Every finding on record at Asbury Place at Maryville

Based on facility policy review, medical record review and interview, the facility failed to administer comfort medications to 1 resident (Resident #118) of 4 residents sampled for hospice service. The facility failure resulted when the facility failed to transcribe the hospice physician's orders timely into the medical record and Licensed Practical Nurse (LPN) T failed to administer the medications as prescribed on the morning of [DATE] when Resident #118 was actively dying. The facility neglected to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress when they failed to administer medications as ordered by the hospice physician which resulted in actual HARM to Resident #118. The findings include: Review of the undated facility policy titled, Guidelines for Pain Management, undated, revealed .It is the intent of the facility to promote resident .comfort .and preserve dignity in an ongoing effort to promote .quality for their lives .one aspect .is to maintain .effective pain management .Methods to Achieve Goals of Pain Management .Promptly and accurately recognizing and assessing pain .using pain medications .Any orders received from the physician to include medications .will be implemented and carried out .The resident will be placed on enhanced monitoring .Pain will be managed in a timely manner to include pain that is new and of a recent onset .Any orders implemented .will be carried out .Nursing observation is critical to pain assessment .especially in non-verbal residents .these include, but are not limited to .facial expressions .body movements .crying out or moaning .rigidity .sweating .increased heart rate .Any time a nurse is contacted regarding a prn [as needed] medication request .the time the nurse was contacted will be documented in the resident's medical record . Review of the undated facility policy titled, Medication Administration, revealed .To ensure resident medications are administered in a timely manner .The reason for not administering .medication will be documented . Review of the Hospice Care Plans and Interdisciplinary Team Notes for Resident #118 dated [DATE] (resident on hospice services prior to admission to the facility) revealed the resident received hospice services with diagnoses including Neurocognitive Disorder with Lewy Bodies, Unspecified Dementia, and Do Not Resuscitate Status. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE] with diagnoses including Neurocognitive Disorder with Lewy Bodies (a degenerative neurological disorder), Encounter for Palliative Care, Anxiety Disorder, and Adult Failure to Thrive. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #118 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and required moderate to maximal assistance with activities of daily living. Review of the Hospice Client Coordination Notes and Corresponding Physician Orders for Resident #118 dated [DATE] (time of Hospice Nurse arrival to the facility was approximately 10:30 AM), revealed .an expected very short life expectancy of days to one week .near death .utilizes non-verbal indicators of pain .labored tachypnea [labored rapid shallow breathing] 32 breaths per minute [normal respirations 12-20] .Pt [patient-Resident #118] is active [actively dying] .No PO [oral] intake in 2 days .HR [heart rate] tachycardic [elevated] and irregular at 132 BPM [beats per minute] [normal heart rate is 60 to 100 beats per minute] .Temp [temperature] 98.9 .skin is warm, clammy to touch .Visits increased to daily .Morphine Sulfate [a narcotic to relieve severe pain] .Ativan [an anti-anxiety medication used to reduce air hunger and anxiety] .Q [every] 4H [hours] .Morphine Q2H .PRN [as needed] .Hyoscyamine [A medication to reduce secretions] Q4H .DTR [Daughter] present for visit .EOL [end of life] education provided .Report given to facility [LPN T] .POC [plan of care] reviewed .instructed [LPN T] to call [hospice provider] with any questions or concerns . Review of a Hospice Facsimile (Fax) transmission record dated [DATE], marked urgent revealed the written physician orders for Resident #118 were successfully transmitted to the facility and the facility's pharmacy provider at 11:26 AM on [DATE]. Review of the Nurse's Note for Resident #118 dated [DATE] at 2:02 PM, written by LPN T revealed .This nurse [LPN T] went in this morning to check on resident [Resident #118] and checked vital signs .HR .147 .Respirations .32 .Resident has not been eating or drinking .Hospice nurse contacted and had come up here [to the facility] and evaluated resident .Hospice nurse states resident appears to be actively dying .Daughter in room with resident . Continued review of the nurse's note showed no references to medication orders or administration of comfort medications to Resident #118. Review of the Nurse's Note for Resident #118 dated [DATE] at 3:56 PM, written by LPN T revealed .CNA [Certified Nurse Aide] came into nurses' station and informed this nurse [LPN T] she [CNA] thinks the patient [Resident #118] is gone [expired]. This nurse [LPN T] went in to check on the resident [Resident #118] and found no vital signs present .Family at bedside .Hospice notified and nurse [Hospice Nurse] is on the way [to the facility] to pronounce [death] . Review of the Nurse's Note for Resident #118 revealed there was no other documentation related to ongoing monitoring of the resident's change in condition after it was determined by the hospice nurse Resident #118 was actively dying at approximately 11:00 AM on [DATE]. Review of the Medication Administration Record (MAR) for Resident #118 dated [DATE]-[DATE], revealed the hospice orders for Morphine, Lorazepam, and Hyoscyamine, transmitted to the facility at 11:26 AM on [DATE] were not administered to the resident as ordered. During a telephone interview on [DATE] at 7:30 PM, LPN T stated she was previously employed at the facility as a contracted travel nurse in 2025 and worked day shift (7:00 AM to 7:00 PM). LPN T stated she recalled Resident #118, but due to the passage of time could not remember many details about the resident. LPN T stated she contacted the hospice nurse on the morning of [DATE] of Resident #118's change in condition but was unable to recall any additional details. During interview on [DATE] at 8:20 AM, Resident #118's daughter stated on the morning of [DATE] between 8:30 AM and 9:30 AM she observed her mother (Resident #118) with altered mental status, faint moaning, rapid shallow breaths, and appeared to be in distress. Resident #118's daughter also stated the resident's skin was pale, moist to touch and abnormally warm. Resident #118's daughter searched for facility staff on the unit and located LPN T at the nurse's station and asked LPN T if she had assessed the resident. Resident #118's daughter stated she contacted the hospice nurse by text message at 9:56 AM to report the resident's change in condition. Resident #118's daughter stated the hospice nurse arrived at the facility around 10:30 AM (after she sent report of0017 0142the residents change in condition) to assess the resident and informed the daughter the resident was actively dying. Resident #118's daughter waited for the arrival of a family friend prior to leaving the facility to retrieve her children around 12:30 PM and to inform Resident #118's family the resident was actively dying. The family friend remained at the bedside until the daughter returned to the facility around 2:00 PM. The family friend informed Resident #118's daughter nursing staff had not assessed the resident or administered any medication during her absence. Resident #118's daughter stated she went to find LPN T and questioned why Morphine or other medications had not been administered to the resident. Resident #118's daughter stated LPN T informed the medication was awaiting delivery from the facility's pharmacy provider. Resident #118's daughter contacted the hospice nurse to inquire why medications were not available. The hospice nurse informed Resident #118's daughter, medications could be retrieved from the facility's emergency medication stock and administered to the resident. Resident #118's daughter requested LPN T to administer the medications as ordered by hospice and received no response from the nurse. Resident #118 continued to be short of breath, clammy, with facial grimace, head tremors, pale, and appeared to be in pain. Resident #118's daughter stated LPN T did not administer comfort medications to the resident despite her repeated requests. When asked how she felt Resident #118's daughter became tearful, was deeply saddened, and angered by the experience. Resident #118's daughter stated her mother suffered unnecessarily as she passed away. During medical record review and interview on [DATE] at 9:30 AM, the Director of Nursing (DON) confirmed there was no evidence medications ordered on [DATE] by the hospice physician were administered to Resident #118 by LPN T. During a telephone interview on [DATE] at 11:17 AM, the former DON reported she left employment at the facility in 2/2025. The former DON stated the facility-maintained emergency stocks of medications to include Morphine, Lorazepam, and Hyoscyamine. These medications could have been removed from the emergency stock and immediately administered to Resident #118 in accordance with hospice provider orders. During a telephone interview on [DATE] at 7:54 PM, the family friend of Resident #118 who remained at the resident's bedside on [DATE] stated she remained at the bedside for approximately 1.5 hours but could not remember exact times. During the family friend's time at the bedside, she did not witness nursing staff assess or administer medications to Resident #118. During a telephone interview on [DATE] at 10:28 AM, the Hospice Nurse recalled Resident #118's case in detail. The Hospice Nurse stated she was notified by Resident #118's daughter by text message on the morning of [DATE] of the resident's decline. The Hospice Nurse stated she had not been notified by staff at the facility of Resident 118's decline. The Hospice Nurse stated she assessed Resident #118 and determined the resident was in pain, with elevated vital signs, and was actively dying. The Hospice Nurse contacted the Hospice Physician immediately, obtained orders for comfort medications and informed the family at bedside of Resident #118's condition. The Hospice Nurse stated she met with LPN T and advised the LPN Resident #118 was actively dying, required PRN medications for comfort, and specifically instructed LPN T on the comfort medication regimen. The Hospice Nurse provided verbal orders to LPN T and advised the LPN to obtain comfort medications from the facility stock and administer the medications immediately. Further interview revealed after Resident #118's death, representatives of the hospice service met with the facility former DON, former social worker, and former Administrator and expressed their concerns LPN T had not followed hospice orders and did not assess Resident #118 between the initial hospice visit on the morning of [DATE] at approximately 10:30 AM and the resident's death at approximately 3:56 PM. The Hospice Nurse confirmed failure to administer comfort medications to Resident #118 caused harm to the resident and in her professional judgement caused the resident to .die in agony .

Based on facility policy review, observations, and interviews, the facility failed to maintain safe food storage in the dietary department and failed to maintain fully operational equipment which had the potential to affect 115 residents. The findings include: Review of the facility policy titled, Sanitation and Food Safety, Labeling and Dating undated, revealed .Leftovers and open foods shall be clearly labeled .With date food item is to be discarded .Food items to be labeled and dated include items prepared in house and food items that are opened and stored for later use .7 day shelf life including date of preparation .label includes .Name of food item .discard date (to be discarded at end of 7th day .30 day shelf life, usually applies to items that are shelf stable until opened .label includes .name of food item .discard date .(i.e.[example] opened 4/30 .discard 5/30) .Discard date cannot exceed use by date stamped on product by manufacturer . During observations of the dietary department dry storage space on 1/12/2026 between 11:05 AM and 11:35 AM revealed the following: 1. One plastic container half full labeled toasted oats undated and available for resident use. 2. One plastic container half full of dry cereal labeled with a use by date of 12/25/2025 and available for resident use. 3. 12, 12.7 ounce packs of flour tortilla shells with a use by date of 8/7/2025 and available for resident use. 4. 5, 16 ounce bags of vanilla wafers with a use by date of 11/11/2025 and available for resident use. 5. 1 sealed half-gallon freezer bag half full with no label identifying the content of the bag or the expiration date and available for resident use. 6. A plastic container half full of coconut flakes with a use by date of 8/3/2025 and available for resident use. 7. A plastic container of breading flakes with approximately a half cup remaining, labeled with a use by date of 3/18/2025 and available for resident use. 8. A plastic container half full of dry macaroni noodles, dated 9/15/2025, no open date, no use by date, no label identifying product and available for resident use. Further observation of the walk-in refrigerator on 1/12/2026 between 11:45 AM and 11:50 AM revealed: 1. A half pan of shredded Parmesan cheese with an open date of 12/30/2025, no use by date, and available for resident use. 2. A 1-gallon freezer bag which contained a half block of American Cheese with no label or use by date and available for resident use. During an observation and interview on 1/12/2026 at 11:53 AM in the food preparation areas revealed the facility's deep fryer was not operational. The Dietary Manager stated the deep fryer had been out of use since October 2025, and she was uncertain when it would be repaired or replaced. Continued observations revealed a reach in refrigerator that was not operational. The Dietary Manager stated the reach in refrigerator had been out of service for several months and she was uncertain when the reach in refrigerator would be replaced or repaired due to manufacturer parts availability issues.During an interview on 1/12/2025 at 11:56 AM, the Dietary Manager confirmed foods observed and noted above had been stored improperly and was in violation of the facility policy.

Based on facility policy review, medical record review, and interviews, the facility failed to obtain consent for administration of psychotropic medications for 4 residents (Resident #11, #92, #4 and #77) of 5 residents reviewed for unnecessary medications.The findings include: Review of the facility policy titled, Psychotropic Drugs Usage, undated, revealed .Any resident receiving psychotropic medication will have a signed informed consent for the use of the medication .Informed consents will be initiated upon the start of the medication usage . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Panic Disorder, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and received antipsychotic medication. Review of the Physician's Orders for Resident #11dated 1/12/2026, revealed an order for Quetiapine (a medication used to treat psychotic disorders) 25 mg (milligram) by mouth once daily at bedtime. Review of the Medication Administration Record (MAR) dated 1/1/2026 to 1/14/2026, revealed Resident #11 received Quetiapine 25 mg daily. Review of the medical record revealed no consent form for the use of Quetiapine for Resident #11. Review of the Physician's Orders for Resident #11 dated 1/12/2026, revealed an order for Olanzapine (a medication used to treat psychotic disorder) 5 mg tablet by mouth twice daily. Review of the MAR for Resident #11 dated 1/1/2026 to 1/14/2026, revealed the resident received Olanzapine 5 mg daily. Review of the medical record revealed no consent form for the use of Olanzapine for Resident #11. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Cognitive Communication Deficit, and Lack of Coordination. Review of a quarterly MDS assessment dated [DATE], revealed Resident #92 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment and received antipsychotic medication. Review of the Physician's Orders for Resident #92 dated 9/19/2025, revealed an order for Quetiapine 12.5 mg by mouth once daily at bedtime. Review of the MAR for Resident #92 dated 1/1/2026 to 1/14/2026, revealed the resident received Quetiapine 12.5 mg daily. Review of the medical record revealed no consent form for the use of Quetiapine for Resident #92. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance and Depression. Review of a significant change MDS assessment dated [DATE], revealed Resident #4 scored a 00 on the BIMS assessment which indicated the resident had severe cognitive impairment and received antipsychotic medication. Review of the Physician's Orders for Resident #4 dated 11/26/2025, revealed an order for Olanzapine 5 mg by mouth two times daily. Review of the MAR for Resident #4 dated 1/1/2026 - 1/14/2026, revealed the resident received Olanzapine 5 mg twice daily. Review of the medical record revealed no consent form for the use of Olanzapine for Resident #4. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Bipolar Disorder, Major Depressive Disorder, Psychosis, and Mood Affective Disorder. Review of the annual MDS assessment dated [DATE], revealed Resident #77 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact and received antianxiety medication. Review of the Physician Order's for Resident #77 dated 3/5/2025, revealed an order for Alprazolam (a medication used to treat Anxiety) 0.5 mg two times daily. Review of the MAR for Resident #77 dated 1/1/2026 to 1/14/2026, revealed the resident received Alprazolam 0.5 mg two times daily. Review of the medical record revealed no consent form for the use of Alprazolam for Resident #77. During an interview on 1/14/2026 at 1:49 PM, the Assistant Director of Nursing confirmed there were no psychotropic medication consent forms in place for Residents #11, #92, #4, and #77.

Based on Long- Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, medical record review, and interviews, the facility failed to ensure Minimum Data Sets (MDS) assessments were accurate for 2 residents (Resident #6 and Resident #84) of 26 residents reviewed for MDS assessments.The findings include: Review of the Long- Term Care Facility RAI 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .1, yes .if PASRR Level II screening determined that the resident has a serious mental illness .Active Diagnosis in the Last 7 Days .Check all that apply .I0600 .Heart Failure .ACTIVE DIAGNOSES Physician- documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status .medical treatments, nursing monitoring, or risk of death during the 7- day look- back period .Check off each active disease . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Post-Traumatic Stress Disorder, Dementia, Bipolar Disorder, and Intellectual Disabilities. Review of a Notice of PASRR (Pre-admission Screening and Resident Review) Level II Outcome dated 3/26/2021, revealed .The Individual [Resident #6] meets criteria for having a diagnosis of .Intellectual disability .Serious mental illness . Review of an annual MDS (Minimum Data Set) assessment dated [DATE], revealed .is resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition .No . Review of a Nurse Practitioner progress note for Resident #6 dated 12/18/2025, revealed .resident has a history of major depressive disorder, bipolar disorder, anxiety disorder, dementia, and trauma/stressor related disorder diagnoses, and intellectual disability . During an interview on 1/14/2026 at 9:15 AM Licensed Practical Nurse MDS Coordinator confirmed Resident #6 had a level II PASRR and the annual MDS assessment dated [DATE] was inaccurate. Review of the medical record revealed Resident #84 admitted to the facility on [DATE] with diagnoses including Acute on Chronic Diastolic Congestive Heart Failure and Pulmonary Hypertension. Review of a Medication Administration Record (MAR) for Resident #84 dated 11/20/2025 through 11/30/2025, revealed the resident had received Furosemide (Lasix) (a medication used to treat fluid retention) 80 mg (milligram) one tablet two times a day from 11/20/2025 through 11/30/2025. Further review revealed the resident had received metolazone (a medication used to treat fluid retention) 5 mg one tablet by mouth in the morning from 11/21/2025 through 11/30/2025. Continued review revealed the resident had received metoprolol tartrate (a medication used to treat high blood pressure) 50 mg one tablet by mouth two times a day from 11/20/2025 through 11/30/2025. Review of the Nurse Practitioner progress note for Resident #84 dated 11/21/2025, revealed .Past Medical History .Diastolic Congestive Heart Failure XXX[AGE] year-old .history of diastolic congestive heart failure .recent hospitalization November 14th through 19th [11/14/2025 through 11/19/2025] .for acute diastolic congestive heart failure exacerbation .Assessment & [and] Plan .Diastolic congestive heart failure .continue diuresis with Lasix 80 mg twice daily and metolazone .Continue metoprolol . Review of an admission MDS assessment dated [DATE], revealed Resident #84 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Heart Failure was not checked to reflect the active diagnosis for Resident #84 and the resident received Diuretics (medications that reduce fluid retention). Review of an Order Summary Report for Resident #84 dated 1/14/2026, revealed the following Physician's orders including Furosemide 80 mg give one tablet by mouth two times a day (start date 11/20/2025), Metolazone 5 mg give one tablet by mouth in the morning (start date 11/21/2025), and Metoprolol Tartrate 50 mg give one tablet by mouth two times a day (start date 11/20/2025). During a medical record review and interview on 1/14/2026 at 1:33 PM, Registered Nurse (RN) MDS Coordinator reviewed the Nurse Practitioner progress note dated 11/21/2025, the Order Summary report dated 1/14/2026, the MAR dated 11/20/2025 through 11/30/2025, and the admission MDS assessment dated [DATE] for Resident #84. The RN MDS Coordinator confirmed the admission MDS assessment for Resident #84 dated 11/27/2025 was inaccurate and did not reflect Resident #84's active diagnosis of Heart Failure.

Based on facility policy review, medical record review, and interviews, the facility failed to develop a comprehensive care plan for 2 residents (Resident #6 and Resident #84) of 26 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/23/2021, revealed .The Comprehensive Care Plan will .expand on the resident's risk, goals and interventions using the 'person centered' Plan of Care approach for each resident that includes measurable objectives and time tables to meet the resident's medical, nursing, physical functioning, mental, and psychosocial needs .The Comprehensive Care Plan will be finalized within 7 days of completion of the Full Comprehensive MDS [Minimum Data Sets] assessments .the Comprehensive Care Plan will include any Specialized Services or Specialized Rehab Services recommended to be provided as a result of any Pre-admission screening and Resident Review (PASARR) that may have been completed .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum .The facility may need to review that care plans more often based on changes in the resident's condition and/or newly developed health/ psycho-social issues .The MDS staff will attend the Morning .meetings where in-depth review of the 24 Hour Report(s) since the prior Morning .meeting are reviewed and discussed as well as new or changed orders, new admissions, readmissions, falls and other pertinent circumstances .They will then see that the care plans for these residents are revised and updated as necessary . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Post-Traumatic Stress Disorder, Dementia, Bipolar Disorder, and Intellectual Disabilities. Review of a Notice of PASRR (Pre-admission Screening and Resident Review) Level II Outcome dated 3/26/2021, revealed .The Individual [Resident #6] meets criteria for having a diagnosis of .Intellectual disability . Serious mental illness . Review of the comprehensive care plan revised 6/17/2025, revealed Resident #6's Level II PASRR was not addressed. During an interview on 1/14/2026 at 9:15 AM, the Licensed Practical Nurse MDS Coordinator confirmed the comprehensive care plan for Resident #6 did not reflect the residents Level II PASRR status. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including Acute on Chronic Diastolic Congestive Heart Failure and Pulmonary Hypertension. Review of a Medication Administration Record (MAR) for Resident #84 dated 11/20/2025 through 11/30/2025, revealed the resident had received Furosemide (Lasix) (a medication used to treat fluid retention) 80 mg (milligram) one tablet two times a day from 11/20/2025 through 11/30/2025. Further review revealed the resident had received metolazone (a medication used to treat fluid retention) 5 mg one tablet by mouth in the morning from11/21/2025 through 11/30/2025. Continued review revealed the resident had received metoprolol tartrate (a medication used to treat high blood pressure) 50 mg one tablet by mouth two times a day from 11/20/2025 through 11/30/2025. Review of the Nurse Practitioner progress note for Resident #84 dated 11/21/2025, revealed XXX[AGE] year-old .history of diastolic congestive heart failure .recent hospitalization November 14th through 19th [11/14/2025 through 11/19/2025] .for acute diastolic congestive heart failure exacerbation .Assessment & [and] Plan .Diastolic congestive heart failure .continue diuresis with Lasix 80 mg twice daily and metolazone .Continue metoprolol . Review of the comprehensive care plan for Resident #84 revised 12/2/2025, revealed the resident's active diagnosis of Heart Failure was not outlined or addressed on the comprehensive care plan. During an interview on 1/14/2026 at 1:33 PM, the Registered Nurse (RN) MDS Coordinator confirmed the comprehensive care plan revised 12/2/2025 for Resident #84 did not address Resident #84's active diagnosis of Heart Failure.

Based on facility policy review, medical record review, observation and interviews, the facility failed to revise the care plan for 1 resident (Resident #3) and failed to provide resident and resident representative notice of quarterly care plan conferences for 1 resident (Resident #105) of 26 residents reviewed for care plans. The findings include:Review of the facility's policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/23/2021, revealed .The facility Social Service Director or designee will notify the resident's responsible party either by letter or a phone call to inform them of the scheduled Care Plan Conference to include the date and time .these notifications will be documented for reference .An IDT [Interdisciplinary Team] note will be made in reference to the meeting to include who attended, significant changes addressed and date and time of the meeting .Review of the facility's policy titled, Care Plans, dated 8/2022, revealed .Care Plans will be updated as changes occur. New problems will be added as they occur as well as resolved when the problem is no longer a problem for the resident . Review of the Medical Record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease Stage 5, Dependence on Renal Dialysis, Presence of Vascular Implants and Grafts.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment indicating the resident was cognitively intact and received dialysis. Review of the Physician Progress Note for Resident #3 dated 1/12/2026, revealed .remove Perma Cath [catheter placed for short term dialysis treatment] and place AV fistula [a surgically created connection between an artery and a vein for hemodialysis] . Further review revealed the Perma Cath is scheduled to be removed on 1/22/2026. Review of a comprehensive care plan for Resident #3 dated 1/13/2026, revealed the care plan had not been revised to include the Perma Cath.During an observation on 1/12/2026 at 1:30 PM, revealed Resident #3 had a Perma Cath in place to the right chest. During an interview on 1/13/2026 at 4:35 PM, the Licensed Practical Nurse MDS Coordinator confirmed Resident #3's care plan did not reflect the presence of a right chest Perma Cath or interventions. During an interview on 1/14/2026 at 4:00 PM, the Regional Registered Nurse confirmed the care plan had not been updated to reflect the Perma Cath. Review of the medical record revealed Resident #105 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Dementia, and Anemia. Review of the medical record revealed a care plan meeting progress note dated 3/24/2024, revealed the interdisciplinary team reviewed medications, diet, and activities. Further review revealed the resident representative was invited to attend the meeting. Continued review revealed no documentation of additional care plan meeting since 3/24/2024. During an interview on 1/13/2026 at 8:49 AM, Resident #105's daughter stated .the family would like more involvement in care planning of mom's care . During an interview on 1/14/2026 at 8:25 AM, the Social Services Director stated she was unable to locate quarterly care plan meeting notes for Resident #105.During an interview on 1/14/2026 at 9:20 AM, the Regional Registered Nurse confirmed there were no quarterly care plan meeting notes/documentation or invitations since 3/18/2024 for Resident #105.

