall experienced by sample resident #6 on [DATE], and no preventive measures were implemented to protect sample #6 from falls. Review of the nurse notes dated [DATE] at 7:30am revealed the nurse was called to the room of resident #6 to find the resident lying face down on the floor with blood everywhere. Vital signs were taken as follows: blood pressure ,[DATE], pulse 66, respirations 18, temperature 98. The resident was noted to have a contusion to his forehead and pressure was held by the nurse to stop the bleeding. Resident #6 was sent to the hospital for evaluation and treatment and returned to the facility on [DATE] at 11:10pm. Review of the Fall Investigation Report dated [DATE] at 7:30am revealed resident #6 was reaching for something on the floor and lost his balance. The nursing interventions initiated after the fall was was encouraged to call for assistance for reaching for things off floor. Review of the medical record revealed a care plan was developed after the actual fall experienced by resident #6 on [DATE]. Interventions included: monitor every 2 hours, keep call light in reach at all times, provide assist with transfers, place frequently used items in reach, PT/OT as ordered, and to place on fall prevention program. On [DATE] at 11:00am, S1DON stated the staff would know which residents were on the fall prevention program because the residents would have a yellow star beside the name plate on their door. On [DATE] at 11:05am, observation of the nameplate on the door of sample #6 revealed no star on it to identify to staff that he was at high risk for falls. On [DATE] at 11:08am, S1DON confirmed there should be a yellow star on the nameplate of resident #6 to identify him to staff as high risk for falls. Review of the facility policy revealed fall risk assessments were to be completed at the time of admission. The facility incident/accident follow-up policy only stated the resident would be monitored each shift for the next 72 hours and it should be documented in the resident's record. On [DATE] at 11:00am, interview with #S1DON and #S2Administrator confirmed there was no other policy requireing frequent assessment and closer supervision after a fall. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. The plan of removal read as follows; 1. The fall risk assessment was completed for resident #6. The DON/ADON will review fall risk assessments for all residents to ensure that they are completed. The DON/ADON will complete fall risk assessments for any residents not having a fall risk assessment. The DON will inservice nursing staff on completion of fall risk assessments for all residents upon admission and quarterly. The DON will monitor fall risk assessments for all new admits and residents due for quarterly staffing weekly x4 then monthly thereafter to ensure that fall risk assessments are completed for all residents upon admission and on a quarterly basis and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 2. The care plan for resident #6 was updated to include fall risk interventions. The DON/ADON will review the care plans for all residents at high risk for falls to ensure that risk for falls/fall prevention measures are addressed in the careplan. The care plan will be updated for each resident following a fall by the ADON and new measures implemented with each fall as needed by the ADON. The DON will inservice nursing staff on proper completion of care plans to include risk for falls/fall prevention measures. The DON will monitor the careplan for all new admits and residents due for quarterly staffing weekly x 4 then monthly thereafter to ensure that risk for falls/fall prevention measures are addressed in the careplan and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] 3. Fall prevention measures were implemented for resident #6. The DON/ADON will review all residents at high risk for falls to ensure that appropriate fall prevention measures are implemented. The DON/ADON will implement any additional fall prevention measures for residents at high risk for falls as needed. The DON will inservice nursing staff on proper implementation of fall prevention measures for all residents at high risk for falls. The DON will monitor all residents deemed to be high risk for falls weekly x4 then monthly thereafter to ensure that all residents at high risk for falls have appropriate fall prevention measures implemented and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 4. Resident #6 will be monitored/assessed thoroughly after any fall. The Administrator/DON will update/enforce the Fall Prevention Policy to include appropriate assessment/monitoring/fall prevention for all residents following a fall and residents at risk for falls. The DON/ADON will monitor all residents with falls weekly x4 then monthly thereafter to ensure that appropriate assessment/monitoring is completed and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 5. A fall risk symbol was placed on resident #6's room name plate. The DON/ADON will review all residents at high risk for falls to ensure that fall risk symbols are posted on their room name plate to alert nursing staff that resident is high risk for falls. The DON/ADON will place fall risk symbol on the resident's name plate if needed for any resident at high risk for falls. The DON will monitor weekly x4 then monthly thereafter all residents at high risk for falls to ensure that they have a fall risk symbol on their name plate and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] II. Based on record review or interview, the facility failed to be administered in a manner that utilized its resources effectively by failing to develop policies regarding the frequency that residents should be visualized. Findings: Review of the medical record of resident #3 revealed she was found dead in her room by a housekeeper on [DATE] at 8:05am. Staff #S1DON conducted an investigation of the incident and it was determined that neither #S2LPN nor #S3CNA had checked on resident #3 throughout the entire night shift. On [DATE] at 10:45am, staff #S1DON stated the night nurse should have checked on the resident within an hour of starting her shift at 11:00pm. She also stated there was no specific policy requiring residents to be visualized at least once per shift.

