Every finding on record at Ascension Living Alexian Village Tennessee

Based on facility policy review, medical record review, facility investigation review, and interviews, and corrective action plans, the facility failed to prevent significant medication errors for 1 (Resident #99) resident of 4 residents reviewed for medication administration. Registered Nurse (RN) M administered medications intended for another resident to Resident #99 in error. The medication error caused Resident #99 to develop severe hypotension (low blood pressure) resulting in hospitalization. The facility's failure to administer medications according to physician's orders resulted in HARM to Resident #99. The facility was cited at F-760 as Past Non-Compliance. No further corrective actions are required. Non-Compliance began 9/1/2025 and ended on 11/17/2025. The findings include:Review of the facility policy titled, Administering Medications, dated 12/2024, revealed .Medications shall be administered in accordance with orders .per best practice/regulatory guidelines .The individual administering medications verifies the resident's identity before giving medications .The individual administering the medication must check the label 3 times to verify right resident, right medication, right dosage, right time and right .route of administration .before giving the medication . Review of the medical record revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Affecting Right Dominant Side, Atrial Fibrillation, Hypertensive Chronic Kidney Disease, Hypertension, and Anemia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #99 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #99 required supervision by staff with activities of daily living.Review of the facility investigation and witness statements dated 9/1/2025, revealed at approximately 8:25 AM, RN M obtained medications from the medication cart which were prescribed to another resident located next door to Resident #99. RN M failed to check the medication labels for the correct resident, medication, dosage, and time prior to the administration of the medications to Resident #99. RN Mfailed to identify the medication error that had occurred during the documentation of the medication administration to Resident #99. Resident #99 became symptomatic at approximately 10:25 AM (2 hours after administration of the incorrect medications) when he reported dizziness, and lightheadedness, and questioned the nurse as to what medications he had been given. RN M discovered she had administered medications intended for another resident located in the room next door to Resident #99, in error. Resident #99 received incorrect medications of Isosorbide Mononitrate Extended Release Tablet 120 milligrams (mg) (medication used to treat Coronary Artery Disease and lowers blood pressure), Jardiance 10 mg tablet (medication used to treat Diabetes, Heart Failure and Chronic Kidney Disease which lowers blood pressure and blood sugar levels), Losartan 50 mg tablet (medication used to lower blood pressure), Mucinex 600 mg (a decongestant), Pantoprazole 40mg (a medication used to treat gastric reflux) and Vitamin D3. Continued review of the facility investigation and nursing notes dated 9/1/2025, revealed .[Resident #99] was given wrong packet of medications .not his .but the person in neighboring room .Resident's BP [blood pressure] was 90/60 HR [heart rate] 53, BG [blood glucose] 168 .Nurse realized he was given wrong meds[medications] .contacted MD [medical doctor] .told to push fluids .give salty and sugary snack to counter [counteract medications] and recheck in half hour .When BP continued to drop 59/36 [critical low] MD ordered IV [intravenous fluids].500 ML [milliliter] bolus .Following bolus, BP improved to 76/53 [critical low] and MD ordered second 500 ML bolus .IV was lost [unable to be used] trying to set up second bolus .Resident reported 'seeing black things' and MD ordered him sent out [emergency room )ER)] and skip placing a new IV .911 was called .Resident was sent to [hospital] .Review of the regional hospital emergency department (ED) medical records for Resident #99 dated 9/1/2025, revealed .Chief Complaint . [Resident #99] is an 85 y.o. [year-old] male admitted [to the ED] with .hypotension .Patient [Resident #99] is direct transfer from [satellite hospital] due to medication error at SNF [skilled nursing facility] .Patient was inadvertently administered another patient's medications .received Isosorbide Mononitrate 120mg, Jardiance 10mg, Losartan 50mg .Mucinex 600mg, Pantoprazole 40mg and Vitamin D3 . Continued review revealed .After patient [Resident #99] was mistakenly given wrong medications .about 1.5 hours later he complained about light headedness, his BP rapidly trended down .An IV was started at the SNF .but was quickly sent by EMS to the [satellite hospital] ED where he arrived with a BP of 82/51 [low] He received another 500ml bolus en route to the ED .Received another 1500ML NS [Normal Saline] [bolus] at [satellite hospital] en route to [regional hospital ED] .On arrival.BP was 80/50 [low] and another 500 ML NS bolus was ordered . Continued review revealed .Subsequent BPs have been 99/57, 94/53, and 96/54 .All antihypertensives suspended and no meds prescribed