Based on facility policy review, medical record review, observations, and interview the facility failed to ensure medications were secured in 1 resident (Resident #43's) room of 115 resident rooms observed.The findings include: Review of the facility Policy titled, Medication Self Administration, undated, revealed .Policy .Residents who request to self-administer drugs will be assessed at the time of admission or thereafter to determine if the practice is safe, based on the results of the Resident Assessment Self-administration Tool .The assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, and Metabolic Encephalopathy. Review of a PPS (Prospective Payment System) Part A discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the Physician's Orders for Resident #43 revealed the resident had no order to self-administer medications. During an observation in Resident #43's room on 1/12/2026 at 12:54 PM, revealed a 0.5 fluid ounce of liquid tear eye drops (medication used to treat dry eyes) on the bedside table, a bottle of extra strength 125 mg (milligram) gas relief tablets, and a bottle of antacid chews 750 mg (medication used to treat heartburn) on the bathroom sink. Further observation revealed a bottle of antifungal powder miconazole nitrate 2% (percent) (medication used to treat skin infections) in the window seal. During an observation and interview in Resident #43's room on 1/13/2026 with Registered Nurse (RN) A at 10:45 AM, revealed a 0.5 fluid ounce of liquid tear eye drops on the bedside table, a bottle of extra strength 125 mg gas relief tablets, and a bottle of antacid chews 750 mg on the bathroom sink. Further observation revealed a bottle of antifungal powder miconazole nitrate 2% in the window seal. RN A stated Resident #43 did not self-administer medications and confirmed the medications were unsecured in the resident's room.

Based on facility policy review, medical record review, observation, and interviews the facility failed to follow Enhanced Barrier Precautions (EBPs) for 1 resident (Resident #15) of 22 residents reviewed for EBPs. The findings include: Review of the facility policy titled, .GUIDELINES for ENHANCED BARRIER PRECAUTIONS---[Enhanced Barrier Precautions] (EPBs), dated 12/2022, revealed .An extension of Personal Protective Equipment---[Personal Protective Equipment] (PPE) .It is the policy of the facility to ensure that additional and appropriate PPE .is utilized .to prevent the spread of Multidrug-resistant Organisms also known as MDRO .Examples of High Contact Resident Care Activities at which time EBP is to be practiced are .Changing Briefs .Resident Care Activities with a resident who has a known MDRO [bacteria resistant to multiple antibiotics making infections difficult to treat] .use .gloves and gowns . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Type 2 Diabetes, Major Depressive Disorder, and Anxiety Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 scored a 7 on the Brief Interview for Mental Status which indicated the resident had moderate cognitive impairment and was always incontinent of urine and bowel. Review of the Physician's Order for Resident #15 dated 12/1/2025, revealed .Enhanced Barrier Precautions .[Multi Dose Resistant Organism] MDRO . During an observation on 1/13/2025 at 5:24 AM, revealed Resident #15's entrance way door had an EBP precaution sign posted which stated .PROVIDERS AND STAFF MUST .Wear gloves and gown for the following High-Contact Resident Care Activities .Changing briefs . Further observation revealed Certified Nursing Assistant (CNA) E entered the room, applied gloves, did not apply a gown, provided incontinence care to the resident (changed brief), removed the gloves, exited the room, and sanitized the hands. During an interview on 1/13/2025 at 5:33 AM, CNA E stated .I didn't realize she [Resident #15] had a sign [EBP] .I feel like the signs are old . CNA E confirmed she did not wear a gown when she changed Resident #15's brief. During an interview on 1/13/2025 at 8:19 AM, the Assistant Director of Nursing stated when a resident was on EBP's staff were expected to wear a gown when providing incontinent care including changing briefs. The ADON confirmed CNA E failed to follow the facilities infection control policy when she failed to wear a gown during incontinence care for Resident #15.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to report allegations of abuse, to include injuries of unknown origin, to Adult Protective Service (APS) or law enforcement for 2 resident investigations (Residents #3 and #4) of 6 resident investigations reviewed for abuse and injury of unknown origin. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated [DATE], showed .It is the policy of this facility to prevent resident abuse .When an allegation .of abuse is reported to the Administrator .Administrator will notify the following .Law Enforcement Officials .Physical abuse involving physical injury .on a resident by a staff member . Resident #3 was admitted to the facility on [DATE] and had diagnoses including Age-Related Osteoporosis with Current Pathological Fracture, Disorders of Bone Density and Structure, and Unspecified Dementia. The resident expired on [DATE]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 had severe cognitive impairment and exhibited no moods or behaviors. Review of a nurse's note dated [DATE] at 12:38 PM, showed Licensed Practical Nurse (LPN) #6 was called to Resident #3's room by Certified Nursing Assistant (CNA) #6 to assess a swollen right thigh.The LPN noted the resident expressed pain with grimacing,which appeared to subside after movement stopped. The Nurse Practitioner (NP) was notified and a new order was obtained to transfer the resident to the emergency department for further evaluation. Review of an xray from a local hospital dated [DATE], showed Resident #3 had a displaced fracture of the right proximal femur. Review of a facility investigation report dated [DATE], showed the facility reported to the state agency Resident #3 had an injury of unknown origin. The investigation showed a nurse observed the resident was grimacing in pain, and the NP was notified. New orders were given for the resident to be sent to an acute care hospital, and radiology studies showed a right femur fracture. The resident's emergency contact and ombudsman were notified. House-wide skin assessments and interviews were performed, the investigation concluded that the injury was a pathological fracture. There was no evidence that APS or law enforcement was notified of the injury of unknown origin after the fracture was discovered on [DATE]. During a telephone interview on [DATE] at 1:50 PM, the Medical Director stated Resident #3 was assessed on [DATE], and the fracture was determined to be a pathological fracture and not the result of abuse. Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Gastroesophageal Reflux Disease, and Hypertensive Heart Disease. Review of an annual MDS assessment dated [DATE], showed Resident #4 had severe cognitive impairment and required extensive assistance of 1 staff member with bed mobility, hygiene, and total dependance of 2 staff members with toileting. The resident was at risk for skin injury and had no moods or behaviors. Review of a nursing note dated [DATE] at 7:30 PM, showed Resident #4 alleged that a male CNA squeezed her arm. A skin assessment was performed and a bruise was identified on the left inner forearm. The Director of Nursing (DON), abuse coordinator, provider on call, and family were notified. Review of a facility investigation report dated [DATE] at 7:30 PM, showed there was an allegation of resident physical abuse by staff when a bruise was discovered on the left inner forearm. The male staff member who had recently cared for the resident was suspended pending an investigation which included resident interviews, house wide skin checks and witness statements. The facility investigation showed they were unable to substantiate the allegation of abuse. The report showed no evidence that APS or law enforcement was notified of the allegation of abuse on [DATE]. During an interview on [DATE] at 3:12 PM, the DON stated after an allegation of abuse or discovery of an injury of unknown origin, the staff would notify her, and she would make sure there was protection for the resident, an investigation was started, and the facility would notify police and APS. The DON confirmed that there was no evidence that law enforcement or APS was notified for Resident #3 after discovery of an injury of unknown origin or Resident #4 after an allegation of abuse.

Based on facility policy review, medical record review, and interviews the facility failed to follow physician orders for 1 resident (Resident #19) of 4 residents reviewed. The findings include: Review of the facility policy titled, Medication Administration Errors, undated, showed .A medication error is any preventable event .Failure to administer an ordered dose unless resident refused .Drug product not delivered to the resident .facility in a timely manner . Resident #19 was admitted to the facility on [DATE] at 5:30 PM, with diagnoses including Atrial Flutter, Chronic Kidney Disease, Coronary Atherosclerotic Disease, and Thrombus (blood clot) in Left Lower Leg. Review of Resident #19's physician orders dated 10/11/2023, showed the resident had an order for Eliquis (blood thinner) 5mg (milligram), Atorvastatin (cholesterol medication) 40mg, Metoprolol Titrate (Blood Pressure medication) 50mg, Risperidone (antipsychotic medication) 1mg, Tamsulosin (medication used for urinary retention) 0.4 mg, Enalapril Maleate (blood pressure medication) 2.5mg, and Mirtazapine (antidepressant medication) 45mg. All medications were to be administered at hour of sleep (HS). Review of Resident #19's Medication Administration Record (MAR) dated 10/11/2023, showed the resident did not receive the HS medications. Further review showed the reason documented was the medications were not available. Review of the medical record showed Resident #19 left the facility Against Medical Advice (AMA) on 10/12/2023 (1 day after admission). Review of the Inventory Summary, undated, for the Pyxis (electronic medication dispensing machine) showed the following medications were available for use: Atorvastatin 40 mg, Risperidone 1mg, and Tamsulosin 0.4 mg. The other scheduled HS medications were not available in the Pyxis. During an interview on 2/7/2024 at 12:16 PM, the Director of Nursing (DON) reviewed Resident #19's MAR dated 10/11/2023 and confirmed the resident had not received the 7 medications ordered to be administered at HS. The DON stated her expectation was the nurse would notify the physician if medications were unavailable. During an interview on 2/7/2024 at 1:40 PM, the Medical Director (MD) was provided a list of Resident #19's bedtime medications and stated there would not be any adverse effect from missing the medications.

Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment which had the potential to affect 85 residents in the facility. The findings include: Review of the facility policy titled, Sanitation & Infection Control Cleaning Schedules dated 1/2016 showed, .Cleaning schedules are used to maintain high levels of sanitation in the Food & Nutrition Services department and serve to assign tasks to various kitchen staff members .The daily cleaning schedule delineates how often equipment must be cleaned and whose responsibility it is to clean each specific piece of equipment or area .the responsible person initialing the item after cleaning has occurred . Review of the weekly cleaning lists dated 8/27/2022 - 9/10/2022 showed the supervisor had not reviewed the weekly cleaning log to ensure it was accurate from 8/27/2022 - 9/10/2022. During an observation and tour of the kitchen with the Dietary Manager (DM) on 9/11/2022 at 10:20 AM, showed the following: 1. The collection bins (2) mounted under both of the gas cook top stove was found with dry brown food debris build up and burnt black food debris filling both bins. 2. The grill was found with dried brown spatter of food debris on various areas on the front of the equipment. 3. The plate at the bottom of the convection oven had dried brown food debris covering the face plate. 4. A storage rack contained 2 stacked pans found to have yellow food debris on the outside of the pans. 5. 1 of 2 fans in the freezer was found to be covered with ice and non-operational. The ceiling of the freezer was covered with ice. During an interview on 9/11/2022 at 11:15 AM, the chef and DM confirmed the kitchen equipment and 2 stacked steam table pans found with food debris were unsanitary available for use. The DM stated the chef was ultimately in-charge to oversee the sanitary operation of the kitchen. The DM confirmed the equipment cleaning schedule was incomplete. The chef stated .we need to do a deep clean .

Based on facility policy review, medical record review, and interview the facility failed to ensure the provider received and responded to a pharmacy recommendation for 1 resident (Resident #52) of 5 residents reviewed for unnecessary medications. The findings include: Review of a facility policy titled Medication Drug Regimen Review dated 1/1/2017, showed .The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible .The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report .will provide the Director of Nursing [DON] Services with a written, signed and dated copy of the report, listing the irregularities found and recommendations for their solutions . Resident #52 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Seizures, Depression, Anxiety, Chronic [CONDITION(S)] (irregular heart rhythm) Hypertension, Type 2 Diabetes Mellitus, and Chronic Pain Syndrome. Review of the medical record showed monthly medication regimen reviews were performed February 2022 - August 2022 for Resident #52. Review of a Note To Attending Physician/Prescriber dated 6/30/2022, showed the Consultant Pharmacist recommended Resident #52's dual administration of [MEDICATION(S)] (diuretic) and [MEDICATION(S)] (medication used to treat hypertension) be evaluated. The provider's response was not documented on the note and the note was unsigned and undated by the provider. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #52 had severe cognitive impairment and had received diuretics during the last 7 days. Review of a Physician Order Sheet dated September 2022, showed Resident #52 was receiving [MEDICATION(S)] 7.5 milligrams (mg) (started on 10/11/2021) and [MEDICATION(S)] 20 mg daily (started on 6/16/2022). During a telephone interview on 9/13/2022 at 4:29 PM, Nurse Practitioner (NP) #1 stated Resident #52 was stable on his current medications and there had been no concerns with his prescribed medications of [MEDICATION(S)] and [MEDICATION(S)]. The NP stated she did not recall receiving the June 2022 pharmacy recommendation for Resident #52. During an interview on 9/14/2022 at 8:50 AM, the Director of Nursing (DON) stated all pharmacy recommendations were to be addressed promptly by the provider upon completion of the monthly medication regimen review. The DON confirmed the June 2022 pharmacy recommendation for Resident #52 had not been addressed by the provider.

Based on medical record review, observation, and interview, the facility failed to include the resident's need for dentures on the comprehensive care plan for 1 resident (Residents #16 ) of 21 residents reviewed for care plans. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's comprehensive care plan, dated 6/29/2021, showed .Effective .to the present time .unable to tolerate regular textured foods . The goal was for the resident to tolerate a mechanically altered diet with no chewing or swallowing issues. The care plan did not address the resident had ill-fitting dentures on admission and did not address the lost of dentures the last week of March 2022 . During a telephone interview on 9/14/2022 at 4:40 PM, the Speech Therapist (ST) stated Resident #16 had ill-fitting dentures when the ST treated the resident from 2/2022 thru 3/10/2022. The ST stated the food texture was modified to help the resident eat with or without her dentures. The interview revealed the ST had been made aware the dentures were missing the last week of March and still had not been located. The ST stated Resident #16 was able to eat the modified food texture diet without dentures. During an interview on 9/14/2022 at 4:50 PM, the Minimum Data Set (MDS) Coordinator, she confirmed Resident #16's had dentures on admission and the loss of dentures in March 2022 was not included in the comprehensive care plan.

Based on medical record review, observations, and interviews, the facility failed to follow a physician's order for an indwelling urinary catheter (a tube inserted into the bladder that remains in place to provide continuous urinary drainage) for 1 resident (Resident #69) of 21 residents reviewed. The findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's order dated 3/21/2022, showed .change .cath [catheter] monthly .18F [french] [size of catheter] 20 cc [cubic centimeter] [balloon volume used to maintain placement] . Review of a quarterly Minimum Data Set assessment dated [DATE], revealed Resident #47 was cognitively intact and had an indwelling urinary catheter. Review of Resident #47's comprehensive care plan dated 8/19/2022, revealed the resident had an indwelling urinary catheter. Review of a Clinical Note Report dated 8/22/2022, showed .Existing [indwelling urinary catheter] d/c'd [discontinued]. New 16F with 5 ml [milliliters] balloon inserted . (physician order was for a 18 F with 20 cc balloon). Review of a Clinical Note Report dated 8/28/2022 showed .Existing [indwelling urinary catheter] d/c'd [discontinued]. New 16F with 30 ml [milliliters] balloon inserted . (physician order was for a 18 F with 20 cc balloon). During an interview on 9/13/2022 at 7:43AM, Licensed Practical Nurse (LPN) #3 confirmed the nursing note showed a new 16F with 5 ml balloon had been inserted on 8/22/2022 and the catherter had been changed to a 16F with 30 ml balloon on 8/28/2022 due to leakage. LPN #3 confirmed the nurse had not followed the physicians order for the catheter on 8/22/2022 at 8/28/2022. During an interview on 9/13/2022 at 2:25 PM, the Director of Nursing (DON) stated Resident #47 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the nurse had not followed the physician's order for the urinary catheter on 8/22/2022 and 8/28/2022.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a fall intervention was functioning prior to a fall, failed to implement an intervention and failed to take immediate action to reduce the risk of a fall for 2 residents (Residents #20 and #55) of 3 residents reviewed for accidents/falls. The findings include: Review of the facility's policy titled Accident and Incident Report-Resident, revised on 1/1/2017, showed .Purpose .assure appropriate follow-through on all accidents . Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Major Depressive Disorder. Review of a facility fall Occurrence Report dated 5/18/2022, showed .Fall .Visually Observed [Resident #20] on Floor .lying on Rt. [right] side .with no injury .Intervention .pressure alarm to chair while up . Review of Resident #20's comprehensive care plan with an effective date of 5/19/2022, showed .Pressure sensor alarm to wheelchair while up in chair . Review of a Nursing Clinical Notes Report dated 6/5/2022, showed .[CNA #1] reported this Pt [patient] was laying on the floor in front of her w/c [wheelchair] .Pt. with a laceration on her right eyebrow and was laying face down with her right arm partially under her .Pt. denied any other injury .cold wet cloth placed onto her eyebrow .bleeding stopped immediately .neuro checks initiated .Received new order .to send to .ER [emergency room ] for eval[evaluation] .receives [name of a blood thinning medication] . Review of a facility fall Occurrence Report dated 6/5/2022, showed .Fall .Visually Observed [Resident #20] on Floor .Found by .[Certified Nursing Assistant [CNA] #1] .Laying face down with her right eyebrow on the floor, right arm partially under her .Alarm .not sounding . Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Further review showed the resident was totally dependent of 2 staff members with bed mobility and transfers. During a telephone interview on 9/12/2022 at 7:30 PM, LPN #2 stated she was the nurse on shift when Resident #20 fell on [DATE]. The resident had a small cut over the right eyebrow. The physician was notified and wanted the resident sent to the ER for evaluation due to the resident received anti-coagulant medication and hit her head on the floor. During a telephone interview on 9/13/2022 at 10:21 AM, CNA #1 stated she worked on 6/5/2022 when Resident #20 fell from the wheelchair and hit her head. The resident had a pressure alarm in place which was not sounding at the time of the fall. During an interview on 9/13/2022 at 3:18 PM, the DON confirmed Resident #20 had a fall on 5/18/2022 and the new intervention put in place was for a pressure alarm be placed in the wheelchair. The resident fell on [DATE] from the wheelchair and the pressure alarm did not sound and was not working properly. Resident #55 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Anxiety Disorder, [CONDITION(S)], and Age-Related Physical Debility. Review of a comprehensive care plan dated 5/11/2020, showed .at risk for falls related to weakness .Nurses and CNAs [certified nursing assistants] to make sure dycem [a non-slip mat] to w/c [wheelchair] prior to getting the resident up . Review of a quarterly MDS assessment dated [DATE] showed Resident #55 was unable to complete a BIMS assessment. The resident required extensive assistance of 2 staff members with bed mobility and 1 staff member for transfers. Resident #55 had 1 fall with no injury and used a chair and bed alarm daily. Review of a Fall Occurrence Report report dated 1/29/2022 showed a nurse and CNA entered Resident #55's room after an alarm sounded. The resident was observed lying in the floor on the left side in front of the wheelchair. Resident #55 had an unwitnessed fall and .Immediate Actions Taken .Therapy Eval requested to evaluate for Rock N Go chair [a high backed wheelchair that tilts and rocks] . Review of a physician's order dated 1/29/2022 showed an order for physical therapy (PT) to evaluate for .Rock-N-Go . chair. Review of an Occupational Therapy (OT) Evaluation & Plan of Treatment dated 2/9/2022 showed Resident #55 was assessed for appropriate wheelchair to prevent fall risk due to sliding out, excessive leaning, or attempts to get up unassisted. The resident was placed in a Rock-N-Go chair on a trial basis. During an observation on 9/12/2022 at 4:09 PM, Resident #55 was seated in a wheelchair with no Dycem in place. During an observation and interview on 9/13/2022 at 10:29 AM, CNA #1 and Registered Nurse (RN) #1 assisted Resident #55 to stand from the wheelchair and found no Dycem in place. RN #1 confirmed the care plan fall intervention of Dycem in the wheelchair had not been implemented. During an interview on 9/13/2022 at 10:54 AM, PT Manager stated PT order for evaluation was received on 1/29/2022 after Resident #55's fall. The PT manager confirmed an evaluation was not conducted until 2/9/2022 (11 days after the fall on 1/29/2022), and the PT order to evaluate the resident after the fall was not an immediate action to prevent a fall. During an interview on 9/13/2022 at 3:45 PM, the DON confirmed Resident #55's fall intervention of the Dycem to be placed in the wheelchair had not been implemented and the PT/OT evaluation for Rock-N-Go chair was not an immediate action to prevent a fall for Resident #55.

Based on facility policy review, medical record review, observation, and interview, the facility failed to start antibiotics timely upon receipt of lab results, resulting in a delay of care for a Urinary Tract Infection ([CONDITION(S)]) for 1 resident (Resident #69) of 2 residents reviewed for catheters. The findings include: Review of the facility's policy titled, Medication Administration and Disposition, with an effective date of 11/18/2021, showed .Resident Medications will be administered appropriately and in a timely manner . Resident #69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's nurse's note dated 8/26/2022, states .lower abdominal [abdomen] distended upon assessment, this nurse performed bladder scan [used to determine amount of urine in the bladder], 1005ml [mililiters] present via [by] scan .[name of Medical Doctor (MD)] .notified, this nurse received verbal orders to replace indwelling .catheter [tube inserted into the bladder to drain urine] and have NP [Nurse Practitioner] to assess resident the following day, this nurse followed orders .catheter placed [indwelling urinary catheter was inserted into the resident's bladder] .resident tolerated well, 1350ml of urine collected over intervals, husband notified of catheter placement . Review of Resident #69's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .please obtain today . Review of Resident #69's Urinalysis dated 8/31/2022, showed the urine was collected on 8/31/2022 at 3:00 PM and the test results were available to the facility on [DATE] at 5:12 PM. Review of Resident #69's NP Progress Note dated 8/31/2022, showed .The patient is being seen today to F/U [follow up] on recent UA that was obtained over the weekend showing positive for bacteria. We are awaiting the C&S results .The patient has a .catheter in place .Will start on antibiotic therapy once UA results are up for viewing .ASSESSMENT/PLAN .Urinary tract infection: Awaiting C&S results . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 11 indicating the resident had moderate cognitive impairment. Resident #69 had an indwelling urinary catheter. The resident had a Urinary Tract Infection and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #69's nurse's note dated 9/1/2022, showed .Resident urine lab result came with a showing of a (+) [positive for] [CONDITION(S)]. NP is aware of the lab results .NP ask that we keep monitoring the Cather [catheter] and notify her if it get [gets] worse . Review of a NP Progress Note dated 9/1/2022, showed .We are still awaiting C&S results on UA for [CONDITION(S)]. The patient is afebrile [without fever]. Negative for urinary symptoms .[indwelling urinary catheter] .is draining appropriately .ABDOMEN: Soft, nontender, and nondistended . [Indwelling urinary catheter] .draining yellow urine .ASSESSMENT/PLAN .Urinary tract infection: Awaiting C&S results. Continue with .[indwelling urinary catheter] . Review of Resident #69's Urine C&S dated 9/4/2022, showed the results were available to the facility on [DATE] at 7:54AM. Review of Resident #69's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's care plan dated 9/9/2022, showed .Actual infection .[CONDITION(S)] .Administer ATB [antibiotics] as ordered . During an interview on 9/13/2022 at 8:49 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #69 had a UA ordered on 8/31/2022 and antibiotics were started on 9/9/2022. The LPN stated it was not typical for it to take this much time for antibiotics to be started following a UA order. The LPN stated the resident did not have symptoms and had not had a fever. During a telephone interview on 9/13/2022, at 3:32 PM, NP #1 stated when the nurses received the culture results, they were to call the NP or MD to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .there needs to be urgency with that . The NP confirmed if the facility received the culture results on 9/4/2022, the nurse should have called and got antibiotics started that day. The NP confirmed that the culture was resulted on 9/4/2022, antibiotics had not been started until 9/9/2022, and there was a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of the facility's policy, review of facility documentation, review of medical records, observation and interview, the facility failed to replace 1 resident's dentures (Resident #16) of 21 residents reviewed. The findings include: Review of the facility policy Dental Services, dated 8/30/2017, showed .Facility must promptly, within 3 days, refer residents with lost or damaged dentures for dental services .If .loss .likely due to facility negligence, the facility shall be responsible for .replacement cost . Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Concern Log dated 3/29/2022, showed Resident #16's .dentures are missing . Review of the Minimum Data Set (MDS) assessment dated [DATE], showed Resident #16 had a Brief Interview for Mental Status (BIMS) assessment score of 3, indicating severe cognitive impairment, required supervision and set-up for eating, weighed 114 pounds and did not have significant weight loss. Review of the Nutritional Progress Note, dated 9/8/2022, showed the Registered Dietician listed Resident #16 as a moderate risk level for weight loss. Review showed the resident was weighed weekly and had an average monthly weight of 116 from January through September 2022. Observation on 9/14/2022 at 9:00 AM, of Resident #16, showed she remained in the dining area and was eating a snack cake without dentures. During an interview on 9/13/2022 at 11:50 AM, the Social Worker and the Director of Nursing (DON) confirmed the facility was responsible for Resident #16's lost dentures. Interview confirmed the Social Worker, hired 8/1/2022, received the complaint from the daughter-in-law on 8/8/2022, shared the complaint of the missing dentures with nursing at the following morning meeting and believed nursing was responsible to follow up. The DON confirmed Resident #16's dentures had been missing for the previous 5 months without steps taken to replace them and the facility's policy had not been followed.