Based on record review and interview, the facility failed to complete fall risk assessments on admission for 2 sampled residents (#4 and #6) that had a history of [REDACTED]. Sampled resident #4 was placed in immediate jeopardy when she was admitted to the facility and the facility failed to assess her as being at high risk for falls and failed to implement measures to prevent falls. On [DATE] sample #4 had 4 falls, sustained a head injury and was transferred to the hospital and died that day of her injuries. The facility failed to increase supervision to prevent further falls and failed to assess the resident for injury including on-going neuro checks. The immediate jeopardy for sample #4 was removed when she was transferred to the hospital. The deficient practice continues at a level H. Sampled resident #6 was placed in immediate jeopardy when he was admitted to the facility and the facility failed to assess him as being at high risk for falls and failed to implement measures to prevent falls. On [DATE] sample #6 had a fall, sustained a head injury and was transferred to the hospital. The immediate jeopardy remains in effect for this resident due to the facility's failure to provide additional supervision and failure to implement interventions to prevent future falls. On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. Findings: 1. Sample #4 was an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Sample #4 was admitted from another nursing home with documentation that she had a history of [REDACTED]. On [DATE] at 1:20pm interview with staff #S4LPN, ADON, confirmed that sample #4 was admitted with a history of falls and head injuries. She stated the resident was admitted from another nursing home. Record review of the Admission Nurse Documentation dated [DATE] at 4:40pm for sample #4 revealed that falls was not identified. Review of the Psychological Functioning area scored sample #4 as disoriented to time, place and person. Record review revealed there was no fall risk assessment done on admission or at any time after admission. Review of the facility policies for Fall Prevention Program revealed that "A Fall Risk Assessment will be completed on all residents upon admission, quarterly and with a significant change in condition". Record review of the incident and accident reports revealed that on [DATE] sample #4 had falls as follows: 1. On [DATE] at 12:15am the resident was found laying on her back on the floor beside her bed. The nursing intervention initiated was "encourage resident to call for assistance when ambulating". Review of the resident's record revealed no monitoring of the resident's condition after the fall 2. On [DATE] at 6:30am the resident was found sitting on the floor against the bed. The nursing intervention initiated was "bed alarm placed on bed, and the resident requested to take it off the bed , it made her nervous and she did not want it." The alarm was not placed on the bed. Review of the resident's record revealed no monitoring of the resident's condition after the fall 3. On [DATE] at 3:00pm blood was found on the floor in front of the recliner in her room, the Fall Investigation Report stated the resident had fell and got herself back up without telling staff. The nursing intervention initiated was to "move her to a room close to the nurses station and the resident refused to change rooms, make a physician appointment on [DATE]". Review of the resident's record revealed no monitoring of the resident's condition after the fall 4. On [DATE] at 3:40pm the resident was found on the floor in her bathroom. The Incident & Accident report stated the resident had a contusion to the back of the head on the left side. The nursing interventions initiated was to "send the resident to the local hospital emergency room ". Record review of the Incident and Accident reports and the nurses notes, all dated [DATE], revealed no monitoring of the resident's condition, no ongoing neurological assessments and no increased supervision was done after any of the 4 falls that day. Review of the local hospital records of a Cat Scan dated [DATE] at 5:35pm revealed sample #4 had a large subdural hematoma involving the right hemisphere with marked shift of the midline structures from right-to-left. The resident progressed to a coma state, was transferred to a higher level of care hospital where she died that day. On [DATE] at 11:00am, interview with S1DON and S5Administrator confirmed sample #4 was admitted with a history of falls