Based on facility policy review, medical record review, and interview, the facility failed to prevent a significant medication error for 1 resident (Resident #338) of 17 residents reviewed for medications. The findings included: Review of the facility's policy titled, Medication Administration and Disposition, with an effective date of 11/18/2021, showed .Resident Medications will be administered appropriately and in a timely manner . Resident #338 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview 9/12/2022 at 9:46 AM, Registered Nurse (RN) #1 stated (Resident #338) was admitted to the facility on [DATE] at 11:30 AM, nurse stated she returned to work on 9/2/2022 at 7:00 PM. The day shift nurse stated Resident #338 was a new admission. The RN stated the resident had medication orders which had not been sent to the pharmacy. The RN stated the day shift supervisor had been told to complete the admission, and fax the orders to pharmacy. The RN stated the day shift supervisior failed to complete assessment and to fax orders to the pharmacy as instructed by the DON. RN #1 stated there was no MAR for Resident #338 until 9/3/2022. RN #1 confirmed the resident did not receive any medications until 9/3/2022. During an interview on 9/14/2022 at 9:59 AM, the Director of Nursing (DON) confirmed the resident had not received any medications as ordered on 9/1/2022 and 9/2/2022. During a telephone interview on 9/14/2022 at 5:44 PM, the Medical Director stated it was her expectation that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director stated Resident #338 had no adverse effects due to not receiving the medications as ordered on 9/1/2022 and 9/2/2022.

Based on the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, medical record reviews, and interviews, the facility failed to assess 1 resident's status on the Minimum Data Set (MDS) assessment to include an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, showed .The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring . Medical record sources for physician diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 8/3/2022, showed . [Resident #36] is on antipsychotic medication [MEDICATION(S)] DX [diagnosis] of [CONDITION(S)] Disorder [a disorder that affects a person's ability to think, feel and behave clearly] . Review of a Psychiatric Note dated 8/8/2022, showed . [CONDITION(S)] d/o [disorder] . Review of Resident #36's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Active Date .8/8/2022 . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 2 indicating the resident had severe cognitive impairment. The assessment showed no documentation of the active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/13/2022 at 2:21 PM, the MDS Coordinator stated Resident #36 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of facility documentation, medical record review, and interview, the facility failed to resolve a grievance for 1 resident (Resident #16) of 21 residents reviewed grievances. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Inventory of Personal Effects dated 12/28/2021, showed Resident #16's inventory included 2 jackets, 13 nightgowns or pajamas, 1 pair of shoes, 18 pair of slacks, 16 shirts, 1 sweater, and 1 blanket. Review showed an accompanying progress note provided a detailed description of 2 print throws, 8 tops, and 6 pairs of pants. Review of the Concern Log dated 2/22/2022 showed, .Daughter-in-law .reports resident is missing .several items of clothing and blankets . Review of the Minimum Data Set (MDS) assessment dated [DATE], showed Resident #16 had a Brief Interview for Mental Status (BIMS) assessment score of 3, indicating severe cognitive impairment. During a telephone interview on 9/11/2022 with Resident #16's daughter-in-law, she confirmed the grievance report for the missing clothing was filed by her on 2/22/2022. She stated in December 2021, the family provided 5 more new changes of clothing and 2 additional blankets. The daughter-in-law stated she had looked through the laundry and both closets in Resident #16's room and was not able to find any of clothing provided at admission or the replacement clothing purchased in December 2021. Resident #16's daughter-in-law stated there had not been a resolution to the grievance she filed on 2/22/2022. During an interview on 9/13/2022 at 10:15 AM, the Social Worker and the Director of Nursing (DON) confirmed the facility was responsible for Resident #16's laundry, none of the clothing had been located in the laundry department, and confirmed the grievance had not been resolved by the facility.

Based on review of Center for Disease Control and Prevention (CDC) guidelines, facility policy review, review of facility documentation, interview, and observation, the facility Administration failed to implement and monitor effective interventions once aware of employees not reporting symptoms of COVID-19 during the facility screening process and failed to ensure staff compliance with Personal Protective Equipment (PPE) usage to provide a safe and sanitary environment to prevent the development and transmission of infections. The facility had 38 residents and 48 staff test positive for COVID-19. These failures placed 38 residents, including Residents #2, #5, #8, #13 and #26, in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Certified Nursing Assistant (CNA) #1 and CNA #2 provided direct care to residents while having symptoms related to COVID-19 and when staff were observed entering droplet precaution rooms without wearing appropriate PPE. The facility's failure had the potential to affect all 97 residents residing in the facility. The Administrator was notified of the Immediate Jeopardy on 2/25/2022 at 5:00 PM. The facility was cited Immediate Jeopardy at F-835, F-865, and F-880 at a scope and severity of L. The Immediate Jeopardy was removed onsite and was effective 1/2/2022 - 3/1/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/2/2022. The corrective actions were verified onsite on 3/2/2022. The findings include: Review of the CDC COVID-19 Guidelines titled Symptoms of COVID-19 dated 2/22/2021, showed .People with COVID-19 have a wide range of symptoms reported - ranging from mild symptoms to severe illness .Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19: cough .sore throat .congestion or runny nose . Review of the facility's Nursing Policies/Procedures Manual for Managing Covid 19 undated, showed .To provide guidance in caring for Covid-19 positive or suspected positive residents and providing a safe environment for residents and associates .each employee is responsible to answer the screening questions truthfully and it is the associate's responsibility to notify their supervisor immediately if they become ill throughout the shift. Associates should report directly to their assigned units . Continued review showed .protective eyewear .Don prior to entrance of facility along with a surgical mask or higher grade .isolation gowns .don only for transmission based precautions (contact, droplet and/or airborne) .facemasks .Universal use is recommended .Do not pull off nose/mouth and wear around neck or around head or remove . Review of the facility guidelines [NAME] Covid 19 Testing Guidelines, dated 10/19/2021, showed .associates vaccinated and unvaccinated with signs or symptoms must be tested .associates with symptoms onset while at work, are expected to notify their supervisor and leave the building as quickly as possible, while donning appropriate PPE . Certified Nursing Assistant (CNA) #1 worked with COVID-19 symptoms on 1/1/2022 and 1/2/2002, and received a positive COVID-19 test result on 1/2/2022. CNA #2 worked with COVID-19 symptoms on 1/9/2022 and received a positive COVID-19 test result on 1/9/2022. During an interview and review of the facility's COVID-19 outbreak investigation documentation with the Infection Control Preventionist (ICP) on 2/14/2022 at 10:45 AM, the ICP confirmed an outbreak investigation started after she learned CNA #1 worked a full shift with COVID-19 symptoms and was observed without appropriate PPE on 1/1/2022. CNA #1 reported to work again while symptomatic on 1/2/2022 and received a positive COVID-19 test result the same day. Continued interview confirmed anyone who entered the facility was required to screen for COVID-19, including all staff, visitors, vendors, and contractors. The screening process required anyone who entered the facility have their temperature taken and were required to report signs and symptoms of illness including cough, congestion, and/or runny nose. The screening questions were to be answered on an App using either a personal cell phone or a facility tablet. Once the questions were answered, a pass or fail screen was to be shown to the facility screener prior to entry. The screener was to document the information on a Temp Logs and Surveillance Checks form. If the person failed the screening, an email was automatically generated and sent to the ICP. Facility documentation review showed CNA #1 was not listed on the Temp Logs and Surveillance Checks on 1/1/2022 and had passed the facility screening on 1/2/2022 (CNA #1 denied any symptoms of COVID-19). On 1/2/2022, the ICP .immediately started an outbreak investigation .put the 2 units where [CNA #1] worked in droplet precautions [used to prevent the spread of pathogens that are passed through respiratory secretions] .started outbreak testing the next day .[CNA #1] is no longer an employee .was dishonest on screening .she had a sore throat .congestion .thought it was just allergies .no fever .[CNA #1] visited .friends on different floors .inappropriately wearing PPE .was told [CNA #1's] mask was down .shield was up .did contact tracing .on 1/4/2022 and 1/6/2022, residents became symptomatic .found more positives as we continued to test . During an observation and interview on 2/14/2022 at 2:12 PM, CNA # 4 entered a droplet precautions room without a gown or gloves and turned off the call light, performed hand hygiene, and left the room. Interview with CNA #4 confirmed the CNA did not don a gown or gloves prior to entering a droplet precautions room (gown and gloves are required PPE for droplet precautions) .I know basics .if not doing direct care I do not need a gown .gloves .I sanitized .that is just my understanding as a CNA . During a telephone interview on 2/16/2022 at 6:10 PM, CNA #1 confirmed .Only thing I had 1/1/2022 .was my nose was stopped up .I was aware of it January the 2nd .my congestion was gone .what I experienced was nothing in the COVID guidelines .I didn't feel bad .little tickle in my throat .itch in ear .no fever .shortness of breath .diarrhea .vomiting .no coughing .no sneezing .all I had was congestion .I went to the main building .checked in .then I drove to Chestnut [facility unit] .both days . During an interview on 2/17/2022 at 11:00 AM, the ICP confirmed while rounding on 1/2/2022, the ICP observed CNA #2 not wearing a mask while feeding a resident. Continued interview confirmed on 1/9/2022, CNA #2 received a positive COVID-19 test and was observed working while symptomatic. The ICP confirmed CNA #2 reported to have .sniffles .sinuses . The ICP confirmed CNA #2 did not report the symptoms on the facility screening questionnaire. During an observation and interview on 2/22/2022 at 10:07 AM, Registered Nurse (RN) #3 enter a droplet precaution room without donning a gown or gloves. Interview with RN #3 confirmed she failed to don appropriate PPE prior to entering a droplet precautions room (quarantined resident) .I had ran and got this [a pen] .to write on the whiteboard .I am a good nurse .I can't believe I just did that . During an interview on 2/22/2022 at 10:41 AM, Laundry Aid #1 confirmed she came to work sometime in January 2022 with COVID-19 symptoms including sinus issues .been to doctor .was negative .feel better .took sinus medication .worked .next day .was positive [for COVID-19] . During an interview on 2/22/2022 at 1:08 PM, the ICP confirmed PPE compliance and screening was discussed during morning meeting after the outbreak .with department heads .talked about the importance of truthful staff .manager's responsibility .ensure communication to their staff .pulled education .from these individuals .they thought nothing of it .it's not like I am not doing an effective job .because people can't control their truthfulness . Continued interview confirmed prior to the facility's COVID-19 outbreak on 1/2/2022, all staff had been educated on hire and periodically during the pandemic on the facility screening process and how to report symptoms of illness. The ICP confirmed she would audit screening logs if there was a concern with a specific staff member not screening in prior to their shift but does not document it. Further interview confirmed the ICP did not pull the screening logs for CNA #1. Continued interview confirmed audits for PPE compliance were last completed on 2/11/2021 and no concerns were identified. On 10/19/2021, staff had been educated on universal eye protection and CDC changes regarding COVID-19 testing, masking, and appropriate PPE use. Further interview confirmed no additional processes were in place prior to the outbreak to monitor staff compliance/adherence to PPE usage and/or the facility's screening process .3 people who are dishonest .we educate .and reeducate .can't control them being dishonest .educate these are the symptoms .I don't know how else I can make people do the right thing .I can't . During an interview on 2/22/2022 at 4:38 PM, CNA #2 confirmed on 1/2/2022 .my mask was on my ear [dangling from the ear and not covering the face] .didn't have my shield with me . Continued interview confirmed CNA #2 reported to work on 1/9/2022 with COVID-19 symptoms .did not know with Omicron it was like a cold .I have sinuses and allergies and asthma .I have medicine I take .realize now . During an interview on 2/25/2022 at 11:34 AM, the Interim Director of Nursing (DON) confirmed she was aware CNA #1 failed to don appropriate PPE and worked with symptoms of COVID-19 .I believe it [outbreak] can be tracked and trended back to that 1 associate .I know [ICP] reached out to the state .to get instruction on what they needed to do .started education across the board .spoke in person with a lot of staff .what to do .who to call .[ICP] covered the education .donning and doffing audits .hand washing audits .no way to ever know what you are doing works .until you know you have a problem .you don't know you have a problem until a problem comes up .bottom line is out of 100 people there will always be those 5 people that are going to do what they want to do . During a telephone interview on 2/25/2022 at 12:04 PM, the Administrator confirmed she was responsible for oversight of the facility and staff and confirmed .contact tracing .that was primarily [the ICP's] arsenal .the screening process was in place .understood associates fill out that .I trusted [ICP] to do the contact tracing . The Administrator confirmed she was made aware of the ICP's conclusions after contact tracing connected the current outbreak back to CNA #1 and CNA #2 .an employee lied .an associate .a person lied .I can tell you that .I can just tell you the system is the system .can't stop people from lying .we can temp .screen .ask them questions .temp when they leave . Continued interview confirmed the Administrator was not aware of staff non-compliance with PPE .made aware yesterday .QAPI meeting .2/21/22 .I know infections were discussed .can't recall if the outbreak was specifically discussed at this point . When asked about the facility's effort to correct staff non-compliance, the Administrator confirmed the facility was .tracking trending and making sure anybody that identifies with symptoms and/or if a questionnaire is not done .they are turned away .if it is an employee .yes they are asked to leave .if they don't follow infection control protocol they are asked to leave .there is a process that [the ICP] managed .I defer to [ICP] on all of those questions .if an employee fails to do that or lies on a form .it's terrible .the system works if the employees follow it . Facility corrective actions included: Corrective Action 1: Education to the Administrator by the Vice President of Operations on the use and application of the screening tool when associates enter the healthcare center. On 2/25/2022, the Vice President of Operations initiated education with the Administer on the current associate Screening Tool (records signs and symptoms, COVID-19 exposure, etc) to be completed when associates enter the facility. On 3/2/2022, the surveyor reviewed the education, Inspection for Screening Tool, and in-service sign in sheet which validated the corrective action plan. On 3/2/2022, the surveyor validated the corrective actions onsite through interviews with the Administrator. The Administrator was able to verbalize understanding of the Screening tool and was able to verbalize understanding of steps or actions to take in the event any staff or associate presented with a fever or illness while on duty. The Administrator was also able to verbalize understanding of the facility's Inspection for Screening audit tool, when to utilize the audit, and with whom to report the findings. Corrective Action 2: The Administrator and/or designee will provide education to all associates who staff the screening area on the use and application of the screening tool when associates/visitors/contractors enter the healthcare center. On 3/2/2022, the surveyor reviewed the in-service education sign-in sheet dated 2/25/2022 and entitled Screening Tool Use and Application. The sign in sheet had been signed by the 4 facility screeners and observation of documentation validated the associates/staff received the mandatory education in-services prior to returning to work. The facility's noncompliance at F-835 continues at a scope and severity of F for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-880.

Based on review of facility policy, review of the Facility Assessment, review of facility documentation, interview, and observation, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program to identify issues related to infection control and prevention and develop plans of action for breaches in infection control and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns. Failure of the QAPI Committee placed 38 residents in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when COVID-19 symptomatic staff provided direct care to residents and staff failed to follow Personal Protective Equipment (PPE) requirements for the mitigation and control of COVID-19 in the facility. The facility had 38 residents and 48 staff members test positive for COVID-19 from 1/2/2022 through 2/10/2022. The facility's failure had the potential to affect all 97 residents residing in the facility. The Administrator was notified of the Immediate Jeopardy (IJ) on 2/25/2022 at 5:00 PM. The Immediate Jeopardy was removed onsite and was effective 1/2/2022 - 3/1/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/2/2022. The corrective actions were verified onsite by a surveyor on 3/2/2022. The findings include: Review of the facility's Quality Assurance Performance Improvement policy dated 1/1/2014, showed .to provide ongoing, data driven assessment of care and services and team driven projects to promote improvement .to make decisions and guide our day-to-day operations. Decisions are made based on data, which includes the input and experience of associates, residents and families . Review of the Facility assessment dated ,d+[DATE] through 11/2021, showed .Our community conducts an infection control risk assessment which evaluated and determined the risk or potential vulnerabilities within the resident population and the surrounding community .review mid-year resulted in deficiencies cited .we conduct daily surveillance for Covid 19 of all people entering the building to include temperature checks, questions related to Covid 19 symptoms, travel, practicing physical distancing and PPE .we have a 'see something say something' program ensuring everyone shares with their supervisors anything, they believe may not be a good practice. Thus, keeping the entire team throughout the campus on alert to always practice appropriate infection control practices. We have educated our teams many times in various ways about infections including Covid 19 .PIP [Performance Improvement Project] Plan - Surveillance .screening of anyone entering the building on campus .ensuring PPE is used appropriately .test according to guidelines . Review of the facility's COVID-19 outbreak investigation documentation showed Certified Nurse Assistant (CNA) #1 worked a full shift with COVID-19 symptoms and was observed without appropriate PPE on 1/1/2022, and later received a positive COVID-19 test result on 1/2/2022. Continued review showed CNA #2 was observed without appropriate PPE on 1/2/2022 and worked with COVID-19 symptoms on 1/8/2022 and 1/9/2022, and later received a positive COVID-19 test result on 1/9/2022. Further review showed from 1/4/2022 through 2/10/2022, 38 residents tested positive for COVID-19, including 3 unvaccinated residents and 4 residents not up to date with COVID-19 vaccinations, and 48 staff members tested positive for COVID-19. During an interview on 2/14/2022 at 10:45 AM, the Infection Control Preventionist (ICP) confirmed the facility had a .large . COVID-19 outbreak after CNA #1 and CNA #2 worked with COVID-19 symptoms, did not report their symptoms on the COVID-19 screening questionnaire (a required questionnaire that prompts staff, visitors, vendors and/or contractors to answer questions related to COVID-19 symptoms, recent travel, pending COVID-19 test result, or exposures prior to entry into the facility) and were observed without appropriate PPE. During an observation and interview on 2/14/2022 at 2:12 PM, CNA #4 entered a droplet precautions room (used to prevent the spread of pathogens that are passed through respiratory secretions and requires use donning gown and gloves) without a gown or gloves. During interview with CNA #4, the CNA stated because he did not provide direct resident care, a gown and gloves were not required. During a telephone interview on 2/16/2022 at 6:10 PM, CNA #1 confirmed on 1/1/2022, she worked an entire shift with symptoms of COVID-19 .my nose was stopped up .what I experienced was nothing in the COVID guidelines .I didn't feel bad .little tickle in my throat .itch in ear .no fever .all I had was congestion .I went to the main building .checked in .then I drove to Chestnut [facility unit] .both days . During a telephone interview on 2/16/2022 at 7:30 PM, CNA #14 stated .staff [were] slack in wearing [isolation] gowns if [the] room does not have box [PPE disposal box] .50% of the time we will [don and doff appropriate PPE] .if I see it .let them know they are on droplet precautions .don't tell on other CNAs .so no I don't report it . During an interview on 2/17/2022 at 11:00 AM, the ICP confirmed she attended monthly QAPI meetings and provided infection control related updates. Continued interview confirmed .everyone in the facility was responsible for monitoring the effectiveness of the education and training related to COVID-19 screening and PPE compliance .I round on the floor everyday .we were not doing audits [just prior to the outbreak] . The ICP confirmed education was provided to staff on 7/28/2021, 7/30/2021, and 10/19/2021, regarding mask use, eye protection, and Centers for Disease Control (CDC) updates related to COVID-19 testing. The ICP confirmed after the outbreak on 1/3/2022 and 1/6/2022, staff were educated on demonstration, knowledge, and understanding of appropriate PPE to prevent the spread of infection, transmission-based precautions, including droplet precautions, proper handwashing, and current data on infection prevention and hospital acquired infections. The ICP confirmed the facility conducted PPE and hand washing audits on 2/11/2022 and found no concerns. However, no additional documentation was provided that monitored the effectiveness of the education related to the facility screening process or an understanding of COVID-19 signs and symptoms and what to do should staff become symptomatic .outside of notes I don't have any [evidence] .verbal education .on the spot education . During a telephone interview on 2/17/2022 at 12:36 PM, the Medical Director confirmed she was aware of the facility's COVID-19 outbreak .[ICP] reports to me daily .when we do have a positive .she notifies me directly .we discuss that in Risk [meeting] .we are following CDC guidance .anyone in quarantine .or suspected or active .full PPE .[ICP] does contact tracing .so they did that initially [placed everyone in quarantine] .we had concerns for close contact with everyone in the building .I agreed with her .until we could confirm widespread activity .I didn't have any issues with that .I know we were able to trace [the outbreak] to a visitor .[the visitor] not forthright with active symptoms and tested positive .the facility is going by guidance .shift monitoring .was heightened .the screening is quite robust .we have done education .I assisted with [ICP] at some point .not aware of any staff non-compliance .I observe people wear PPE .I feel pretty good about it .I think [ICP] is auditing pretty regularly .reports in QAPI .being done .no need to question it .last [QAPI] meeting was January 10th .[ICP] gives infection control report .we review other infection issues . Continued interview confirmed she was not aware of the results of the ICP's contact tracing which concluded staff coming to work symptomatic and not donning appropriate PPE had led to the outbreak. During an observation and interview on 2/22/2022 at 10:07 AM, Registered Nurse (RN) #3 entered a droplet precaution room without donning a gown or gloves. Interview with RN #3 confirmed she should have donned appropriate PPE .I can't believe I just did that . During an observation and interview on 2/22/2022 at 10:30 AM, CNA #13 was observed with a face shield not pulled down to cover the face .just came out of the shower. Forgot to put it back on .cooling off . During an interview on 2/22/2022 at 10:41 AM, Laundry Aid # 1 confirmed she worked with symptoms of COVID-19 .felt better after taking sinus medications .next day .tested positive [for COVID-19] . During an interview on 2/22/2022 at 4:38 PM, CNA #2 confirmed on 1/2/2022 .my mask was on my ear [dangling from ear and not covering face] .didn't have my shield with me . Continued interview confirmed CNA #2 reported to work on 1/9/2022 with COVID-19 symptoms .did not know with Omicron it was like a cold .I have sinuses and allergies and asthma .I have medicine I take . During an interview on 2/25/2022 at 11:34 AM, the Interim Director of Nursing (DON) confirmed she became the Interim DON .Sometime in the middle of January . and attended the QAPI meetings on 12/13/2021 and 2/21/2022. Continued interview confirmed she was made aware of CNA #1 and CNA #2 working with symptoms of COVID-19 and non-compliance with PPE .started education across the board .understanding what they are supposed to do [if symptomatic with COVID-19 symptoms] .spoke in person with a lot of staff .[ICP] covered the education . When asked what was done related to staff compliance with the facility's COVID-19 screening guidelines, the Interim DON confirmed .don't have anything to do with screening .bottom line is out of 100 people there will always be those 5 people that are going to do what they want to do . During an interview on 2/25/2022 at 12:04 PM, the Administrator confirmed she became employed by the facility on 2/1/2022, was responsible for facility and staff oversight, and was made aware of the ICP's conclusions after contact tracing connected the outbreak back to CNA #1 and CNA #2. Continued interview confirmed she attended the most recent QAPI meeting on 2/21/2022 .I know infections were discussed .the screening process was in place .understood associates fill out that . Further interview confirmed when asked to provide evidence of the QAPI committee's activities after 2/21/2022, to ensure mitigation efforts to control the spread of COVID-19 had been put into place, including efforts to prevent staff from working with symptoms of illness or to increase staff compliance with PPE, documentation provided showed handwashing and PPE audits were completed on 2/11/2022, however, no further audits had been completed, and no additional evidence was provided. Facility corrective actions included: Corrective Action: The Quality Assurance Performance Improvement Steering committee, which is comprised of but not limited to, the Licensed Nursing Home Administrator, Interim Director of Nursing, Infection Preventionist, and Medical Director will convene an ad hoc meeting to review remedy plan by 3/2/22. On 3/2/2022, the surveyor reviewed the QAPI Ad Hoc Meeting sign in sheet dated 3/2/2022. The sign in sheets had been signed by the Administrator, the ICP, the Interim DON, and the Medical Director. On 3/2/2022, the corrective actions were validated onsite by the surveyor through interviews with the ICP and Interim DON. Both confirmed the topics discussed during the QAPI ad hoc meeting included: the facility's IJ removal plan, a Performance Improvement Project related to PPE compliance, additional staff education, and continued audits/monitoring of infection control related topics. The facility's noncompliance at F-865 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Refer to F-880

Based on review of Centers for Disease Control (CDC) Guidelines, review of the facility's Nursing Policies/Procedures Manual for Managing COVID-19, facility documentation review, interview, medical record review, and observation, the facility failed to prevent COVID-19 symptomatic staff from providing direct care to residents and failed to ensure staff followed Personal Protective Equipment (PPE) requirements for the mitigation and control of COVID-19 in the facility. The facility had 38 residents, including Residents #2, #5, #8, #13 and #26, and 48 staff members test positive for COVID-19 from 1/2/2022 through 2/14/2022. The facility's failure placed 38 residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) and had the potential to affect all 97 residents residing in the facility. The Administrator was informed of the Immediate Jeopardy (IJ) on 2/25/2022 at 5:00 PM. The Immediate Jeopardy was removed onsite and was effective 1/2/2022 - 3/1/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 3/2/2022. The corrective actions were verified onsite by a surveyor on 3/2/2022. The findings include: Review of the CDC COVID-19 Guidelines titled Symptoms of COVID-19 dated 2/22/2021, showed .People with COVID-19 have a wide range of symptoms reported - ranging from mild symptoms to severe illness .Anyone can have mild to severe symptoms. People with these symptoms may have COVID-19: cough .sore throat .congestion or runny nose . Review of the facility's Nursing Policies/Procedures Manual for Managing Covid 19 undated, showed .To provide guidance in caring for Covid-19 positive or suspected positive residents and providing a safe environment for residents and associates .each employee is responsible to answer the screening questions truthfully and it is the associate's responsibility to notify their supervisor immediately if they become ill throughout the shift. Associates should report directly to their assigned units . Continued review showed .protective eyewear .Don prior to entrance of facility along with a surgical mask or higher grade .isolation gowns .don only for transmission based precautions (contact, droplet and/or airborne) .facemasks .Universal use is recommended .Do not pull off nose/mouth and wear around neck or around head or remove . Further review showed COVID-19 positive residents required .complete active monitoring and documentation at least 3 times daily to include .respiratory exam .signs and symptoms (improvement, resolution) .vital signs . Review of the facility guidelines [NAME] Covid 19 Testing Guidelines, dated 10/19/2021, showed .These guidelines are required for use by skilled nursing centers .symptomatic individual identified .associates vaccinated and unvaccinated with signs or symptoms must be tested .associates with symptoms onset while at work, are expected to notify their supervisor and leave the building as quickly as possible, while donning appropriate PPE . Review of the facility's training documentation Covid 19 What You Need to Know (New Hires) undated, showed .Know the symptoms of Covid 19 .cough .sore throat .congestion or runny nose . During an interview and review of the facility's COVID-19 outbreak investigation documentation with the Infection Control Preventionist (ICP) on 2/14/2022 at 10:45 AM, the ICP confirmed an outbreak investigation started after she learned Certified Nurse Assistant (CNA) #1 worked a full shift with COVID-19 symptoms, had not reported the symptoms during screening when she reported to work, and was observed without appropriate PPE on 1/1/2022. CNA #1 reported to work again while symptomatic on 1/2/2022, and later the same day at work received a positive COVID-19 test result. Continued interview confirmed anyone who entered the facility was required to screen for COVID-19, including all staff, visitors, vendors, and contractors. The screening process required anyone who entered the facility to have their temperature taken and were required to report signs and symptoms of illness including cough, congestion, and/or runny nose. The screening questions were to be answered on an App using either a personal cell phone or a facility tablet prior to beginning their scheduled shift. Once the screening questions were answered, a pass or fail screen was to be shown to the facility screener prior to entry in the facility. The screener was to document the information on a Temp Logs and Surveillance Checks form. If the employee failed the screening, an email was automatically generated and sent to the ICP. Facility documentation review showed CNA #1 was not listed on the Temp Logs and Surveillance Checks on the day she worked 1/1/2022, and had passed the facility screening on 1/2/2022, but had reported no symptoms upon screening. On 1/2/2022, the ICP .put the 2 units where [CNA #1] worked in droplet precautions .started outbreak testing the next day .[CNA #1] is no longer an employee .was dishonest on screening .she had a sore throat .congestion .thought it was just allergies .no fever .[CNA #1] visited .friends on different floors .inappropriately wearing PPE .on 1/4/2022 and 1/6/2022, residents became symptomatic .found more positives as we continued to test . Medical record review showed Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Complete Vaccination Record showed the resident was up to date for the COVID-19 vaccination series on 10/21/2021. Review of Resident #2's Rapid [CONDITION(S)] CoV-2 test (rapid test to detect presence of COVID-19 virus) dated 1/4/2022, showed Resident #2 received a positive test result. Medical record review of a Daily COVID-19 Daily Evaluation dated 1/5/2022, showed Resident #2 had a new onset of cough and fatigue. Review of facility documentation showed Resident #2 recovered from COVID-19 on 1/15/2022. Medical record review showed Resident #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation showed Resident #5 was offered the COVID-19 vaccination but declined on 10/29/2021. Medical record review of a Nurse Progress Note dated 1/4/2022, showed .resident c/o [complained of] not feeling well .fatigue, sore neck, and dry cough .[temperature] 100.7 .rapid covid test performed showing positive test . Review of facility documentation showed Resident #5 recovered from COVID-19 on 1/15/2022. Medical record review showed Resident #13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's COVID-19 Vaccination Record showed the resident was up to date for the COVID-19 vaccination series on 10/29/2021. Medical record review of Activities of Daily Living (ADL) documentation showed Resident #13 received care from CNA #1 on 1/1/2022. Review of the facility's COVID-19 outbreak investigation documentation showed Resident #13 tested positive for COVID-19 on 1/6/2022, with symptoms including lethargy, congestion, and a low-grade fever. Review of the COVID-19 Daily Evaluation dated 1/7/2022, showed the resident was asymptomatic for COVID-19. Continued review showed from 1/7/2022 through 1/17/2022, active monitoring and documentation of vital signs, respiratory status, and signs and symptoms or improvement or resolution were not completed at least 3 times daily, as indicated in the facility policy. Review of facility documentation showed Resident #13 recovered from COVID-19 on 1/17/2022. Medical record review showed Resident #26 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's COVID-19 Vaccination Record and facility documentation review showed the resident received one dose of the COVID-19 vaccination on 1/8/2021. Continued review showed the resident declined the second dose of the COVID-19 vaccination due to an adverse reaction. Review of the facility's COVID-19 outbreak investigation documentation showed Resident #26 tested positive for COVID-19 on 1/20/2022, with symptoms including decreased oxygenation and increased confusion. Review of a Nurse Practitioner (NP) COVID Monitoring note dated 1/20/2022, showed .called to the patient's room for a temp [temperature] of 103.8 .and a positive covid test .has been given Tylenol .weak and lethargic. Noted to have Dementia .unable to carry on a conversation with me .right shoulder is red and swollen, and warm to touch. There has been no recent reported injury or fall .I am concerned with infection in that shoulder .has had some hypoxic episodes per nursing staff .currently at 92 [percent oxygenation saturation] on room air .did ask that nursing staff place on oxygen .will send this patient to the hospital as her clinical presentation is significantly different than baseline for her . Review of Resident #26's hospital History and Physical dated 1/20/2022, showed .tested positive for covid 19 virus, febrile and confusion .fever .103.7 .Upon arrival her [oxygenation saturation] were in the mid 80's on room air. Was quite confused and agitated. Received a small dose of [MEDICATION(S)] [antianxiety medication] with improvement of symptoms. Chest x-rays as well as her baseline labs were unremarkable .does not have respiratory distress or evidence of pneumonia . Review of Resident #26's hospital Discharge Summary dated 1/25/2022, showed .primary diagnosis .covid [positive] .hospital course .decision not to treat covid 19 was made on admit as minimal symptoms and on and off room air .CXR [chest x-ray] w/o [without] infiltrates [associated with pneumonia] . Review of facility documentation showed Resident #26 recovered from COVID-19 on 2/10/2022. Review of the facility COVID-19 outbreak investigation documentation showed from 1/4/2022 through 2/10/2022, 38 residents tested positive for COVID-19, including 3 unvaccinated residents and 4 residents not up to date with COVID-19 vaccinations. Review of facility employee documentation dated 1/2/2022 - 2/10/2022, showed staff members who tested positive for COVID-19 included: 12 CNAs, 12 LPNs, 3 RNs, including the Interim DON, 1 Nurse Practitioner, 3 Physical Therapist Assistants (PTAs), the Therapy Director, 1 Certified Occupational Therapist Assistant, 1 Speech Therapist, 3 Dining Staff, 1 Housekeeper, 2 Screeners, 2 Laundry Aides, 1 Information Technician, the Clinical Nurse Educator, 1 Business Office staff member, the Receptionist, 5 Maintenance employees, including the Facilities Director, 1 Transportation Driver, 1 Bistro Staff Member, the Executive Assistant, and 1 Activities Assistant. During an observation and interview on 2/14/2022 at 2:12 PM, CNA #4 entered a droplet precautions room, did not don a gown or gloves, turned off the call light, performed hand hygiene, and left the room. Interview with CNA #4 confirmed the CNA did not don a gown or gloves prior to entering a droplet precautions room (gown and gloves are required PPE for droplet precautions) .I know basics .if not doing direct care I do not need a gown .gloves .I sanitized .that is just my understanding as a CNA . Review of CNA #4's employee file confirmed the CNA received infection control education related to donning and doffing PPE for droplet precaution rooms prior to working in the facility. During a telephone interview on 2/15/2022 at 10:32 PM, CNA #3 stated .[CNA #1] was on the elevator with me and co-worker and [CNA #1] did not have her mask on .back in January .had no mask or no shield or nothing .told our supervisor .immediately . During a telephone interview on 2/15/2021 at 10:37 PM, CNA #1 stated .I took mask off .put mask back on .we have to take a picture on kiosk .in the nurses office I would take my shield off .had my glasses on . CNA #1 denied working with symptoms of COVID-19 .I have asthma .it's nothing symptomatic to COVID .so yeah I am short of breath .when I have asthma I have sinus pressure .when that happens .I get Tylenol sinus .took them went to work .worked whole shift [1/1/2022] no problem .I blew my nose .in the med room .nurse was standing out there .she could see me .trying to sneeze but couldn't come out .asked do you need anything .was going to take another sinus pill .next day [1/2/2022] tested positive . Review of CNA #1's employee file confirmed the CNA received infection control education related to COVID-19 symptoms, the facility screening process, and donning and doffing PPE prior to working in the facility. During an additional telephone interview on 2/16/2022 at 6:10 PM, CNA #1 stated .Only thing I had 1/1/2022 .was my nose was stopped up .I was aware of it January the 2nd .my congestion was gone .what I experienced was nothing in the COVID guidelines .I didn't feel bad .little tickle in my throat .itch in ear .no fever .shortness of breath .diarrhea .vomiting .no coughing .no sneezing .all I had was congestion .I went to the main building .checked in .then I drove to Chestnut [facility unit] .both days . CNA #1 denied being on the elevator without appropriate PPE. During a telephone interview on 2/16/2022 at 7:05 PM, Registered Nurse (RN) #5 stated .[CNA #1] . had a bad scratchy throat [on 1/2/2022] .coughing .I screened her .before she went into work .came back positive on our rapid [COVID-19] screen .don't recall her coughing or complaining [on] 1/1/2022 .I would have done a COVID test on her at that time .asked her how she felt .said not great .we asked her to leave .she had no contact with residents on that day .tested every patient on Chestnut .spoke with [ICP] . During a telephone interview on 2/16/2022 at 7:30 PM, CNA #14 stated .staff [were] slack in wearing [isolation] gowns if [the] room does not have box [PPE disposal box] .50% of the time we will [don and doff appropriate PPE] .if I see it .let them know they are on droplet precautions .don't tell on other CNAs .so no I don't report it . During an interview on 2/17/2022 9:52 AM, Licensed Practical Nurse (LPN) #8 stated .I work at Chestnut .night shift .I was getting off [work] that morning .one of the CNAs .instantly .showing signs and symptoms [COVID-19] on 1/2/2022 .I was getting off .[CNA #1] said she had asthma .that is still a symptom so we tested her .immediately turned positive .right after I swabbed [CNA #1] was going to leave her mask down we told her to pull it up .had a raspy voice .it is still a symptom .said her voice felt itchy .we educated her .sent her home . During an interview on 2/17/2022 at 11:00 AM, the Infection Control Preventionist confirmed after she began rounding on 1/2/2022, she observed CNA #2 feeding a resident without wearing her mask. She confirmed CNA #2 was not symptomatic at the time. Continued interview confirmed after routine weekly testing on 1/6/2022, CNA #2 received a positive COVID-19 result on 1/9/2022. The ICP confirmed at the time she reported the positive results to CNA #2 on 1/9/2022, the CNA appeared to be symptomatic with illness. CNA #2 reported to the ICP it was just .sniffles .sinuses . Further interview confirmed CNA #2 did not report the symptoms on the facility's COVID-19 screening questionnaire. Review of facility documentation for CNA #2 who tested positive for COVID-19 showed CNA #2 worked on 1/8/2022, reported for work on 1/9/2022, symptomatic for COVID-19, and received a positive COVID-19 test result on 1/9/2022. During a telephone interview on 2/17/2022 at 12:36 PM, the Medical Director confirmed she was aware of the facility's COVID-19 outbreak .[ICP] reports to me daily .when we do have a positive .she notifies me directly .we discuss that in Risk [meeting] .we are following CDC guidance .anyone in quarantine .or suspected or active .full PPE .[ICP] does contact tracing .so they did that initially [placed everyone in quarantine] .we had concerns for close contact with everyone in the building .I agreed with her .until we could confirm widespread activity .I didn't have any issues with that .I know we were able to trace [the outbreak] to a visitor .[the visitor] not forthright with active symptoms and tested positive .and then once in the facility .with Omicron .transmission is widespread .anticipated that after the 1st positive .the facility is going by guidance .shift monitoring .was heightened .the screening is quite robust .we have done education .I assisted with [ICP] at some point .not aware of any staff non-compliance .I observe people wear PPE .I feel pretty good about it .I think [ICP] is auditing pretty regularly . Continued interview confirmed the Medical Director was not aware the results of the ICP's contact tracing concluded staff coming to work symptomatic and not donning appropriate PPE had led to the outbreak. During an interview on 2/17/2022 at 1:09 PM, the ICP confirmed visitors did not cause the outbreak .not the original cause .they were outliers on that floor .they had the least number of residents and staff affected by COVID cases .feel like .[CNA #1 and CNA #2] that caused the initial outbreak . Observation on 2/22/2022 at 10:07 AM, on 1 North showed RN #3 enter a droplet precaution room without donning a gown or gloves. Interview with RN #3 confirmed she failed to don appropriate PPE prior to entering a droplet precautions room (quarantined resident) .I had ran and got this [a pen] .to write on the whiteboard .I am a good nurse .I can't believe I just did that . During an interview on 2/22/2022 at 10:41 AM, Laundry Aid #1 stated she came to work sometime in January 2022, with symptoms related to COVID-19 .have problem with sinuses .one time come to work .been to doctor .was negative .feel better .took sinus medication .worked .next day .was positive [for COVID-19] . During an interview on 2/22/2022 at 11:04 AM, LPN #2, when asked about the difference between allergies and COVID-19, stated .with allergies you don't have a fever . During an interview on 2/22/2022 at 12:31 PM, Utility Worker #2 stated kitchen staff were observed without appropriate PPE .seen with [masks] down .not completely off .[Utility Worker #1] .was reprimanded .had COVID .out 3-4 weeks ago .had to be before that .[mask] hanging down .is in the front [of the kitchen] .I think I may have said something to the supervisor .said [Utility Worker #1] was already being talked to . During an interview on 2/22/2022 at 12:41 PM, Food Operations Manager #1 stated .[Utility Worker #1] was seen without a face shield .I don't know about the mask .caught in the hallway without a shield .hasn't happened again .I don't personally [audit for handwashing and PPE] we just go around and look . During an interview on 2/22/2022 at 1:08 PM, the ICP stated PPE compliance and screening was discussed .with department heads .talked about the importance of truthful staff .manager's responsibility .ensure communication to their staff .pulled education .from these individuals .they thought nothing of it .it's not like I am not doing an effective job .because people can't control their truthfulness .3 people who are dishonest .we educate .and reeducate .can't control them being dishonest .educate these are the symptoms .I don't know how else I can make people do the right thing .I can't . During an interview on 2/22/2022 at 4:38 PM, CNA #2 stated they had reported to work with COVID symptoms .we didn't know .we knew with Delta .what the signs and symptoms were .did not know with Omicron it was like a cold .like I said I have sinuses and allergies and asthma .I have medicine I take in the AM and PM . During interview, CNA #2 confirmed they had failed to adhere to the facility PPE guidelines on 1/9/2022, .went to the bathroom .come out .my mask was on my ear [dangling from the ear and not covering the face] .[ICP] said put your mask back on .got a face shield because I didn't have my shield with me .I was about 3 feet from residents .did get disciplinary action .apologized .realize now . During an interview on 2/25/2022 at 11:34 AM, the Interim Director of Nursing (DON) confirmed she was aware CNA #1 failed to don appropriate PPE and worked with symptoms related to COVID-19 .I believe it [outbreak] can be tracked and trended back to that 1 associate .I know [ICP] reached out to the state .to get instruction on what they needed to do .started education across the board .spoke in person with a lot of staff .what to do .who to call .[ICP] covered the education .donning and doffing audits .hand washing audits .no way to ever know what you are doing works .until you know you have a problem .you don't know you have a problem until a problem comes up .bottom line is out of 100 people there will always be those 5 people that are going to do what they want to do . During an interview on 2/25/2022 at 12:04 PM, the Administrator confirmed she became employed by the facility on 2/1/2022, and was made aware of the ICP contact tracing conclusions for the facility's recent COVID-19 outbreak .an employee lied .an associate .a person lied .I can tell you that .I can just tell you the system is the system .can't stop people from lying .we can temp .screen .ask them questions .temp when they leave . Continued interview confirmed she was not aware prior to the survey that staff were non-compliant with PPE guidelines. When asked about the facility's effort to correct staff non-compliance with screening of COVID-19 symptoms and PPE adherence, the Administrator replied .tracking, trending, and making sure anybody that identifies with symptoms and/or if a questionnaire is not done .they are turned away .if it is an employee .yes they are asked to leave .if they don't follow infection control protocol they are asked to leave .there is a process that [the ICP] managed .defer to [ICP] on all of those questions .staff know to call [the ICP] .if symptomatic .[ICP] will report to me .make sure they are clear when the employee comes back .what the next steps are .you know as well as I do it is contagious .don't want to have an employee that comes to work with symptoms .if an employee fails to do that or lies on a form .it's terrible .the system works if the employees follow it . Facility corrective actions included: Corrective Action 1: Education to the Administrator by the Vice President of Operations on the use and application of the screening tool when associates enter the healthcare center. On 2/25/2022, the Vice President Operations initiated education with the Administer on the current associate Screening Tool (records signs and symptoms, COVID-19 exposure, etc) to be completed when associates enter the facility. On 3/2/2022, the surveyor reviewed the education, Inspection for Screening Tool, and in-service sign in sheet which validated the corrective action plan. On 3/2/2022, the surveyor validated the corrective actions onsite through interviews with the Administrator. The Administrator was able to verbalize understanding of the Screening tool and was able to verbalize understanding of steps or actions to take in the event any staff or associate presented with fever or signs and symptoms of illness while on duty. The Administrator was also able to verbalize understanding of the facility's Inspection for Screening audit tool, when to utilize the audit and with whom to report the findings. Corrective Action 2: The Administrator and/or designee will provide education to all associates who staff the screening area on the use and application of the screening tool when associates/visitors/contractors enter the healthcare center. On 3/2/2022, the surveyor reviewed the in-service education sign-in sheet dated 2/25/2022 and entitled Screening Tool Use and Application. The sign in sheet had been signed by the 4 facility screeners and observation of documentation validated the associates/staff received the mandatory education in-services prior to returning to work. On 3/2/2022, the surveyor validated the corrective actions onsite through interviews with 2 of the facility screeners. The Screeners were able to verbalize understanding of the screening tool and were able to verbalize understanding of steps or actions to take in the event any staff or associate presented with fever or signs and symptoms of COVID illness while on duty. Corrective Action 3: The Infection Preventionist will provide educational in-services to all associates on the following: 1. Management of COVID-19 which included: Understanding of COVID symptoms, screening guidelines, how to address symptoms if present on screening, and return to work guidelines for exposed and/or symptomatic associates 2. CDC Guidance on Donning and Doffing PPE 3. Transmission Based Precautions On 3/2/2022, the surveyor reviewed the in-service education sign-in sheets dated 2/25/2022, related to the education listed in the corrective action plan. The sign in sheets had been signed by most of the facility associates. An associate check-off list was also observed and validated the associates/staff received the mandatory education in-services either via telephone or prior to returning to work. Documentation was provided by the Administrator and showed all staff that had not received the education were not scheduled to work and/or would be educated by the Infection Preventionist upon return to work. On 3/2/2022, surveyor observed a Knowledge Verification Posttest workstation at the facility's main entrance screening station which contained a sign in sheet along with instructions on how to complete the test. On 3/2/2022, the corrective actions were validated onsite by the surveyor through interviews onsite and via telephone with 4 CNAs, 2 LPNs, 2 RNs, the ICP, 1 Maintenance Technician, 1 Housekeeper, 1 Cook, 1 Dietary Aid, and 2 Food Operations Managers. The staff were able to verbalize understanding of steps or actions to take in the event any staff or associate presented with a fever or signs and symptoms of illness while on duty. The staff were able to verbalize understanding of how to review the Associate Screening Log upon entrance and exit for signs or symptoms of COVID-19 and fevers and steps or actions to take if discovered. The staff verbalized understanding if they were to become ill while on duty to continue with appropriate PPE, report to supervisor and/or administration and leave any resident care area and go home. Corrective Action 4: Infection Preventionist will educate Department Heads/designee on the PPE observation tool to facilitate identification of opportunities for improvement to mitigate risks for the spread of COVID-19 by 2/28/2022. On 3/2/2022, the surveyor reviewed an In-Service/Education Sign-in Sheet dated 2/28/2022 and entitled Personal Protective Equipment (PPE) Competency Evaluation. The sign in sheets had been signed by all Department Heads, including the Food Service Manager, Director of Food Services, Registered Dietician, Director of Environmental Services, Director of Facilities, Dietary General Manager, Activities Lifestyle Coordinator, Social Worker, and the Director of Rehabilitation and was used to identify knowledge and understanding associated with the appropriate use of PPE, when to screen staff, how often, and who to report the findings. On 3/2/2022, the corrective actions were validated onsite by the surveyor through interviews with Food Service Manager, Director of Food Services, and Director of Environmental Services who were able to verbalize understanding of the random associate PPE screening with use of the PPE Observation Tool to begin on 3/3/2022 with twice weekly audits until 4/2/2022, then weekly until 5/7/ , then every other week until 6/18/2022, then once monthly until 8/18/2022, and with whom to report the findings. On 3/2/2022, interview with the Interim DON and ICP confirmed the facility had implemented observations and audits on use of PPE and infection control practices and how often the tools were to be utilized (twice weekly until 4/2/2022, then weekly until 5/7/ , then every other week until 6/18/2022, then once monthly until 8/18/2022). Review of PPE compliance audits were reviewed, and the findings were validated by the surveyor onsite. Corrective Action #5: The Quality Assurance Performance Improvement Steering committee, which is comprised of but not limited to the Licensed Nursing Home Administrator, Interim Director of Nursing, Infection Preventionist, and Medical Director will convene an ad hoc meeting to review remedy plan by 3/2/22. On 3/2/2022, the surveyor reviewed the QAPI Ad Hoc Meeting sign in sheet dated 3/2/2022. The sign in sheets had been signed by the Administrator, the ICP, the Interim DON, and the Medical Director. On 3/2/2022, the corrective actions were validated onsite by the surveyor through interviews with the ICP and Interim DON, both confirmed the topics discussed during the QAPI ad hoc meeting included: the facility's IJ Removal Plan, a Performance Improvement Project related to PPE compliance, additional staff education and continued audits/monitoring of infection control related topics. The facility's noncompliance at F-880 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on review of the Medical Director Contract, review of the Advanced Practice Nurse (APN) Protocol, review of the Facility Assessment, medical record review, review of facility falls investigations, observation, and interview, the Medical Director failed to ensure identification, development, and implementation of appropriate plans of action and ensure the effective use of its resources to maintain the highest practicable well-being of all residents, failed to ensure performance improvement was implemented and monitored, failed to provide an individualized pain management plan to avoid pain and mental anguish, failed to ensure interventions were implemented for residents with repeated occurrences with falls which placed residents at risk of harm, failed to ensure revision of care plans were done with appropriate and individualized interventions to prevent falls, failed to prevent avoidable pressure ulcers, failed to ensure an appropriate falls intervention program was implemented to prevent residents from having multiple falls and injuries, and failed to ensure a facility assessment was performed and implemented. The Medical Director's failure placed 7 residents (#119, #28, #34, #39, #40, #47, #80) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 835, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the Medical Director Contract revealed .4. Services to be performed by provider .Responsible for the overall coordination of medical care at the Facility. Coordination of care means Provider shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident care policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies .Participate, upon request, in personnel evaluations and other quality monitoring programs established by the Facility including attendance at the Facility's Quality Assurance Committee meetings .Provider will deliver high quality services that .Promote standards of timeliness .enhance continuity of service to all Health Center residents .conform to federal and state regulations . Review of the Advanced Practice Nurse (APN) Protocol, undated, revealed .Requiring Authority .the (APN) will provide health care services under the general supervision of (Medical Director) .F. Interpret and analyze patient data to determine patient status, care management and treatment and effectiveness of interventions . Review of the Facility Assessment (YEAR), dated 6/2/18, revealed .Community Staff .The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma; and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #39 developed 3 avoidable wounds: 1 stage II on the right buttock, 1 stage III to left buttock, and an unstageable to the coccyx; Resident #80 developed 1 avoidable unstageable wound to the right clavicle; Resident #86 developed 1 avoidable stage IV wound to the right hip; and Resident #119 developed 2 avoidable wounds: 1 unstageable to the left ischium and 1 stage II to the right foot. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 8/29/17 - 7/24/18 revealed the Medical Director attended 11 out of 13 QAPI meetings. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed she attended the QAPI meetings and falls were reviewed monthly in the meetings. Continued interview confirmed recurrent falls were reported to the Nurse Practitioners (NP) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . Continued interview confirmed .involvement with pressure ulcers primarily supervisory. I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up . Continued interview confirmed when the Medical Director signed the Incident/Accident reports she was agreeing with the interventions put in place. The Medical Director stated .the reports are not always timely . Refer to F 550, F657, F 677, F 686, F 689, F 697, F 725, F 726, F 835, F 867, and F 947.