and had no fall risk assessment done on admission as required by the facility policies. They also confirmed that no fall prevention measures were initiated or care planned. They confirmed that after each of the resident's 4 falls on [DATE] there were no fall interventions initiated, no monitoring to assess the resident's condition after a fall and no care planning to prevent further falls. Review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition, Chapter 63, pages 1913 - 1920, "The importance of ongoing assessment and monitoring of the brain-injured patient cannot be overstated. As soon as the initial assessment is made, the use of a neurologic flow chart is started and maintained. Changes in a brain-injured patient can occur minutes, hours or days after the head injury. Elderly patients must be assessed very carefully. Even given similar mechanisms of injury, an elderly person will often suffer more severe injury than a young person and will often recover more slowly and with more complications." On [DATE] at 11:30am, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal and documentation that the plan had been implemented. The plan of removal read as follows; 1. The fall risk assessment was completed for resident #6. The DON/ADON will review fall risk assessments for all residents to ensure that they are completed. The DON/ADON will complete fall risk assessments for any residents not having a fall risk assessment. The DON will inservice nursing staff on completion of fall risk assessments for all residents upon admission and quarterly. The DON will monitor fall risk assessments for all new admits and residents due for quarterly staffing weekly x4 then monthly thereafter to ensure that fall risk assessments are completed for all residents upon admission and on a quarterly basis and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 2. The care plan for resident #6 was updated to include fall risk interventions. The DON/ADON will review the care plans for all residents at high risk for falls to ensure that risk for falls/fall prevention measures are addressed in the careplan. The care plan will be updated for each resident following a fall by the ADON and new measures implemented with each fall as needed by the ADON. The DON will inservice nursing staff on proper completion of care plans to include risk for falls/fall prevention measures. The DON will monitor the careplan for all new admits and residents due for quarterly staffing weekly x 4 then monthly thereafter to ensure that risk for falls/fall prevention measures are addressed in the careplan and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE] 3. Fall prevention measures were implemented for resident #6. The DON/ADON will review all residents at high risk for falls to ensure that appropriate fall prevention measures are implemented. The DON/ADON will implement any additional fall prevention measures for residents at high risk for falls as needed. The DON will inservice nursing staff on proper implementation of fall prevention measures for all residents at high risk for falls. The DON will monitor all residents deemed to be high risk for falls weekly x4 then monthly thereafter to ensure that all residents at high risk for falls have appropriate fall prevention measures implemented and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 4. Resident #6 will be monitored/assessed thoroughly after any fall. The Administrator/DON will update/enforce the Fall Prevention Policy to include appropriate assessment/monitoring/fall prevention for all residents following a fall and residents at risk for falls. The DON/ADON will monitor all residents with falls weekly x4 then monthly thereafter to ensure that appropriate assessment/monitoring is completed and will immediately inservice nursing staff if any problems are noted. Date of completion: [DATE] 5. A fall risk symbol was placed on resident #6's room name plate. The DON/ADON will review all residents at high risk for falls to ensure that fall risk symbols are posted on their room name plate to alert nursing staff that resident is high risk for falls. The DON/ADON will place fall risk symbol on the resident's name plate if needed for any resident at high risk for falls. The DON will monitor weekly x4 then monthly thereafter all residents at high risk for falls to ensure that they have a fall risk symbol on their name plate and will inservice nursing staff immediately if any problems are noted. Date of completion: [DATE]