Based on review of the facility's (YEAR) Assessment, review of the facility's computer based training documentation, and interview, the facility failed to implement a system to track nurse aide competency levels in order to ensure training was sufficient based on the resident population. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F657, F689, F725, F726, F841, F867 and F947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the (YEAR) Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population. Certified nursing assistants may have additional required competencies .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Review of the facility's computer based training documentation revealed no tracking system in place to determine nurse aide competency after required annual training and in-service education, including understanding falls and skin checks. Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, confirmed she was not involved in decision making of when nurse aides were competent and did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. She was still trying to find out where deficiencies in education were and developing an education month to month if someone told her there was a need. Interview with the Staff Development Coordinator on 8/20/18 at 2:49 PM, in the conference room confirmed .(Nurse) Mentors check (computer based training) and HR (human resources) follows that .I just started .orientation begins with me .goes on to mentor .(mentors) pick a preceptor .(nurse mentors) evaluate in 1st 90 days and if not performing .mentors talk to DON (Director of Nursing) .(nurse mentors) keep in contact with HR for Relias (computer based training) .Excel (spreadsheet) is more for me to know who is with what mentor .what household they are (on) . Interview with the Staff Development Coordinator on 8/20/18 at 4:55 PM, in the conference room, confirmed the facility did not have a system in place to track and trend the competency levels of nurse aides. Refer to F-550, F-677, F-689, F-725

Based on review of the facility Quality Assurance and Performance Improvement Plan, Facility Assessment review, medical record review, observation, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to have an effective, ongoing QAPI program to ensure an effective falls program was implemented to prevent repeated falls for residents, resulting in injuries after falls. The QAPI committee's failure to ensure an appropriate falls intervention program was implemented, failure to ensure care plans were revised after falls, failure to ensure sufficient staffing to supervise residents at risk for falls, and failure to ensure competent staff, resulted in residents having multiple falls and injuries, and placed 7 residents (#119, #28, #34, #39, #40, #47, and #80) of 40 residents in the facility who had falls, in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .Purpose .(QAPI) Program utilizes an on-going, data driven, pro-active approach to advance the quality of life and quality of care for the residents .Quality Assurance and Performance Improvement principles drive our decision making as we endeavor to produce positive outcomes .QAPI committee consists of representatives from various departments .Performance Improvement Projects (PIPs) will be implemented when an opportunity for improvement is identified. These PIPs may apply to processes or systems throughout the community .QAPI program is ongoing, comprehensive and addresses the services provided .data will be obtained from the following reports .Clinical reports - infection, medication error, pressure injuries, falls .The QAPI team will meet monthly, or more often as needed, to review findings and identify potential PIPs .The Nursing Home Administrator (NHA) and Board of Directors are responsible and accountable for the development, implementation and monitoring of the QAPI program .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .The QA Committee meets at least quarterly to coordinate and evaluate the activities under the QAPI program .The QAPI Steering Committee, which includes the Medical Director as co-chair, meets monthly and is accountable for the continuous improvement in Quality of Life and Quality of Care .The QAPI Steering Committee collects data from QA sub committees (e.g., pain, falls, and weight loss) .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process .PIPS .identify areas where gaps in performance may negatively affect resident .In prioritizing activities, the team will consider: high-risk to residents .high-volume or problem prone areas .health outcomes .resident safety .resident choice .At least annually a project that focuses on high risk or problem-prone areas will be addressed through the QAPI program including PIP development .The team will utilize root cause analysis to identify the cause of the problem and any contributing factors. Plan-Do-Study-Act PDSA will also be used .Our community uses a systematic approach to determining the root cause of an issue and any contributing factors. Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of Facility Assessment (YEAR), dated 6/2/18, revealed .Community Assessment and QAPI .Information from the Community Assessment will be incorporated into the Quality Assurance Performance Improvement (QAPI) process .The identification of residents will help to drive the activities of the QAPI process. The description of care, services and resources available at our community provides both areas for monitoring of processes and outcomes as well as information for investigation of root causes of adverse events and gaps in performance .Community Staff .Our community is overseen by a Board of Directors, an Executive Director and a licensed Nursing Home Administrator. The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated she was not familiar with Long Term Care and had a background in acute care. The DON stated the facility had plans to reinstate a weekly fall meeting that the facility used to conduct before her arrival in (MONTH) of (YEAR). The DON was not sure when weekly fall meetings had stopped, but they had reviewed the falls and ensured care plans were updated. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The accident reports were filed and tracked by the Minimum Data Set (MDS) Coordinator in an excel spread sheet that was brought to QAPI. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement (used when deciding which intervention to put in place) .no education on falls .just their (staff) clinic experience . The DON stated fall investigation reports were then brought to a leadership huddle with leadership staff, to the DON, to the Administrator, and to the Medical Director for signatures. The DON stated in the leadership huddles they just reviewed the investigation completed by the unit nurses and looked at what the nurses indicated was the probable cause, interventions nursing implemented, time of fall, and any patterns. The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans (were updated) .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they (residents) forget they can't get up . The facility started a PIP for falls in (MONTH) after there had been 3 falls with injury and the facility needed to re-evaluate falls. The DON then stated the facility started looking at fall interventions when the new Administrator arrived in June. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, confirmed she led the QAPI meeting and staff discussed how many falls during a month and any trends or patterns. QAPI looked at residents with multiple falls in a month but did not look back further. The Administrator stated they didn't go back and look at every fall back in (MONTH) or last year. .we haven't gotten there yet . The Administrator started a PIP plan and they reviewed falls in the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month (review of falls in morning meeting), our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . The Administrator stated root cause analysis during falls and related to a history of falls was not being discussed and the first root cause analysis was conducted in July. The facility saw an increase in falls and increase in multiple resident falls, and they looked at one month of falls. The Administrator stated they knew the fall rate increased. The Administrator stated .as we are starting the PIP plan we would talk .about education .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed he did not attend the falls meetings or huddles and stated he did not have clinical experience. He stated he relied on the nurses for implementation of interventions. Further interview revealed he became aware approximately the 3rd week of (MONTH) falls had increased and he .Called on MDS (Minimum Data Set nurse) . to address. He stated, .MDS would facilitate those meetings .informal monitoring to ensure meetings (huddles) being held with (MDS #1) were informal .nothing formal . Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed recurrent falls were reported to the Nurse Practitioners (NPs) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . (Medical Director's) involvement with pressure ulcers primarily supervisory, I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff .and turnovers in leadership have not been helpful .Falls .We can't tie them up . Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-835, F 841, and F-947.

Based on facility policy review, medical record review, review of facility falls investigations, review of facility dailycensus and staffing, observation, and interview, the Administrator failed to ensure facility policy and procedures were implemented for falls; failed to ensure revision of care plans was completed with appropriate and individualized interventions to prevent falls; failed to prevent avoidable pressure ulcers; failed to ensure an effective falls program was implemented to prevent residents from having multiple falls and multiple injuries with falls; and failed to ensure adequate staffing to supervise residents who had falls and adequate staffing to provide activities of daily living care (ADL) care to residents. The Administrator's failure to ensure an effective falls program was implemented placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator's failure to ensure residents were provided assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator's failure to ensure residents received pain control resuled in Harm to Resident #236. The Administrator's failure to ensure residents did not develop pressure ulcers resulted in Harm to Resident #80. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F 689, F725, F 726, F 841, F 867 and F 947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left [MEDICAL CONDITION]; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a [MEDICAL CONDITION] femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left [MEDICAL CONDITION] and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma (a collection of blood outside the brain); and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #80 developed 1 avoidable unstageable wound to the right clavicle. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, revealed the Administrator led the Quality Assurance and Performance Improvement (QAPI) meeting. During the meeting they discussed how many falls during a month looking for trends and patterns. Falls were reviewed during the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month (review of falls in AM meeting) our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . Further interview confirmed the facility had not used root cause analysis during falls and a resident's historical falls was not being discussed. The facility conducted the first root cause analysis in July. Further interview revealed, .saw increase in falls .increase multiple resident falls .we knew fall rate increased . Further interview revealed, .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the facility's previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed the falls program included household huddles daily to find interventions. The previous Administrator stated he did not attend the meetings and did not have clinical experience and relied on the nurses for interventions. Further interview revealed that approximately the 3rd week of (MONTH) he became aware falls had increased. The previous Administrator called on the Minimum Data Set (MDS) nurse to assist in decreasing falls. The previous Administrator stated there was a falls task force with in the form of huddle meetings. The previous Administrator confirmed he had no involvement in the huddles or Interdisciplinary Team (Interdisciplinary Team) meetings. He stated MDS would facilitate those meetings and .informal monitoring to ensure meetings (huddles) being held with (MDS #1) were informal .nothing formal . Refer to Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-867, F-947

Based on review of the facility's Quality Assurance and Performance Improvement Plan, review of the facility's (YEAR) Assessment, and interview, the facility failed to implement a program to ensure nursing staff education and competency were completed The failure to ensure nursing staff were educated and competent placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process . Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of the (YEAR) Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, and review of falls investigations and interventions put in place by staff to prevent further falls, revealed and intervention for Resident #119 included Velcro noodles to the bed. The DON stated .I don't know what Velcro noodles would be exactly, maybe pool noodles . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed Resident #236 had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on Resident #236 and most times she had pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it (wound) hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, revealed the nursing staff has an orientation period that begins with Human Resources (HR) onboarding. The nurses have HR videos they watch and Relias (computer-based training modules) they watch. Some modules are for all staff and some are specific to nursing. The Staff Development Coordinator conducts a diabetic lab with the nurses that lasts approximately ½ a day with competency checked on insulin administration. When the nurses have completed the videos, the Staff Development Coordinator sends them to their nursing unit with an orientation checkoff sheet and then the House Mentor is responsible for the nurse's training. The nurses are paired with a preceptor of the House Mentor's choosing. The Staff Development Coordinator only receives the orientation checkoff sheet from the Mentors when they are done and states she is not involved in decision making of when nurses are competent. Further interview revealed she did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. The Staff Development Coordinator stated she was still trying to find where deficiencies in education were, where annual trainings were due and had not been done, and was developing education month to month if someone told her there was a need. The Staff Development Coordinator stated the monthly trainings she had developed since being in her role was on the evacuation policy in (MONTH) (YEAR), then they conducted mock evacuation drills in (MONTH) and (MONTH) (YEAR) and she was currently conducting one on one training with everyone on Personal Protective Equipment (PPE) and handwashing. Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement (used when deciding which intervention to put in place) .no education on falls .just their (staff) clinic experience . The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans (were updated) .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they (residents) forget they can't get up . Interview with the DON on 8/18/18 at 7:15 PM, in the conference room, revealed, .I am not familiar with long-term care, and she (Administrator) had taught me regarding (fall) interventions . Further interview with the DON revealed the DON was familiar with Resident #47 and stated as far as she was aware the resident had not had any further falls once he was admitted to the secured unit following his return to the facility after a psychiatric hospital stay (resident had 2 falls since his return). Refer to F-657, F-689, F-725, and F-947.

Based on review of the facility's CMS-672 Resident Census and Conditions of Residents, review of the Matrix for Providers, review of the facility's Daily Census Report, review of facility staffing schedules, observation, medical record review, review of facility incident reports, and interview, the facility failed to maintain adequate staffing levels to ensure the supervision of residents to prevent repeated falls for 7 residents (#28, #34, #39, #40, #47, #80, #119) of 40 residents reviewed for falls in the facility, and to ensure residents were provided assistance with activities of daily living (ADLs) care for 3 residents (#53, #80, and #89) of 52 residents reviewed. The facility's failure to ensure adequate staffing levels resulted in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for 7 residents (#28, #34, #39, #40, #47 #80, #119) with serious injuries after falls. The facility's failure to provide assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/20/18 at 8:10 PM, in the conference room. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents signed by the Administrator on 8/13/18 revealed the facility had a census of 137 residents. Further review revealed 90 residents were occasionally or frequently incontinent of bladder; 80 residents were occasionally or frequently incontinent of bowel; 25 residents ambulated with assistance or assistive devices; 92 residents had dementia; 86 residents had behavioral healthcare needs; and 8 residents had pressure ulcers. Review of the Matrix for Providers completed on 8/13/18 revealed the facility had 40 residents who had experienced falls while in the facility, with 10 residents having an injury with a fall and 7 residents having a major injury as a result of a fall. Residents who had major injuries after a fall were Residents #119, #47, #28, #34, #39, #40, and #80. Review of the facility's Daily Census Report dated 8/13/18 for the Secured Unit revealed the unit had 31 residents and 2 empty beds. Review of the facility's staffing schedule for the Secured Unit for (MONTH) (YEAR) revealed the unit was to have 1 Licensed Practical Nurse (LPN) and 4-5 Certified Nursing Assistants (CNAs) working Monday through Friday day shift; 1 LPN and 3 CNAs working weekend day shift; 1 LPN and 3-4 CNAs working Monday through Friday evening shift; 1 LPN and 2 CNAs working weekend evening shift; either 1 LPN or 1 Registered Nurse (RN) and 2-3 CNAs working Monday through Friday night shift; and 1 LPN or RN and 2 CNAs working weekend night shift. Observation on Thursday 8/16/18 at 10:50 AM, in the Secured Unit dining room, revealed residents seated in chairs and wheelchairs. Continued observation revealed no CNA or nurses were in the line of sight of the residents in the dining room and sunroom. Further observations revealed all the residents' doors were open without a staff member in line of sight. Further observation revealed the Wound Care Nurse and Wound Nurse Practitioner were in one of the resident's rooms. Medical record review and review of facility incident reports revealed Resident #119 had 9 falls between 7/1/17 and 7/10/18, with 3 falls requiring transfer to the emergency room , and 2 falls resulting in fractures of the legs. Interview with CNA #16 on 8/16/18 at 2:42 PM, in the Secured Unit hallway, revealed .We don't have enough supervision for her (Resident #119) .If we do have enough staff they pull us . Interview with Household CNA Coordinator #4 on 8/16/18 at 2:47 PM, in the Secured Unit hallway, revealed .We always have staff, but (they are) pulled .When (they) get pulled, don't have enough staff .With 3 people just can't do it . Interview with CNA #5 on 8/18/18 at 8:59 AM, on the Secured Unit hallway, revealed .Right before supper we position them (residents) (in chairs) that is how we supervise .last 3 months before it was horrible . Observation on Saturday 8/18/18 at 9:10 AM, in the secured unit sunroom, revealed Resident #119 was seated in her wheelchair. Continued observation revealed no CNAs or nurses were in line of sight of the resident. Medical record review and review of facility incidents revealed Resident #47 had 10 falls between 4/9/18 and 6/13/18 with one fall requiring sutures for a laceration. Further review revealed the resident was not safe to ambulate independently. Observation on 8/18/18 at 10:30 AM, in the Secured Unit dining room, in front of the kitchen, revealed LPN #5 was at the medication cart between the dining room and the sunroom, preparing medications for a medication pass. Continued observation revealed 16 total residents were in the dining room, sitting area, and sunroom. Further observation revealed Resident #47 ambulated into the dining room, in front of the kitchen, pushing his wheelchair towards the sunroom. Further observation revealed LPN #5 began to yell out to the homemaker/cook staff member, who was located in the kitchen, to find a staff member to help assist the resident, who was observed to be unsteady on his feet. Further observation revealed the other CNAs were in resident rooms. Further observation revealed the homemaker staff member went out on the unit and tried to find a CNA to help with Resident #47. Continued observation revealed LPN #5 assisted the resident back into a wheelchair and continued to prepare medications for medication pass while the homemaker was locating a CNA to assist. Review of the facility's Daily Census Report dated 8/13/18 for 2 South revealed the unit had 31 residents and one empty bed. Review of the facility's staffing schedule for 2 South for (MONTH) (YEAR) revealed the unit was to have 1 nurse and 3 CNAs per shift Monday through Friday and 1 nurse and 2 CNAs per shift on the weekends. Interview with Resident #61, who lived on 2 South, on 8/13/18 at 10:31 AM, in the resident's room, revealed Resident #61 did not think there was always enough staff to provide baths. Continued interview confirmed .the girls (CNAs) will come in and say there are only 2 of us (CNAs) and we can't do your bath today . Further interview revealed .sometimes there is only 1 to 2 to take care of all of us (residents) .because they have to go to the kitchen to work sometimes . Interview with Resident #96, who lived on 2 South, on 8/13/18 at 10:39 AM, in the resident's room, revealed .(the facility) short staffed .staff have quit and they haven't replaced them .a lot of times there is just 1 or 2 (CNAs) on the floor . Interview with Resident #53, who lived on 2 South, on 8/13/18 at 11:08 AM, in the resident's room, revealed .didn't get a shower last week at all .not Tuesday or Friday they told me they were short staffed .it has happened .several times .not enough of them . Interview with CNA #3 on 8/15/18 at 9:25 AM, in the 2 South dining rooms, revealed the facility did not always have enough help to take care of the residents. Continued interview revealed there had been times when residents had not received showers. Interview with Household CNA Coordinator #1 on 8/15/18 at 9:40 AM, in the 2 South dining room, revealed there had been .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2 to 3 days out of the week . Continued interview revealed .pulled to the kitchen sometimes 3 to 4 times a week . Further interview confirmed there had been times the residents had not received showers because of staffing. Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 South dining room, revealed there was not always enough staff to meet the needs of the residents .it upset me .we are understaffed. I can't do my job the way I would like . Continued interview revealed .At least once a week we try to give a shower .there have been times on the weekends that we have not been able to get some residents up out of bed because there is not enough staff . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 South living room area, revealed there was not always enough staff to meet the needs of the residents. Continued interview confirmed .like today the person I was working with put her notice in so there is only 1 nurse. The weekends are not enough CNAs. Last Sunday there was only 1 nurse and 2 CNAs .there have been times the residents have not received a shower due to staffing . Review of the facility's staffing schedule for 1 South for (MONTH) (YEAR) revealed the unit was to have 1-2 nurses for each shift Monday through Friday; 3-4 CNAs on day shift, 2-3 CNAs on evening shift, and 2 CNAs on night shift Monday through Friday; 1 nurse each shift on weekends; and 2 CNAs on day and evening shift and 1 CNA on night shift on the weekends. Further review revealed there were no nurses scheduled for 7:00 AM - 3:00 PM shift on 8/18/18 and 8/19/18. Interview with Nurse Mentor #5 on 8/14/18 at 7:50 AM, in the 1 South nursing station, revealed .we need the help last night .I only have 1 nurse (LPN #13) working today . Review of the staffing schedule for 8/14/18 day shift on 1 South revealed the unit was supposed to be staffed with 2 nurses. Interview with LPN #13 on 8/14/18 at 8:25 AM, in the 1 South hallway, confirmed .I am the only nurse on the floor today .I have 30 patients today .it happens all the time being the only nurse on the floor . Interview with Resident #89, who lived on 1 South, on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with RN #4 (night shift nurse on 1 South) on 8/17/18 at 6:35 AM revealed .I had 30 patients last night .I was the only nurse with 1 CNA . Review of the staffing schedule for 2 South for 8/16/17 11:00 PM - 7:00 AM shift revealed the unit was to be staffed with an RN and 2 CNAs. Interview with CNA #2 on 8/17/18 at 5:45 PM, on the 2 South hallway, revealed .just 2 of us working down here and I don't even know these patients .I work upstairs on the skilled .I was pulled from the 3rd floor and that left 1 CNA up there to take care of 17 or 18 patients . Review of the staffing schedules for 2 South and 3rd floor for the evening shift of 8/17/18 revealed 2 South was to have 2 CNAs and the 3rd Floor was to have 2 CNAs. Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 South hallway, revealed .is never enough staff .recently had a setback with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the DON (Director of Nursing) and the Administrator . Interview with the DON on 8/20/18 at 5:30 PM, in the conference room, revealed the Nurse Mentors and Household CNA Coordinators schedule staff 6 weeks in advance and staffing is to be reviewed by each house daily. The DON stated staffing in the facility was consistent, unless a staff member needed to be pulled to another unit in the facility. Further interview revealed staffing was based upon census and acuity in each house and was determined by utilizing a computerized staffing calculator. Further interview revealed staff turnover was discussed in the leadership meetings every 2 weeks and CNA turnover was high, but nursing turnover was stable. Interview with the DON on 8/20/18 at 5:35 PM, in the conference room, revealed staff had reported to the DON there was not enough staff, but the DON stated staffing was adequate. The DON stated if someone was pulled to work on another unit or another role, then staff felt they didn't have enough adequate staff. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up (restrain residents) . Telephone interview with the Chair of the Board on 8/20/18 at 3:47 PM, confirmed .the facility had staff turnover .turnover in these positions are critical . Refer to F-550, F-657, F-677, F-689, F-726, F-835, F-841, F-867, and F-947.

Based on facility policy review, medical record review, interview, facility investigation review, and observation, the facility failed to implement an effective fall prevention program for 7 residents (#119, #40, #39, #80, #28, #34, #47) of 7 residents reviewed for falls with injuries, of 40 residents in the facility with falls. The facility's failure to implement new interventions and have an effective falls prevention program resulted in injuries for 6 Residents (#119, #40, #80, #28, #34, and #47) and placed Residents (#119, #40, #39, #80, #28, #34, #47) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/18/18 at 8:20 PM, in the conference room. The Immediate Jeopardy (IJ) was effective 11/10/17 and is ongoing. The facility was cited F689 at a scope and severity of K, which constitutes Substandard Quality of Care (SQC). The findings include: Review of facility policy Falls-Clinical Protocol-Assessment and Recognition, last revised 9/12, revealed .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observation of the events, etc. 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. Those that occur while upright and attempting to ambulate; and c. Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Cause Identification- 1. For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for example, a balance problem caused by an old or recent stroke. b. Often, factors in varying degrees contribute to a falling problem .Treatment/Management - 1.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful . Review of facility policy, Accident and Incident Report-Resident, dated 1/1/17 revealed .When an accident or incident involving a resident occurs, any person witnessing the incident will call for appropriate assistance .To assure appropriate follow-through on all accidents and incidents. To study the cause of accident and incidents and to give guidance for corrective/preventive action .Do not move the resident until a licensed nurse evaluates the condition . Medical record review revealed resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #119's Brief Interview for Mental Status (BIMS) score was 0, indicating the resident had severe cognitive impairment. Continued review of the MDS revealed the resident was extensive 2 person assist for bed mobility, transfers, and toilet use and was frequently incontinent of urine. Review of facility documentation revealed Resident #119 had 9 falls between 7/9/17 to 7/10/18 and 2 falls resulted in traumatic injury. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review of a Clinical Notes Report dated 7/1/17 at 10:16 PM, revealed, .res (resident) alarm heard sounding at same time of a loud crash .res in bathroom, on the floor, wheelchair by sink. Brakes on wheelchair not on .no injuries .Will continue to monitor closely and respond to alarms . Interview with the DON on 8/17/18 at 10:25 AM, in the conference room, confirmed an investigation was not conducted for the fall on 7/1/17 in order to determine the cause of the fall and to implement interventions to prevent further falls. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 22 (high risk for potential falls). Review of a facility Incident/Accident Report dated 8/20/17 revealed on 8/20/17 at 5:00 PM the resident had a fall. Further review revealed .Resident observed lying in hallway in front of her w/c (wheelchair). Lying with face down and toward right side. Laceration to right forehead, scratch on right cheek .Additional comments and/or steps taken to prevent recurrence: Will ask PT (physical therapy) eval (evaluation) for cushion . Review of a Written Statement for the accident on 8/20/17 revealed, I just sat (Resident #119) back in her chair, she had been leaning forward. I sat down at kiosk by kitchen to chart my vitals. I also noticed before incident she was dragging rt (right) foot under chair. I told her several times from 3 - 4:30 pm to slow down and sit back in her chair so she wouldn't fall (Resident #119 had severe cognitive impairment). As I started charting .another CNA (Certified Nursing Assistant) said oh no, I turned to see (Resident #119) w/c rolling over her, she was on the floor, the w/c flipped . Review of a Written Statement for the accident on 8/20/17 revealed, This nurse was notified that resident had fallen out of her w/c in hallway. Observed lying on the floor in front of her w/c (wheelchair) .Was lying with face down on floor and toward her right side large amt (amount) of blood from laceration on right forehead . Medical record review of a physician's orders [REDACTED].#119 to the emergency room (ER) for evaluation. Medical record review of a Clinical Notes Report dated 8/20/17 at 11:13 PM, revealed, .Resident has stitches in right forehead . Review of the Interdisciplinary Team Review for the accident on 8/20/17, revealed, Interventions implemented was not completed and Probable Cause was leaning forward in w/c. Request eval for cushion . Interview with the Clinical Therapy Manager on 8/17/18 at 3:55 PM, in the therapy room, confirmed .She (Resident #119) was not evaluated for wheelchair seating and positioning after 8/20/17 .No recommendations were done, there was no eval . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed the resident's BIMS was 0 and was occasionally incontinent of urine. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #119 scored a 23 (high risk for falls). Medical record review of a Clinical Notes Report dated 10/15/17 at 11:16 PM revealed, This nurse was informed that resident was sitting in the floor in the bathroom .Resident sitting beside commode trying to get self up. States that she slid off the commode after she went to the bathroom. No injuries found .Resident reminded by staff and family to please ask for assist when needing to go to the bathroom (Resident had severe cognitive impairment) . Review of an Incident/Accident Report dated 10/15/17 revealed the actual time of the fall was 5:15 PM. Review of the CNA's Written Statement revealed I was getting (another resident) up for supper. I heard (Resident #119) calling HELP ME. I found her on floor in .bathroom. She was trying to get in her w/c and slid into floor . Further review revealed, .steps taken to prevent recurrence: try to keep resident in sight of staff to help her go to BR (bathroom) . Review of the Interdisciplinary Team Review for the fall on 10/15/17 revealed Interventions implemented was to toilet the resident at least every 2 hours (an expected nursing intervention) and the Probable Cause was Toileting self et (and) fell . Medical record review of a Clinical Notes Report dated 11/10/17 at 8:53 AM revealed, 0805 (8:05 AM) Notified by CNA that chair alarm was activated and she entered room and observed resident sitting in the floor in the bathroom. Resident was attempting to pull herself up from a sitting position. CNA assisted resident into w/c and then notified this nurse. This nurse observed resident and noted to have deformity to right lower extremity . Further review revealed at 1:35 PM, .[DIAGNOSES REDACTED]. Review of the Incident/Accident Report for the accident on 11/10/17 revealed the steps taken to prevent recurrence was not completed. Continued review of a Written Statement by the CNA revealed The alarm was going off on the chair in (Resident #119) room and she was in the bathroom trying to get up hanging on the rail and on the floor and her right leg was around bottom of the toilet between the wall. She was hanging so help transfer her to the wheelchair and let the nurse know . Medical record review of ER (Emergency) Trauma Worksheet dated 11/10/17 revealed .unwitnessed fall .fell this morning out of her wheelchair while attempting to stand .Granddaughter states this happens quite frequently at patients nursing home and has resulted in several injuries in the past .Patient complains of right lower leg pain . Review of the Investigation Tool for the accident on 11/10/17 revealed for the Interdisciplinary Team Review, Interventions implemented was not completed and Probable Cause: Res transferring self. No safety awareness. Medical record review of the acute care Hospital Discharge Summary dated 11/14/17 revealed .Right tib-fib (tibia-fibula) fracture following a fall .suffered a fall at (facility) and sustained a right tib-fib fracture .cast was applied . Interview with Licensed Practical Nurse (LPN) #3 on 8/16/18 at 3:00 PM, in the 1 North nurses station, revealed .(on 11/10/17) CNA assisted her to the wheelchair .then came to get me .when I went in there observed a clear deformity to right lower leg .the CNA was not supposed to move her . Interview with the DON on 8/16/18 at 9:52 AM, in the conference room confirmed it did not appear an intervention to prevent falls was put in place after the fall on 11/10/17. Medical record review of a Clinical Notes Report dated 11/16/17 at 10:30 AM revealed, CNAs report that chair alarm was activated and staff went to investigate alarm and observed (Resident #119) sitting in the bathroom .This nurse entered room and observed resident sitting in the floor beside the toilet with both legs stretched out in front of her. No apparent injuries .Resident had an incontinence episode of stool and was assisted on toilet. Resident transferred to sunroom and seated in bean bag chair . Review of an Incident/Accident Report dated 11/16/17 revealed the steps taken to prevent recurrence: Res had just been toileted @ (at) 9:30 (fall occurred at 10:30). Will ask res more freq (frequently) if toilet needs. Bean bag utilized as well . Review of a CNA's Written Statement for the accident on 11/16/17 revealed, Chair alarm was going off .(Resident #119) was trying to get on the toilet alone . Review of the Interdisciplinary Team Review for the accident on 11/16/17 revealed, Interventions implemented: Toilet more freq. Utilize bean bag. Probable Cause: apparently attempting to toilet self. Medical record review of a Clinical Note Entry dated 11/19/17 at 12:45 PM revealed, .Observed resident sitting in the floor next to the bed with bilateral legs outstretched in front of her. W/C was also next to the bed and alarm had activated. When resident was asked what she was doing, she places her hands on her hand and states 'I don't know' .no apparent injuries .Daughter states that during a visit this week her mother told her she needed to go to the bathroom, and before she could get help, her mother was attempting to go to the bathroom unassisted . Review of a CNA's Written Statement for the accident on 11/19/17 revealed, Light was going off in (Resident #119) room and when I went in she was on the floor beside her bed. Review of the Incident/Accident Report for the accident on 11/19/17 revealed .steps taken to prevent recurrence .therapy picked her up . Review of the Interdisciplinary Team Review for the accident on 11/19/17 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of Resident #119's ongoing care plan revealed an intervention on 11/24/17 of self-releasing safety belt in the wheelchair. Medical record review of a quarterly MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 4/13/18 at 2:36 PM revealed 1400 (2:00 PM) Called to sunroom by CNA. CNA reports walking into dining room and observing resident laying in the floor in the sunroom. Reports that resident was previously sitting at the dining room table for meal. Upon assessment, observed resident laying on her left side in front of her w/c which was left in the sunroom during meal .Resident crying and yelling out in pain .resident does grab at her left hip and leg . Review of a Clinical Notes Report dated 4/13/18 at 11:42 PM revealed, .resident was admitted to (hospital) with a Lt. (left) femur fx. Medical record review of an acute care hospital Surgical Consultation Note dated 4/13/18 revealed .female who has profound dementia fell today injuring her left hip. X-rays in the emergency room reveal comminuted angulated intertrochanteric [MEDICAL CONDITION] hip . Review of the Incident/Accident Report for the accident on 4/13/18 revealed the .steps taken to prevent recurrence was not completed. Review of the Investigation Tool revealed under Devices .Ordered sensor, alarm in place it was written N/A (not applicable). Under Interventions, (indicating interventions that were to be in place at the time of the fall) was a self-releasing seat belt, mats, pressure sensor alarm, nonskid socks, low bed, and night light. Review of the Interdisciplinary Team Review for the accident on 4/13/18 revealed no documentation a review was conducted, no interventions were implemented, and a probable cause was not indicated. Medical record review of the acute care hospital Discharge Summary dated 4/16/18 revealed .Left proximal femur fracture postop (postoperative) 4/15 (4/15/18) ORIF (open reduction internal fixation) . Interview with LPN #3 on 8/16/18 at 3:08 PM, in the 1 north nurses station, revealed .(on 4/16/18) After lunch saw her sitting at one of the dining room tables .was in a regular chair .wheelchair was in the sunroom .was attempting to ambulate to her wheelchair .I assessed her .Complain of pain left hip area .Was grabbing and grimacing Left hip/leg area . Medical record review of Resident #119's ongoing care plan revealed an intervention on 4/19/18 of Lap Buddy (cushion placed across the lap and hooks under arms of wheel chair) while in wheel chair and on 4/21/18 sensor alarm to wheel chair (an intervention that was to be in place since 1/8/16). Medical record review of a Clinical Notes Report dated 4/19/18 at 6:00 PM revealed, Interdisciplinary Meeting held this day, in attendance: (3 family members), Administrator, Medical Director, DON, Therapy Manager, Clinical Mentor, and Social Worker. Resident family concerned regarding resident numerous falls .remain concerned with number of falls that have occurred. Family understands that resident has a dx (diagnosis) of Dementia, which is advancing. Resident has no safety awareness due to her cognitive deficits. Current interventions reviewed and will remain, with the addition of a lap buddy to apply to w/c, unfortunately the current armrests on resident w/c will not accommodate this lap buddy. Therapy to order new arm rests for w/c, then we will apply further Velcro to add another layer of protection and another step for resident to attempt to self transfer or remove these intervention devices. We will continue with current lap buddy until these new arm rests arrive. Hipsters provided to staff and instructed on use and to also leave resident in her w/c for meals . Review of an undated letter addressed to the family of Resident #119 and written by the facility Administrator revealed, .Thank you for taking time to meet regarding (Resident #119)'s care plan. More specifically, we discussed your concerns regarding the potential for (Resident #119) to suffer an injury by falling .it is important you clearly understand that (the nursing facility) cannot eliminate the potential for falls to occur .as we discussed, we will not have a staff member consistently within close proximity of (Resident #119), nor are we required to do so. Even with a staff member nearby, a resident still may accidentally fall. It is simply an unavoidable risk .you may consider hiring a private duty aide to remain with (Resident #119) . Medical record review of a Significant Change in Status MDS assessment dated [DATE] revealed Resident #119's BIMS was 0 and the resident was frequently incontinent of urine. Medical record review of a Clinical Notes Report dated 6/27/18 at 8:09 PM revealed, Residents bed sensor alarm sounded and noted that resident was partly off bed onto bedside matt. Bed was in lowest position and resident had legs and bottom on matt and upper torso on bed hanging onto side rails. Noted that resident had a skin tear on back and left arm . Review of an Incident/Accident Report dated 6/27/18 revealed .steps taken to prevent recurrence: Pool noodles . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed, .Interventions implemented: Pool noodles. Probable Cause: Climbing out of bed, side rails are padded, has low air loss mattress w/ (with) sensor alarm, mats et low bed. Medical record review of a Clinical Notes Report dated 7/10/18 at 3:10 AM revealed, Pt (patient) alarm going off when CNA went to room, found pt half in bed and half out of bed. Head and upper body in bed and legs and feet on floor. Pt. has abrasion in middle of forehead . Review of an Incident/Accident Report dated 7/10/18 revealed .steps taken to prevent recurrence: Velcro noodles to mattress rail . Review of the Interdisciplinary Team Review for the accident on 7/10/18 revealed, Interventions implemented: Velcro noodle to mattress. Probable Cause: Unknown due to cognition. Res could not explain. Interview with Registered Nurse (RN) #2 on 8/15/18 at 7:03 AM, in the 1 north nurse's station, revealed .She (Resident #119) has fallen on numerous shifts .when up has to be in wheelchair and has a belt .she knows how to unhook .she is like a Houdini . Interview with the DON on 8/16/18 at 9:05 AM, in the conference room, confirmed . She (Resident #119) has had frequent falls. She continues to fall with all the interventions she has. We even told family they might want to consider hiring a 24 hour sitter. We have a few frequent fallers . Interview with CNA #16 on 8/16/18 at 2:42 PM, in the 1 north hallway, revealed .We don't have enough supervision for her (Resident #119) . Observation and interview with the Director of Nursing (DON) on 8/17/18 at 7:33 AM, in Resident #119's room, revealed the resident was in bed lying on her left side. Further observation revealed Velcro pads were hanging downward, on the outer upper end of the bed rails, and the pool noodles were up against the wall. Interview with the DON confirmed .the Velcro noodles are not attached to the bed correctly and the pool noodles are not in the resident's bed . Interview with Licensed Practical Nurse (LPN) House Mentor #1 on 8/17/18 at 8:10 AM, in the 1 North dining room, revealed .If she is sitting in a regular chair a staff member has to be with her. No intervention to address resident supervision .she continues to try to transfer herself and fall. She has no safety awareness .The lap buddy I just an extra measure to free herself. It is to slow her down. The lap buddy is working to certain extent. Gives us more time to get to her . Further interview confirmed no interventions were put in place to prevent further falls after Resident #119's fall on 11/10/17. Interview with House Mentor #1 on 8/18/18 at 9:25 AM, in the Mentor's office, confirmed staff were not documenting toileting. Further interview confirmed Resident #119 needed more frequent toileting than every 2 hours. The Mentor stated . All of us are responsible to make sure intervention is to be implemented . Further interview revealed when a fall occurred, .Nurse Fills out incident report .IDT (Interdisciplinary Team) comes up with new intervention . Further interview confirmed a root cause analysis was not done for the falls on 11/19/17 or 4/13/18 to determine the probable cause of the falls in order to implement interventions to prevent further falls. Further interview revealed, .(Resident #119) needs supervision within eye sight .She wanders all over unit . Further interview revealed the interventions implemented of toileting more frequently and toileting as needed were not different and not specific. Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, revealed .I don't know what Velcro noodles would be exactly, maybe pool noodles . Interview with the DON on 8/18/18 at 12:39 PM, in the conference room, revealed .I've not seen a bean bag chair since I've been here .The lap buddy slows her down. We have recommended to family they do the 24 hour sitter .A lap buddy wouldn't prevent falls .You can't really prevent falls . Telephone interview with CNA #23 on 8/18/18 at 1:00 PM revealed the CNA had never seen any pool noodles with Velcro and did not know what Velcro noodles (intervention that was to be put in place after the fall on 7/10/18) were. Interview with CNA #5 on 8/18/18 at 8:59 PM, revealed the CNA did not know what Velcro pool noodles were. Medical record review revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record of Resident #40's care plan dated 5/23/18 revealed the resident was at risk for falls due to weakness, history of falls, Dementia, and Hypertension. Continued review revealed interventions included wear non-slick footwear, instruct the resident on safety measures to reduce risk of falls, attempt to engage in Activities of Daily Living (ADL's) that improve strength, balance, and posture, and keep areas free of obstacles to reduce the risk of falls or injury. Medical record review of the Admission MDS dated [DATE], revealed Resident #40 had a BIMS score of 3, indicating the resident was severely cognitively impaired, and required extensive assistance of 1 for mobility, toileting, and transfers. Review of a facility Incident/Accident report dated 6/27/18, revealed Resident #40 was found on her knees in her room with 2 skin tears to the left wrist. Continued review revealed steps taken to prevent recurrence included .Call before you fall signs - visual cueing . Review of the Interdisciplinary Team Review for the accident on 6/27/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Medical record review of a Nursing Note dated 7/6/18, revealed .Ambulates w(with) walker w/one assist, however she frequently forgets to ask for assist and attempts to get out of chair and ambulate to/from room by herself. Frequent reminders given to call for assist. Gait is unequal and unsteady . Medical record review of a Nurses note dated 7/30/18, revealed Resident #40 was in her recliner, attempted to pick up a cup that had fallen on the floor, and slid out onto the floor. Further review revealed the resident had non slip socks on. Continued review revealed the resident was instructed to always use the call light. Review of a facility Incident/Accident report dated 7/30/18 revealed Resident #40 had a fall in her room with no injuries noted. Continued review revealed steps taken to prevent recurrence .Reinstructed & (and) demo (demonstrate) call light use . Review of the Interdisciplinary Team Review for the accident on 7/30/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Review of a falls assessment dated [DATE] revealed Resident #40 scored 11 (at risk for falls). Review of an Incident/Accident report dated 8/2/18 revealed Resident #40 was found lying on her back in her bathroom with her walker on top of her. Continued review revealed .Two knots were found on the back of her head with a laceration on one of them .It was determined to send her out for evaluation . Review revealed interventions in place at the time of the fall were mats and non-skid socks. Further review revealed steps taken to prevent recurrence .Reiterate use of call light .Removal of hosiery and use slipper socks . Review of CNA #15 Written Statement revealed, (CNA #14) and I were in (another resident's room) with another resident, and heard someone yelling. Ran out to see what happened next door. Went into (Resident #40) room and found her lying on bathroom floor . Review CNA #14 Written statement revealed, (CNA #15) & (and) I were in (another resident room) and heard some one yelling and went to check in each room & it was (Resident #40) laying in bathroom floor . Review of the Interdisciplinary Team Review for the accident on 8/2/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature from the Medical Director, Administrator or DON to indicate the fall was reviewed. Review of a falls assessment dated [DATE] revealed Resident #40 scored a 14 (at risk for falls). Medical record review revealed the resident was admitted to an acute care hospital on [DATE] for .Mechanical fall .Subdural hematoma .[MEDICAL CONDITION] .Patient was admitted after falling backwards in bathroom at (facility) . Medical record review of a Computed Tomography (CT) of the Head radiology report dated 8/2/18 revealed the resident had an acute subdural hematoma (SDH). Medical record review of a Nursing Note dated 8/6/18 revealed .Resident arrived back from (named hospital) 8/6/18 .Family at bedside .daughter states she is alert at times and does not recognize her. She has severe bruising to back of head and neck, w/a (with a) small scab to back of L (left) side of head. Bruising to R (right) arm, R index finger swollen and red. Small skin tears to bilateral arms. L lower arm skin tear . Medical record review of Resident #40's care plan dated 8/6/18, revealed the resident was at risk for falls related to weakness, History of Falls, Dementia, [MEDICAL CONDITION] medication use and status [REDACTED]. Medical record review of a Nursing Note dated 8/12/18 revealed the nurse heard Resident #40 yelling out, the nurse entered the room, and found the resident lying in the corner of her room with her back against the wall. Further review revealed the resident was found to have a large bruise to the left hip and a skin tear to the right arm. Continued review of the note revealed earlier the same day, the resident was found standing in the resident's room, going to the bathroom, and other staff reported she gets up without calling for assistance. Further review revealed the resident's call light was in reach at the time of the fall and staff re-educated the resident on the use of the call light. Review of a facility Incident/Accident Report dated 8/12/18, revealed the resident was found in the corner of her room between the bed and the bathroom and the resident stated she slipped. Continued review revealed under steps taken to prevent recurrence there were no interventions implemented. Review of the Investigation Tool for the accident on 8/12/18 revealed, under the section Interventions, which indicated the interventions in place at the time of the fall, none of the interventions were marked, and handwritten in the section was Re-Educate. Review of the Interdisciplinary Team Review for the accident on 8/12/18 revealed no documentation a review had been completed, no documentation of interventions implemented to prevent further falls, and no documentation of the probable cause of the fall. Further review revealed no signature of the Medical Director, Administrator or DON to indicate they had reviewed the accident. Medical record review of a falls assessment dated [DATE] revealed the falls assessment was incomplete and no score was documented. Medical record review of a physician's orders [REDACTED].Please get floor mat that alarms @ nurses station & place beside bed . Interview with RN #3 and medical rec (TRUNCATED)

Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to revise 7 residents' (#119, #28, #34, #39, #40, #47, and #80) care plans after falls with effective interventions to prevent further falls of 52 sampled residents, placing residents #119, #28, #34, #39, #40, #47, and #80 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The facility's failure is likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17, and is ongoing. The findings include: Review of the facility policy Care Planning-Interdisciplinary Team dated 1/1/17 revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan .is at the discretion of the Care Planning Committee . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review revealed Resident #119 had 9 falls from 7/1/17 - 7/10/18 with dates of falls 7/1/17, 8/20/17 (resulting in a laceration to the forehead requiring sutures), 10/15/17, 11/10/17 (resulting in a bone [MEDICAL CONDITION] leg), 11/16/17, 11/19/17, 4/13/18 (resulting in a femur fracture), 6/27/18, and 7/10/18. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #119 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was dependent for toileting. Continued review revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Medical record review of the Care Plan dated 12/24/15 and revised 7/10/18 revealed the care plan was not revised with the interventions indicated by falls investigations including to toilet every 2 hours (10/15/17 fall), toilet more frequently and utilize bean bag (11/16/17 fall), and for Velcro noodles to mattress rail (7/10/18 fall). Interview with Nurse Mentor (nurse Unit Manager) #1 on 8/18/18 at 9:25 AM in the Mentor's office, confirmed .All of us are responsible to make sure the intervention is to be implemented (revised) on the care plan .Ultimately the mentor is responsible . Interview with the Director of Nursing (DON) on 8/18/18 at 10:36 AM in the conference room, confirmed the care plan had not been revised to include new interventions for toileting interventions (10/15/17 fall and 11/16/17 fall) and Velcro noodles to the mattress (7/10/18 fall) . Medical record review revealed Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #28's current care plan, not dated revealed, (Resident #28) is at risk for falls d/t (due to): Decreased mobility, LT (left) [MEDICAL CONDITION] s/p (status [REDACTED]. Actual Falls: 5/19/17, 6/17/17, 2/15/18 with FX (fracture) L (left) distal femur (resolve) Interventions: Assist (Resident #28) to wear non-slick footwear that fits. Attempt to engage (Resident #28) in ADL's (Activities of Daily Living) that improve strength, balance and posture. Instruct (Resident #28) on safety measures to reduce the risk of falls (posture, changing positions, use of handrails.) Keep areas free of obstructions to reduce the risk of falls or injury. Keep nurse call light within reach, Instruct (Resident #28) to use call bell or call out of assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked. Review of an Incident/Accident Report revealed Resident #28 had a fall on 2/15/18 at 9:45 AM, in the resident's room with injury. Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: Ensure w/c (wheelchair) is within reach while in bed . Medical record review revealed the resident's care plan was not revised to include the intervention to keep the wheelchair within reach while the resident was in bed. Review of an Incident/Accident Report revealed Resident#28 had a fall on 6/7/18 at 2:00 PM in the dining room, CNA (Certified Nurse's Assistant) observed res. (resident) topple forward from her w/c to the floor. Res. remained alert. Skin tear noted to left forearm. Res. did hit her head on right forehead. No bruising @(at) this time . Additional comments and/or steps taken to prevent recurrence: Res. cautioned re: leaning forward in w/c . Medical record review of the resident's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 6/7/18. Interview with Licensed Practical Nurse (LPN) #4 on 8/17/18 at 4:36 PM, in the secure unit, revealed the Household Nurse Mentor for each unit was responsible for updating a resident's care plan after a fall. Interview with Household Nurse Mentor #1 on 8/17/18 at 5:05 PM, in the secure unit nurse's office, revealed the Mentor was responsible for updating Resident #28's care plan with new fall interventions. Continued interview and review of the resident's care plan with the Nurse Mentor confirmed the resident's care plan had not been revised after the resident's fall on 2/15/18 to keep the resident's wheelchair within reach, and confirmed the facility failed to update the resident's care plan after the resident's fall on 6/7/18. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #34 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #34's current care plan, not dated, revealed, (Resident #34) is at risk for falls related to Decreased Mobility, Scoliosis, Narcotic and [MEDICAL CONDITION] Medication Use . Continued review revealed the following interventions: .Assist with toileting as needed. Attempt to engage (Resident #34) in ADL's that improve strength, balance and posture. Fall risk assessment as indicated. Keep call light within reach and remind how to use as needed. Keep room free from clutter, walkways clear. Keep frequently used items within reach. Monitor medications for changes that may effect falls. Footwear will fit properly and have non-skid soles. Instruct (Resident #34 on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .Goals: Resident #34 will have no falls this review period . Review of an Incident/Accident Report revealed Resident #34 had a fall on 2/25/18 at 4:30 AM in the resident's room .Heard someone crying and found pt (patient) on the floor in her room. She states she was going to BR (bathroom) and fell . C/O (complain of) lt (left) hip pain. Skin tear to Lt elbow . Continued review revealed, Additional comments and/or steps taken to prevent recurrence: Call before you fall posted . Medical record review of the resident's care plan revealed Resident #34's care plan was not revised to reflect the resident's fall on 2/25/18 or the new intervention to post the call before you fall sign. Review of an Incident/Accident Report revealed the resident had a fall on 6/16/18 at 9:55 PM in the resident's room .I was told by CNA (Certified Nurse Assistant) that resident was on the floor in her room, went to assess resident, she had skin tear to lt. hand, bump on left side of head and was c/o lt hip pain . Further review revealed, .Additional comments and/or steps taken to prevent recurrence .Call before you fall, posey grip (rubberized mat for resident to sit on while in wheelchair to prevent sliding from chair) . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall the resident had on 6/16/18 or the new intervention to add the posey grip to the wheelchair. Review of an Incident/Accident Report revealed the resident had a fall on 7/14/18 at 7:05 PM in the resident's room .Resident's roommate was calling for help (staff) and I went to the room and resident was on the floor in front of the sink and blood was pooled around her head . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: Call before you fall. Encourage out of room more . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall on 7/14/18 or the intervention to .encourage out of room more . Interview and review of the resident's care plan on 8/18/18 at 12:08 PM with the DON, in the conference room, revealed the Household Nurse Mentors on the units were responsible for ensuring revisions to the care plan were completed after a fall. Continued interview confirmed Resident #34's care plan had not been revised to reflect any of the resident's falls, and did not accurately reflect the fall interventions. Medical record review revealed Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 required extensive assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 7, indicating severe cognitive impairment. Medical record review of Resident #39's care plan with a goal date of 6/10/18, revealed the resident was .at risk of falls d/t (due to) weakness, Left sided weakness s/p (status [REDACTED]. Review of the facility documentation revealed the resident had a total of 9 falls between 4/3/18 and 8/11/18. Medical record review revealed Resident #39's care plan was updated to reflect 5 dates the resident had falls: 4/3/18, 4/15/18, 6/7/18, 6/27/18 (fall was actually 6/26/18 according to Icident/Accident Report) and 6/30/18. Continued review revealed the only times the resident's care plan was revised to reflect a new intervention after a fall were 6/7/17 - Call before you fall sign; 6/27/18 (for the 6/26/18 fall) - Pool noodles to bed; 6/30/18 - Frequent rounds; and 7/2/18 - Scoop mattress ordered. Interview with Household Nurse Mentor #2 on 8/15/18 at 7:40 AM, on the 400 unit confirmed the resident's care plan was not revised to reflect new or effective interventions to address Resident #39's continued falls. Interview with the DON on 8/16/18 at 9:30 AM, in the conference room confirmed the facility failed to revise the resident's care plan and failed to implement new or effective interventions to address the resident's continued falls. In summary, Resident #39 had 9 falls between 4/3/18-8/11/18. Interventions on the falls investigation were not consistently placed on the care plan. There were 6 falls with no intervention added to the care plan. Medical record review revealed Resident #40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #40 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #40's care plan dated 5/23/18, revealed Resident #40 is at risk of falls due to weakness, History of Falls, Dementia and Hypertension. Interventions including wear non-slick footwear that fits; instruct the resident on safety measures to reduce risk of falls; attempt to engage in activities of daily living (ADL's) that improve strength; balance and posture, and keep areas free of obstacles to reduce the risk of falls or injury Medical record review of facility documentation revealed the resident had a total of 4 falls between 6/27/18 and 8/2/18. Medical record review of Resident #40's care plan dated 8/6/18 revealed the care plan was not updated to reflect the resident had falls on the following dates: 6/27/18, 7/16/18, 7/30/18 and 8/2/18. Continued review revealed the resident's care plan was not revised to reflect new or effective interventions to address the resident's continued falls resulting in the resident sustaining a head injury. Observation and interview with LPN Nurse Mentor #2 on 8/17/18 at 10:00 AM, in the resident's room, confirmed the resident was in bed with the head of the bed up, fall mats to both sides of the bed were without alarms, and the call light was out of reach of the resident. Further observation revealed the Nurse Mentor took the Call Before You Fall sign off the closet door and asked the resident to read the sign. Continued observation revealed Resident #40 held the sign in her hand, smiled, and stated nice. The resident was not able to read the Call Before You Fall sign. Further interview confirmed .She doesn't use the call bell, she hollers for us . Continued interview confirmed the Call Before You Fall sign was not an appropriate intervention for Resident #40 and re-education on the use of a call light for a severely cognitively impaired resident was not an appropriate fall prevention intervention. Interview with the DON on 8/20/18 at 11:15 AM, in the conference room confirmed the resident had multiple falls without appropriate interventions put in place. In summary, Resident #40 had 4 falls between 6/27/18 and 8/2/18. Interventions on the falls investigation were not placed on the care plan. There were no new interventions added to the care plan after each fall. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed Resident #47 required extensive assistance of I person with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #47's comprehensive care plan with an effective date of 4/5/18 revealed, .at risk for falls d/t weakness, RT (related to) acetabular fracture (a break in the socket portion of the hip joint) s/p (status/post) fall, vision impairment, [MEDICAL CONDITION], dementia, anxiety, [MEDICAL CONDITION] disorder, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] med use . Continued review of the care plan revealed, .Actual falls 4/9/18, 4/10/18, 4/11/18, 4/14/18, 4/23/18, 4/25/18, 4/26/18, 4/27/18, 5/6/18 .Goals .will maintain current level of mobility with no increase in the incidence of falls/injuries .Interventions .Assist .to wear non-slick footwear that fits .attempt to engage .in ADLs that improve strength, balance, and posture .instruct .on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .keep areas free of obstructions to reduce the risk of falls or injury .keep nurse call light within easy reach .Instruct .to use call bell or call out for assistance .keep personal items within easy reach; bed to be in lowest position with wheels locked .bean bag provided to reduce the risk of falls .self-releasing lap buddy to reduce the risk for falls with injury . Continued review revealed none of the interventions documented on the care plan had been dated to illustrate when the interventions were initiated and implemented. Review of an Incident/Accident Report dated 4/5/18 and timed 7:30 PM revealed Resident #47 .crawled from his room into (another room). Multiple skin tears on bilateral elbows and L (left) knee bruise . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: call before you fall, bed in low position Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 4/5/18 or the intervention to post call before you fall sign. Review of an Incident/Accident Report dated 4/9/18 and timed 10:30 PM revealed the resident had a fall in the resident's room without injury .called to resident room. CNA report that resident had been on floor mat by bed on knees . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: call before you fall, increased rounds . Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the new intervention of increased rounds. Review of an Incident/Accident Report dated 4/11/18 and timed 2:45 PM revealed, .sitting in wheelchair in day room with spouse. Leaned forward and slid out of chair. Landed on buttock . Continued review revealed, .Additional comments and/or steps to prevent recurrence: Informed spouse of need for full time sitter . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the recommendation for the family to hire a sitter. Medical record review of a nurse note dated 4/25/18 revealed, .resident was transferred to floor (to another unit) .he has been getting out of his w/c since he arrived to floor, causing his personal alarm to go off, staff has been able to prevent resident from falling or scooting on the floor up to this point, he has wandered in the area between staff bathroom and med room and scooted himself out of his chair and onto the floor .transferred back to his chair after assessment for injury . Medical record review of the resident's care plan revealed the use of a personal emergency alarm for the resident was not included on the resident's care plan. Review of an Incident/Accident Report dated 4/25/18 and timed 11:30 PM revealed, .CNA notified this nurse that resident was lying in floor beside bed . Review of a Fall Investigation Tool dated 4/25/18 revealed, .intervention .fall mats . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the use of fall mats for the resident. Review of an Incident/Accident Report dated 6/13/18 and timed 11:50 AM revealed, .called to room by PT (physical therapy) staff. Pt (patient) was already back in bed but was asleep on mat beside bed when physical therapy found him .he says 'I did not fall or get hurt' . Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: offer rest periods, know whereabouts . Medical record review of Resident #47's care plan revealed the care plan was not revised to reflect the fall on 6/13/18 and was not revised to reflect the interventions of offering rest periods and .know whereabouts . Observation and interview on 8/18/18 at 3:50 PM, in the resident's room, with CNA #17 revealed no call before you fall sign posted. Interview with CNA #17 confirmed fall mats were located on each side of the resident's bed (not on the resident's care plan). Continued interview revealed the CNA had never known the resident to have had any alarms or seatbelts since the time the resident was moved to the secure unit (approximately 2 months ago). Continued observation in the resident's room also revealed no bean bag chair was in the resident's room as documented on the resident's care plan. Interview and review of Resident #47's care plan with the DON on 8/20/18 at 3:45 PM, in the conference room, revealed the Household Nurse Mentor was responsible for ensuring revisions to the resident's care plan after a fall. Continued interview and review of Resident #47's care plan confirmed the resident's care plan was not revised to reflect the fall on 6/13/18 or the interventions of offering rest periods and .know whereabouts . Continued interview confirmed the resident's current plan of care did not accurately reflect the actual interventions which were observed to be in place at this time. Medical record review revealed Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed Resident #80 required extensive assistance with bed mobility and personal hygiene, and was totally dependent upon staff for dressing, eating and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of the quarterly care plan undated revealed Resident #80 was at risk for falls. Further review revealed Resident #80's care plan was not updated with effective interventions after falls on 3/1/18, 4/20/18 and 6/19/18 nor after a fall with serious injury on 7/2/18. Medical record review of the clinical notes dated 7/2/18 revealed .returned from (hospital) .C1(cervical)-C2 Fx (Fracture) and Aspen (Rigid neck brace) collar placed around residents neck, collar is to stay in place for 3 months .laceration to forehead with stitches .will continue to monitor . Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hallway, revealed interventions were to be placed on the care plan and updated by the .care plan manager . Refer to F689

Based on review of facility policy, medical record review, observation and interview, the facility failed to maintain dignity by not providing timely assistance with toileting for 1 resident (#89) and not providing incontinence care for 1 resident (#80) of 52 residents sampled. This failure resulted in psychosocial harm to Resident #89 and Resident #80. The findings include: Review of the facility Dignity Policy dated 1/1/17 revealed .Each resident shall be cared for in a manner that promote and enhances quality of life, dignity, respect and individuality .1. Residents shall be treated with dignity and respect at all times .11. Demeaning practices and standards of care that compromise dignity are prohibited . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) 14 day assessment dated [DATE] revealed Resident #89 had an indwelling catheter and was frequently incontinent of bowel. Medical record review of the unscheduled MDS assessment dated [DATE] revealed the Resident's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident required extensive 2 person assist for bed mobility, transfers, and toileting. Interview with Resident #89 on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with the Director of Nursing (DON) on 8/20/18 at 3:11 PM in the conference room, confirmed .she (Resident #89) was not treated with respect and dignity . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed the resident scored a 0 on the BIMS indicating the resident was severely cognitively impaired. Continued review revealed Resident #80 required 1 person assist for bed mobility, locomotion on unit, eating, toileting, dressing and hygiene. Continued review revealed the resident was always incontinent of urine and bowel and was not managed on a bowel and bladder incontinence program. Medical record review of the quarterly care plan, undated, revealed the resident was always incontinent .nursing to check every 2 hours and change if wet/soiled and clean skin with mild soap and water .apply moisture barrier . Continued review revealed Bowel Continence: incontinent of bowel movement .check for incontinence .every 2 hours .clean and dry skin if wet or soiled . Further review revealed Resident #80 required extensive assistance with bathing, hygiene, dressing and grooming with goal .will be odor free . Medical record review of the ADL (Activities of Daily Living) Verification Worksheet revealed Resident #80 was provided incontinence care on 8/13/18 at 12:54 AM with the next incontinence care documented on 8/13/18 at 6:40 PM at time lapse of 17 hours and 46 minutes. Observation of Resident #80 on 8/13/18 at 10:48 AM, in the 2 South dining room, revealed the resident with front of pants and perineal area wet. Observation of Resident #80 on 8/13/18 at 11:59 AM, in the dining room, revealed the resident with front of pants and perineal area wet and had a strong urine odor. Observation of Resident #80 on 8/13/18 at 4:03 PM, in the resident's room, revealed the resident sitting in a wheelchair in his room. Continued observation revealed Resident #80's pants and the bottom front of his shirt were wet and soiled with a brown and dark yellow ring at the bottom of the shirt and had a strong urine odor. Interview with Licensed Practical Nurse (LPN) #1 on 8/13/18 at 4:06 PM, in the resident's room, confirmed the resident's pants and shirt were wet with urine and he was in need of incontinence care. Continued interview revealed the last time resident had been provided incontinence care or toileted was unknown. Further interview confirmed the resident had a strong odor of urine. Interview with the DON on 8/15/18 at 3:50 PM, in the conference room, confirmed a resident wet with urine and with a strong odor of urine, sitting in the dining room area, could be offensive to other residents and could result in feelings of embarrassment for the resident.

Based on medical record review, observation and interview, the facility failed to provide assistance with activities of daily living for dependent residents by failure to provide bathing assistance for 1 resident (#53), and failure to provide timely incontinence care and toileting for 2 residents (#80 and #89) of 52 residents sampled. This failure resulted in Harm for Resident #80 and Resident #89. The findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly care plan updated on 5/30/18 revealed self-care deficit .Extensive assistance required with bathing .Scheduled shower days: Tuesday and Friday AM .2 Times Weekly Starting 06/23/2016 .Staff to ask (Resident #53) Every other day if she would like a bath .Active (Current) . Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Continued review revealed the resident required 2 person assistance with bed mobility and toileting and 1 person assistance with dressing, hygiene, and bathing. Medical record review of the Activities of Daily Living (ADL) Verification Worksheet revealed from 7/10/18 through 7/18/18, revealed Resident #53 received 1 shower. Interview with Resident #53 on 8/13/18 at 11:08 AM, in the resident's room, revealed the resident did not receive a shower .last week at all not Tuesday or Friday they told me they were short staffed .it has happened before .not enough of them . Continued interview revealed .I was supposed to get a shower twice a week . Interview with Certified Nursing Assistant (CNA) #3 on 8/15/18 at 9:25 AM, in the 2 South Dining room, revealed the facility did not always have enough help to take care of the residents. Further interview revealed there have been times residents have not received showers and missed a shower day that resulted in the residents receiving only 1 shower per week .Our Kiosk that we document in does not differentiate in partial showers, bed baths, showers or whatever it just says bathing and we mark that no matter what we do but that does not mean that a .shower is done .but it looks like it . Interview with Household CNA Coordinator #1 (a CNA also) on 8/15/18 at 9:40 AM, in the 2 south dining room revealed there are .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2-3 days out of the week . Further interview revealed there had been times the residents had not received showers because of staffing . Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 south dining room, confirmed .not always enough staff to meet the needs of the residents .it upsets me .we are understaffed, I can't do my job the way I would like . Continued interview revealed .It's that way almost every day just 2 of us . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 south den area, revealed there was not always enough staff to meet the needs of the residents .like today the person I was working with put her notice in so there is only 1 nurse, the weekends there are not enough CNA's, last Sunday there was only 1 nurse and 2 CNA's .there have been times the residents have not received a shower due to staffing . Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 south hallway, confirmed there .is never enough staff .recently had a set back with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the Director of Nursing (DON) and the Administrator . Medical record review revealed Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS 14 day assessment dated [DATE] revealed Resident #89 had an indwelling catheter and was frequently incontinent of bowel. Medical record review of the unscheduled MDS assessment dated [DATE] revealed the Resident # 89's BIMS score was 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was extensive 2 person assist for bed mobility, transfers, and toileting. Interview with Resident #89 on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with the DON on 8/20/18 at 3:11 PM in the conference room, confirmed .she (Resident #89) was not treated with respect and dignity . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the significant change MDS dated [DATE] revealed the resident was moderately cognitively impaired. Continued review revealed Resident #80 required 1 person assist for bed mobility, locomotion on unit, eating, toileting, dressing and hygiene. Continued review revealed Resident #80 was always incontinent of urine and bowel and was not managed on a bowel and bladder incontinence program. Medical record review of the quarterly care plan, undated, revealed the resident was always incontinent .nursing to check every 2 hours and change if wet/soiled and clean skin with mild soap and water .apply moisture barrier . Continued review revealed Bowel Continence: incontinent of bowel movement .check for incontinence .every 2 hours .clean and dry skin if wet or soiled . Further review revealed a self-care deficit with extensive assistance required with bathing, hygiene, dressing and grooming with goal .will be odor free . Medical record review of the ADL (Activities of Daily Living) Verification Worksheet revealed Resident #80 was provided incontinence care on 8/13/18 at 12:54 AM with the next incontinence care documented on 8/13/18 at 6:40 PM at time lapse of 17 hours and 46 minutes. Observation of Resident #80 on 8/13/18 at 10:48 AM, in the 2 South dining room, revealed the resident with front of pants and around perineal area wet. Observation of Resident #80 on 8/13/18 at 11:59 AM, in the dining room, revealed the resident with front of pants and around perineal area wet and had a strong urine odor. Observation of Resident #80 on 8/13/18 at 4:03 PM, in the resident's room, revealed the resident sitting in a wheelchair in his room. Continued observation revealed Resident #80's pants and the bottom front of his shirt were wet and soiled with a brown and dark yellow ring at the bottom of the shirt and had a strong urine odor. Interview with LPN #1 on 8/13/18 at 4:06 PM, in the resident's room, confirmed the resident's pants and shirt were wet with urine and he was in need of incontinence care. Continued interview revealed the last time resident had been provided incontinence care or toileted was unknown. Further interview confirmed the resident had a strong odor of urine. Interview with the DON on 8/15/18 at 3:50 PM, in the conference room, confirmed a resident wet with urine and with a strong odor of urine, sitting in the dining room area, could be offensive to other residents and could result in feelings of embarrassment for the resident.

Based on facility policy review, medical record review, observation and interview, the facility failed to prevent the development of a pressure ulcer for 1 resident (#80) wearing a medical device of 5 residents reviewed for pressure ulcers and failed to practice proper infection control prevention through hand hygiene during a dressing change for 1 resident (#119) of 2 persons observed for dressing changes of 52 residents sampled. The facility's failure resulted in the development of a pressure ulcer and Harm for Resident #80. The findings include: Review of the facility policy, Pressure Ulcers dated 5/1/11 revealed .To provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .All wounds, regardless of cause will be evaluated with documentation at each dressing change. A thorough wound evaluation will be completed at least weekly .Documentation will contain information regarding: Location and Staging .Size .Exudate .Pain .Wound bed .Description of wound edges .All pressure ulcers must be monitored daily .For pressure ulcers that do not have daily .dressing change ordered, the TAR (treatment record) should reflect daily monitoring .An interdisciplinary team will perform weekly wound rounds to observe and measure all pressure ulcers in the facility. Documentation of findings will be kept on the Weekly Pressure Ulcer Record .Skin/Wound Care Protocols .Relieve pressure in and out of bed . Review of the facility policy, Pressure Ulcer Prevention dated 6/2013 revealed .To assure that no pressure ulcers develop within the facility unless it is unavoidable . Review of the facility Skin Assessments/Checks Policy revised 7/24/18, revealed .A skin assessment will be conducted by the nurse on a weekly basis. Documentation will include any and all skin issues noted .Skin assessments will be done by nursing assistants on bath/shower days. Any skin issues noted will be reported to the resident's nurse . Review of the facility policy, Pressure Ulcer Treatment, revised 7/18, revealed .If a resident is noted to have a pressure ulcer the nurse in charge of the resident's care should be notified. The nurse should notify the Wound Nurse and Physician .Follow standing orders for pressure ulcers including writing the order as 'per treatment guidelines' .these guidelines have been approved by the Medical Director .The Wound Nurse will evaluate the initial treatment based off the standing orders on their next working day to determine if any changes need to be made based on the condition of the ulcer . Review of the facility policy, Infection Control: Handwashing dated 1/1/17 revealed .All personnel will follow the handwashing procedure to prevent the spread of infection and disease .Employees will perform appropriate handwashing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions .Before, during and after performance of normal duties such as handling dressings .Whenever doubt of contamination .Using gloves does not replace handwashing/hand hygiene . Medical record review revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident had moderate impaired cognitive skills for daily decision making. Continued review revealed the resident required assistance of 1 person for bed mobility, locomotion on unit, eating, toileting, dressing, hygiene, and 2 person assistance for transfers. Medical record review of the Clinical Note dated 7/2/18, at 10:19 AM, revealed the resident suffered a fall from the bed at approximately 9:10 AM, and was sent to the emergency room for evaluation. Medical record review of the Clinical Note dated 7/2/18 at 8:30 PM, revealed the resident returned from the emergency room at 8:10 PM, with the [DIAGNOSES REDACTED]. Continued review revealed the collar was to stay in place for 3 months then have a follow-up with x-rays to monitor progress. Continued review revealed the resident was also sent with a collar for bathing. Medical record review of the Weekly Skin Assessment Form dated 7/27/18 revealed .Open area to Rt. (right) Clavicle. Medical record review of the Clinical Note dated 7/28/18 at 8:24 AM, revealed on 7/27/18 at 9:21 PM, an open area described as a skin tear was discovered on the resident's right clavicle measuring 3 centimeters (cm) in length by 0.8 cm in width. Medical record review of the Physician's Order and progress notes dated 7/30/18 revealed .Consult wound care team for evaluation and treatment of [REDACTED]. Medical record review of the Clinical Note dated 8/2/18 at 7:29 AM, revealed the resident was evaluated by the Wound Nurse Practitioner (NP). Continued review revealed the wound to the resident's right clavicle measured 3.2 cm by 2.6 cm by 0.2 cm. Continued review revealed the NP described the wound as unstageable at this time and facility acquired pressure ulcer, medical device related injury. Medical record review of the Physician's Order and progress notes dated 8/2/18 revealed .refer to (neuro surgeon) for cervical fracture follow up .Please D/C (discontinue) Hard C-collar .Place patient in soft cervical collar .D/C current wound treatment .[MEDICATION NAME] Blue .R (right) cervical wound .change every 3 days and PRN (as needed) . Medical record review of the Clinical Note dated 8/7/18, revealed the wound to the right clavicle was evaluated by the NP and measured 2.3 cm by 1.1 cm. Review of the Care Plan undated, conducted on 8/14/18 revealed no documentation or update that included C1-C2 fractures, care and use of the cervical collar, pressure ulcer development and specific treatment or interventions. Observation of the resident on 8/14/18 at 5:17 PM, in the resident's room, revealed the resident received wound care to unstageable right clavicle wound provided by Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. Continued observation revealed the soiled dressing to right clavicle was removed and contained a moderate amount of yellowish-brown drainage on the dressing, and the wound bed was covered with slough which indicated an unstageable wound. Interview with the Director of Nursing (DON) on 8/16/18 at 9:05 AM, in the conference room, confirmed the expectation was a daily skin assessment to be conducted on residents who wore a splint, or a Cervical Collar. Interview with Licensed Practical Nurse (LPN) #2 on 8/16/18 at 9:30 AM, on 2 South Hallway, revealed skin assessments were conducted by nursing staff weekly. Continued interview revealed the CNAs (Certified Nursing Assistant) reported skin issues that were observed during bathing or care. Further interview revealed residents who wore splints or cervical collars should have had skin checked weekly and when bathed. Interview with CNA #4 on 8/16/18 at 2:21 PM, in the 2 South living room area, revealed CNAs were not allowed to remove the C-Collar. Continued interview revealed the nurse changed the soft collar out with one used on bath days. Further interview revealed the C-collar had not been removed except for bath days. Interview with CNA Household Coordinator #1 on 8/16/18 at 2:23 PM, in the 2 South living area, revealed CNAs did not remove cervical collars. Continued interview revealed the nurse changed the cervical collar for shower days. Interview with CNA #3 on 8/16/18 at 2:42 PM, in the 2 South living room area, revealed the C-collars were exchanged for showers and that was the only time the C-collar was removed. Interview with the wound NP on 8/17/18 at 5:10 PM, in the conference room, revealed the wound to right clavicle was a preventable, avoidable, medical device induced pressure ulcer. Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation with the Wound Care Nurse on 8/15/18 at 8:14 AM, in Resident #119's room, revealed the Wound Care Nurse prepared for wound care for 2 pressure ulcers and 1 lesion: *Stage 2 pressure ulcer located on the right heel *Lesion on the left foot *Stage 2 pressure ulcer located on the L ischial Continued observation revealed the Wound Care Nurse washed her hands, applied clean gloves, removed sock from the right heel, applied wound cleanser and applied [MEDICATION NAME] to pressure ulcer. Continued observation revealed she reapplied sock to the right foot and removed sock from left and applied wound cleaner to the left foot lesion with her contaminated glove. Further observation revealed she placed her gloved contaminated fifth digit of her hand in triad cream and placed it on the left foot lesion. Continued observation revealed the Wound Care Nurse reapplied the resident's left sock and repositioned the resident's pants to reveal the left ischium pressure ulcer. Further observation revealed she removed the dressing with her contaminated gloved hands then removed the contaminated gloves. Continued observation revealed she applied clean gloves to her uncleaned hands. Further observation revealed she measured the left ischium pressure ulcer with her contaminated gloves, applied wound cleanser to the pressure ulcer, placed the [MEDICATION NAME] Blue directly on the wound, and applied a new dressing with unclean hands. Continued observation revealed she placed the contaminated items in the bag, removed her contaminated gloves and washed her hands. Interview with the Wound Care Nurse on 8/15/18 at 8:25 AM in the conference room, confirmed, .I failed to remove my gloves and wash hands during the dressing change .I applied treatment with dirty gloves . Interview with the Director of Nursing (DON) on 8/16/18 at 9:52 AM in the conference room confirmed .She failed to wash her hands and apply clean gloves during the dressing change. She (Wound Care Nurse) did not follow infection control practices and did not follow our policy .

Based on facility policy review, medical record review, observation, and interview the facility failed to assess and monitor the effectiveness of an individualized Pain Management Program for 1 resident (#236) of 3 residents reviewed for pain of 52 sampled residents. The facility's failure to effectively control Resident #236's pain resulted in actual Harm to the resident. The findings include: Review of the facility policy, Pain Management, undated, revealed .Pain is always subjective; pain is whatever the person says it is .Fear of dependence, tolerance and addiction does not justify withholding opioids [MEDICATION NAME] in residents suffering with pain .Alert Communicative Resident .1. Resident identified with having pain will be asked degree of pain according to Numerical Pain Scale (0-10), with zero representing no pain and 10 representing the worst possible pain .4. Efficacy will be documented within one hour after administration of [MEDICATION NAME] .9. Physician will be notified of ineffective [MEDICATION NAME] .10. Physician will be notified immediately if pain suddenly becomes severe .18. Prevalent pain breakthrough should be reported to physician . Medical record review revealed Resident #236 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set assessment dated [DATE], revealed the resident had a score of 15 on the Brief Interview For Mental Status, indicating she was cognitively intact. Medical record review of a care plan, undated, revealed .Potential for altered level of comfort-chronic pain related to .recent pressure ulcer s/p (status [REDACTED].Interventions .Notify MD (Medical Doctor) of unusual complaints of pain . Medical record review of a Nurse Practitioner's (NP) note dated 8/2/18 revealed .Discussion with patient regarding pain management had requested an increase in pain meds due to wound. Education provided re (regarding) pain management and good stewardship of use. Discussed times of administration important to better manage pain related to wound . Neurological .Patient is awake, alert and oriented x 3 . Medical record review of a nurse's note dated 8/6/18 at 3:29 PM revealed .Resident had c/o (complaints of) pain unrelieved by PRN (as needed) medication .NP notified. New orders to continue pain medication and new order for [MEDICATION NAME] (medication to treat anxiety) PRN for anxiety . Medical record review of a Physicians Order dated 8/6/18 revealed [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) 10 milligrams (mg)-325 mg tablet PRN every 6 hours and [MEDICATION NAME] (medication to treat anxiety) 0.5 mg tablet PRN every 12 hours. Resident went to [MEDICAL TREATMENT] this AM .Resident did not tolerate dressing changes well . Medical record review of a nurse's note dated 8/6/18, revealed .Resident stated she did not need the [MEDICATION NAME] at this moment .Wound care done on L (left) hip this AM. Resident is now refusing to have wound care done on R (right) hip d/t (due to) pain, wound care nurse made aware. Will continue to monitor for further changes . Medical record review of a Wound Nurse note dated 8/6/18 revealed .Talked a long time for importance of changing drsgs (dressings) twice a day with reasoning .Right buttock wound was surgically had debridement done. Measured 12.8 x 9.8 .Left buttock wound measured 14 x 14 .There is another small wound noticed just below it measures 3 x 1.5 . Medical record review of a nurse's note dated 8/7/18 revealed .Resident complained of pain that is unrelieved by PRN pain medication . Wound care completed. Resident did not tolerate dressing changes well . Medical record review of a nurses note dated 8/8/18 at 4:06 PM revealed .Also discussed about the importance of accepting and managing the wound care as ordered .Ensured that pain management prior to the dressing change for the best outcome . Medical record review of a Physicians Order dated 8/9/18 revealed .medicate for pain prior dressing change . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of a Nurse's Note for Resident #236 dated 8/13/18 at 1:50 PM revealed pain on a scale of 10 while dressings being changed . Interview with the Licensed Practical Nurse (LPN) #13 on 8/15/18 at 9:30 AM, on the 300 unit, confirmed the resident had complained of pain during dressing changes on 8/13/19 and 8/15/18 and had been given the medication prior to dressing change but did not report the unrelieved pain to the Physician. Interview with Certified Nursing Assistant (CNA) #23 on 8/15/18 at 9:40 AM, on the 300 hallway confirmed she had been in the resident's room during a dressing change and the Resident #236 .hollered out . when the dressing was changed and when the resident was repositioned. Observation and interview with Resident #236 on 8/15/18 at 9:55 AM, in the resident's room revealed the resident was awake and alert, resting in bed. Continued observation revealed mild facial grimacing noted with movement. Continued interview with the resident confirmed she received pain medication before the dressing change but still had severe pain during the dressing changes twice a day. Further interview confirmed she had reported the pain to the nurses and the Nurse Practitioner. Continued interview confirmed on a scale of 1 to 10 the pain is a 10, and that she has yelled out and asked the staff to stop during the dressing change. Further interview confirmed she just bears it .I don't think the pain medication is strong enough to control it . Continued interview confirmed she had refused to have dressing changes done due to the dressing changes being so painful. Interview with the Wound Nurse on 8/15/18 at 11:25 AM, in the conference room, confirmed the resident had experienced pain during dressing changes, and she required a lot of emotional support and encouragement to get through the treatment. Further interview confirmed she had not notified the Nurse Practitioner of Resident #236 having pain during the dressing changes. Continued interview confirmed .The dressing change cannot be pain free . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed the resident had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Continued interview confirmed she asked the resident if it always hurt like this and the resident stated yes. Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on the resident and most times she has pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it (wound) hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Further interview confirmed pain is to be monitored every shift. Interview with the Nurse Practitioner #1 on 8/16/18 at 10:05 AM, in the conference room, confirmed she addressed the resident's complaints of pain with the resident when she was first admitted and did not want to increase the pain med at that time but discussed timing of the pain medication related to timing of the dressing changes. Continued interview confirmed she was not made aware by staff that the resident was experiencing extreme pain during the dressing changes. Interview with the Director of Nursing on 8/16/18 at 5:20 PM, in the conference room confirmed staff failed to monitor, manage and report unrelieved pain for Resident #236 and failed to follow the facility's pain management policy to use the numerical pain scale with a cognitively intact resident and reassess pain within 1 hour after administration of an [MEDICATION NAME](pain medication.

Based on medical record review, review of a facility investigation, facility policy review, and interview, the facility failed to ensure residents were free of significant medication errors for one resident (#124) of thirty-nine residents reviewed. The medication error resulted in an emergent hospitalization and harm for resident #124. The findings included: Resident #124 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired and required extensive staff assistance for all activities of daily living. Medical record review of a Physician's Progress Note dated January 4, 2013, revealed the resident had been administered the following medications prescribed for the resident's roommate: [MEDICATION NAME] 100 milligrams (mg) (anithypertensive medication), [MEDICATION NAME] 5 units (insulin/diabetic medication), [MEDICATION NAME] 500 mg (anticonvulsant), Tylenol, Aspirin, [MEDICATION NAME], Carvedilol 25 mg (antihypertensive), [MEDICATION NAME] 20 mg (antidepressant), and [MEDICATION NAME] 60 mg (cardiac medication/lowers blood pressure and heart rate). Continued review of the Physician's Progress Note dated January 4, 2013, revealed the medication error resulted in a sharp decrease in blood pressure (72/40) and heart rate (48) for the resident, and required emergent transport to the local hospital, and a three day admission to the intensive care unit. The resident was returned to the facility by ambulance on January 7, 2013. Review of an undated facility policy, Medication Administration, revealed "...before giving a resident any medication: validate the medication: right resident, right medication, right dose, right route, right time...identify the resident by using one of the following: photo identification, resident's identification bracelet, or have the resident state their name...no medication will be given if the resident cannot be identified..." Review of a facility investigation dated January 4, 2013, revealed a Medication Error Report which stated "...Description of error: resident rec'd (received) ASA 81 mg (aspirin), [MEDICATION NAME] 25 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 500 mg, MPAP 500 mg...nurses will be more careful to identify correct resident...pictures of residents put (with) MAR (Medication Administration Record) and ID (identification) bracelets applied to each resident..." The facility investigation included a statement by the Director of Nursing (DON), who responded at the time of the medication error. The DON assisted the LPNs in attempts to stabilize the resident's blood pressure with IV (intravenous) fluids, and obtained physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN #2) on January 10, 2013, at 10:25 a.m., in the third floor nurse's station, confirmed on January 4, 2013, during the morning medication pass, the facility policy regarding medication administration and resident identification had not been followed. Continued interview confirmed a medication error occurred when resident #124 received the roommate's medications (listed above). The LPN provided a signed statement, to the DON, as a part of the facility investigation into the medication error. The LPN's signed statement revealed a new nurse/orientee had administered the medications, in the third floor dining area, without correctly identifying the two residents. The error was discovered and reported when the roommate's family member, familiar with both residents, recognized resident #124 had received an insulin injection prescribed for the roommate. During the interview LPN #2 confirmed the signed statement was complete regarding the details of the incident. Interview with the DON and Administrator on January 10, 2013, at 2:00 p.m., in the Administator's office, confirmed on January 4, 2013, the facility policy related to medication administration and resident identification had not been followed, and a medication error occurred. This medication error resulted in harm and hospitalization for the resident.

Based on medical record review, review of facility investigation documentation, observation, and interview, the facility failed to ensure safety devices were in place to prevent falls with injury for one (#5) of eleven residents reviewed, resulting in harm to Resident #5 who was transferred to the Emergency Department for sutures for a head laceration. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Psychiatric Note dated March 15, 2012, revealed, "...confused...Orientation: self...Insight:poor...Judgment: poor..." Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was severely impaired with decision-making skills, non-ambulatory, totally dependent on staff for all activities of daily living, and required the assistance of two staff for transfers. Medical record review of a Fall Risk assessment dated [DATE], revealed a score of seven and included, " ...Requires aid with transfers...and is unwilling/unable to ask for assistance...If resident score 4 or more a fall leaf will be placed outside the door and care planned at risk." Medical record review of the care plan effective through June 21, 2012, revealed, "...at risk for falls related to history of fall...safety unawareness...Full side rails with padding to bed..." Medical record review of a nurse's note dated April 30, 2012, at 8:50 p.m., revealed, "Heard alarm sounding, upon entering room resident noted lying on floor beside bed. Laceration freely bleeding noted to R (right) forehead. Pressure applied to stop bleeding. R siderail down ...Sent to (Hospital #1)..." Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated April 30, 2012, at 8:50 p.m., revealed, "...Sent to (hospital)..." Medical record review of a hospital emergency room record dated April 30, 2012, revealed, " ...Chief Complaint: Fall ...presents via EMS (Emergency Medical Services) from nursing home secondary to sustaining a head laceration. Apparently the patient was placed in bed and bed rails were not put in place and the patient slid out of bed striking the floor ...laceration noted on the forehead ...pertinent history ...Left side weakness Dementia ...Insomnia ...total of ten ...sutures were placed ...Diagnosis: [REDACTED]. Review of facility investigation documentation dated April 30, 2012, revealed, "...Describe exactly what happened...Resident found lying on floor next to bed. Alarm was sounding. Laceration to forehead. Pressure applied to stem bleeding. Side rail x 1 down...Nursing applied pressure to head wound. Paramedic applied head bandage..." Continued review revealed, "...What was the resident doing prior to the fall? Placed into Bed for HS (bedtime)...Resident activity prior to fall: in bed...Medication: Ativan 0.5 mg (milligrams) @ 8 PM...aware of own limitations: no...Environmental factors...Side rails: up x 1..." Medical record review of a nurse's note dated May 1, 2012, at 12:15 a.m., revealed, "Resident returned to facility ...DRSGS (dressings) applied to forehead, forearm, and bil (bilateral) elbows ..." Medical record review of a Therapy Screen dated May 2, 2012, revealed, "...Diagnosis/Condition/Problem: fell [DATE] OOB (out of bed). siderail down on bed...Comments: Pt (patient) has been in bed or Jeri-chair (geri-chair) @ all times. Lift use to get pt OOB..." Observation on June 12, 2012, at 9:30 a.m., revealed the resident asleep in bed, siderails raised, and mats on both sides of the bed. Observation on June 13, 2012, at 9:58 a.m. revealed the resident awake, in bed, and a Certified Nursing Assistant (CNA) #1 shaved the resident. Continued observation and interview with the resident revealed siderails raised, mats on the floor on both sides of the bed; the resident was unable to respond appropriately to questions and unaware of (resident's) fall. Interview with CNA #1 on June 13, 2012, at 9:58 a.m., in the resident's room, revealed the resident did not attempt to get out of bed, and the CNA stated, "(Resident) does scoot around..." Interview with the Director of Nursing (DON) on June 13, 2012, at 3:00 p.m., in a conference room, confirmed the facility failed to ensure siderails were in place to prevent a fall with injury for Resident #5 on April 30, 2012.

Based on review of the facility's plan of correction, medical record review, observation, and interview, the facility failed to ensure safety devices were in place to prevent falls for one resident (#5) of six sampled residents. The findings included: Review of the facility's Plan of Correction from a complaint survey completed on June 25, 2012, with a correction date of July 13, 2012, revealed, "...Side rails have been raised x (times) 2 with mats on floor beside bed. Care plan has been updated with current safety precautions. Side rail assessments have been completed on all residents on (resident's floor)..." Resident #5 (#5 for survey completed June 25, 2012) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Side Rail Evaluation dated May 15, 2012, revealed the resident was unable to get out of bed safely and included, "...Interventions utilized...will communicate with family about removing full rails and replace with half rails..." Medical record review revealed no documentation regarding another Side Rail Evaluation. Medical record review of a Minimum Data Set, dated dated dated [DATE], revealed the resident was impaired with decision-making skills, totally dependent on staff for all activities of daily living, and had a history of [REDACTED]. Medical record review of a care plan dated June 20, 2012, revealed, "...SAFETY PRECAUTIONS...Floor mats...at risk for falls...safety unawareness...Full side rails with padding to bed..." Medical record review of a physician's orders [REDACTED]." Medical record review of nurse's notes revealed no documentation on or since July 13, 2012. Observation on August 8, 2012, at 9:18 a.m., revealed the resident asleep on a low bed, a 3/4 unpadded siderail on the right side of the bed was raised and the siderail on the left side of the bed was lowered. Continued observation revealed a mat on the floor on the left side of the bed and no mat on the right side of the bed. Observation with Licensed Practical Nurse (LPN) #1 on August 8, 2012, at 9:20 a.m., revealed the resident on the bed and the left siderail on the resident's bed was not raised. Observation on August 8, 2012, at 10:23 a.m., revealed the resident on the bed and the left side rail was not raised. Interview with Certified Nursing Assistant (CNA) #1 on August 8, 2012, at 10:30 a.m., in the hallway outside the resident's room, revealed CNA #1left the siderail down after providing care for the resident. Continued interview revealed the information regarding safety devices required by residents was available in a notebook, and CNA #1 stated, "...It (left siderail) stays down." Review of a list in a notebook "Restraints Bedrails" with CNA #1on August 8, 2012, at approximately 10:35 a.m., in a nurse's station, revealed, "...(Resident #5) Bed lowest position - Bedrails Down x 2-Leftside Bedside mat x 1 (Half Rails)..." Interview with LPN #2 (the resident's nurse) on August 8, 2012, at 10:50 a.m., at a nurse's station, revealed safety precautions to prevent falls for Resident #5 included a low bed with the left siderail lowered. Interview with Nurse Practitioner (NP) #1 on August 8, 2012, at 11:07 a.m., revealed the facility attempted to reduce the number of residents requiring the use of siderails. NP #1 stated, "...feel like (Resident #5) would benefit from (the use of) two siderails..." Interview with the Director of Nursing on August 8, 2012, at 9:30 a.m., in the family room, revealed no assessment for use of siderails had been completed since May 15, 2012. Continued interview confirmed the facility failed to ensure safety devices were in place to prevent falls for Resident #5 and/or implement the plan of correction.

Based on medical record review, review of facility provided documentation, observation, and interview, the facility failed to ensure safety devices were functioning and in place to prevent a fall with injury (harm) for one (#3) resident., and failed to ensure safety devices were in place to prevent falls for one (#6) of twenty-five residents reviewed. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed resident #3 had impaired short and long term memory, moderate difficulty with decision making, had a history of [REDACTED]. Medical record review of the resident's current care plan updated on November 10, 2010, December 8, 2010, and January 5, 2011, revealed "...deficits in memory, decision making, communication and judgement R/T (related to) Alzheimer's Dementia...Personal alarm: bed chair 11-10-10 Pressure sensor: bed..." Medical record review of the nurse's notes dated August 18, 2010, to November 10, 2010, revealed the resident had several falls without injury. Medical record review of the nurse's notes dated November 24, 2010, revealed "...found sitting in floor beside bed. Res(resident) had removed personal alarm and bed sensor did not alarm. No injuries found..." Review of the facility documentation dated November 24, 2010, revealed "...resident removed personal alarm & sensor did not sound. Therapy to screen... Interventions; (no interventions were marked). See Interdisciplinary note..." Medical record review of the Therapy Screen dated December 1, 2010, revealed "...Reminded resident to push call button. Pt does have confusion..." No documentation was found if the function of the alarms was assessed to improve the resident's safety. Review of the facility documentation dated December 4, 2010, revealed resident #3 "...was lying on the floor next to the bed...Personal alarm hx (history) of taking it off...found in bed unattached to resident...Pressure sensor (pad in the bed that sounds when resident attempts to get out of the bed) on- did not activate until CNA (Certified Nurse Assistant) pushed it to see why it didn't work...Level of Consciousness A (alert) & OX1 (oriented to one {self})" Continued review revealed no documentation the function of the alarms was assessed to improve the resident's safety. Medical record review of a nurse's note dated December 6, 2010, revealed "...resident in hospital (transfered to the hospital on December 5, 2010)...X-ray results Fx (fracture) R (right) femur (long bone in the leg connected to the hip)..." Review of the Falls Interdisciplinary Team Narrative Note dated December 6, 2010, revealed "...Resident curently in hospital. Screen completed prior to hospitalization with poor safety awareness..." Medical record review of the resident's careplan revealed the resident was readmitted on [DATE], and no new interventions for safety were put in place upon re-admission. Review of the facility provided documentation dated January 8, 2011, revealed "...Res found in floor @ (at) FOB (foot of bed)...Personal alarm removed by pt & cord wound up &(and) set on bedside table ..." Continued review revealed no documentation the use of the alarms was assessed to improve the resident's safety. Observation on June 1, 2011, at 1:30 p.m., in the dining room revealed the resident in the wheel chair with the personal alarm attached to the sweater and the control box in a bag on the back of resident's wheel chair (wc). Continued observation revealed resident #3 heard a beeping noise, reached into the bag on the back of the wheel chair removed the control box, checked if the tab was still attached to the box, and returned it to the bag. Observation and interview on June 2, 2011, at 1:40 p.m., near the 1 South nurse's desk with Licensed Practical Nurse (LPN) #1, CNA #1 and CNA #2, revealed the resident in the wheel chair without the personal alarm attached to the resident. Continued observation revealed LPN #1 searched the resident's bag on the back of the wheel chair, and the bag contained the personal alarm with the string wrapped around the control box. Continued observation revealed CNA #1 and CNA #2 re-attached the personal alarm to the resident and put the control box into the bag on the back of the resident's wheel chair. Interview with LPN #1, CNA #1, and CNA #2 all confirmed resident #3's personal alarm was not attached to the resident to alert staff of unsafe attempts to transfer self. Interview on June 2, 2011, at 1:05 p.m., in the facility conference room with the Director of Nursing (DON) confirmed the resident removed the personal alarm and the bed sensor alarm did not sound on November 24, 2010, resulting in the resident falling with no injury. Continued interview confirmed the resident again removed the personal alarm and the bed sensor did not sound on December 4, 2010, the resident fell fracturing the right femur resulting in harm. Continued interview revealed the DON could not find any documentation the functioning of the alarms, and the positioning of the alarms, was assessed to provide safety for the resident until the January 8, 2011, fall. Resident # 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk Assessment and the care plan dated November 12, 2010, revealed "... increased risk for falls related to weakness, psychotropic medications, tremors and rigidity associated with Parkinson's Disease, unaware of safety issues, forgetful, and leans forward in wc with history of falls." Continued review of the care plan revealed the resident required assistance of one, with transfers, positioning, ambulation and toileting. The resident also required a personal safety alarm (psa) while in the chair and in the bed. Medical record review of a nurse's note dated May 6, 2011, as a late entry regarding a May 4, 2011, "...resident found sitting on floor in front of w/c no apparent injuries ..." Continued medical record review of facility provided documentation dated May 4, 2011, revealed "...resident found sitting on floor in front of wc... personal alarm found on top of night stand...not on resident." Interview with the Assistant Director of Nursing on June 1, 2011, at 2:04 p.m., at the 2 South Nurse's Station, confirmed the resident had fallen forward, out of the wheelchair, and the psa was not on the resident as ordered, to alert the staff of unassisted transfers.