that might adversely impact BP .He is awake, alert, oriented x4 [person, place, time, and circumstances] .denies any complaints .understands situation .Patient [Resident #99] is admitted for observation [to the hospital] overnight .once BP is stabilized . and side effects are resolved .During an interview on 12/9/2025 at 11:37 AM, RN M stated on the morning the error was made (9/1/2025), she was distracted as she spoke to another staff member while preparing medications from the medication cart. RN M stated she had inadvertently pulled the wrong medications (intended for another resident) from the medication cart and administered the medications to Resident #99, in error. RN M confirmed at the time of the medication error, she had not checked the labels or medications according to established clinical standards and facility policy, to verify the correct resident, medication, dosage, time, or route of administration before administering the medications to Resident #99.During an interview on 11/9/2025 at 11:50 AM, the Director of Nursing (DON) confirmed the facility investigation and root cause analysis conducted by the facility in response to the significant medication error of Resident #99 was a result of RN M violating facility policies, and not following the clinical standards of practice related to safe medication administration, which led to the severe hypotension, and hospitalization (HARM) to Resident #99. The facilities corrective action plans were reviewed, verified, and validated on site by the Surveyor from 12/8/2025 - 12/10/2025 as follows:On 9/1/2025, RN M informed facility administration of the error as soon as it was determined on 9/1/2025 and began monitoring and documenting Resident #99's vital signs and clinical status. The nurse and facility supervisor immediately notified the attending Physician and Responsible Party for Resident #99 of the error and impacts on the resident. The Physician ordered supportive treatments. The nurse and supervisory staff completed all required internal documentation of the incident which was reported to facility leadership. On 9/1/2025, an Ad HOC (unplanned meeting for a specific urgent purpose) Quality Assurance (QA) meeting of the incident was performed which included the house supervisor, DON, and the physician by phone, which was verified and validated onsite by the surveyor through review of the QA meeting minutes, sign in sheets, and interviews of administrative staff and physician from 12/8/2025 - 12/10/2025.On 9/1/2025, the facility Quality Director and DON performed a full audit of all medication carts in the facility for all resident medications and no other medication errors were identified. Surveyor verified and validated onsite from 12/8/2025 - 12/10/2025 through review of audits, documentation, and multiple staff interviews with no concerns identified. 0n 9/1/2025, after the facility investigation and root cause analysis was conducted, the facility initiated immediate re-education of all licensed nurses on duty which was conducted by the House Supervisor and the Quality Director related to the 5 rights of medication administration, standards of practice related to medication administration, and facility policy. All staff who were not on duty between 9/1/2025-9/2/2025 were required to complete online re-education prior to start of their next scheduled shift. Staff Education for all licensed nursing personnel was completed by 9/5/2025. Surveyor verified and validated onsite through review of staff education, sign in sheets, and facility documents, and through multiple staff interviews conducted on 12/8/2025 - 12/10/2025. On 9/5/2025, RN M received corrective counseling which was documented in the personnel file. RN M was reassigned to an alternate clinical unit after completion of counseling and re-education related to the five rights of medication administration. Surveyor verified and validated onsite RN M had received corrective counseling and was knowledgeable about the 5 rights of medication administration through employee record review and interview conducted on 12/10/2025. On 9/5/2025, the facility Quality Assurance (QA) Team reviewed the incident findings and ordered additional interventions which included Pharmacy Audits for 4 weeks that included observations of medication administration for accuracy and medication administration competency testing conducted from 9/5/2025 through 9/30/2025. The surveyor verified and validated onsite through review of the completed Pharmacy Audits, nurse competency testing, observations of medication administration, and medical record review of physician orders from 12/8/2025-12/10/2025. The facility QA team re-evaluated findings of the weekly audits and identified no other errors had occurred, and additional education related to medication administration and related facility policies, was completed on 10/20/2025. The QA team elected to continue observations and knowledge checks for two additional periods performed on 10/21/2025 and 10/30/2025 with no additional negative findings. The surveyor verified and validated onsite through facility documentation review from 12/8/2025 - 12/10/2025. The Surveyor verified, the facility continued with observations and knowledge checks with no concerns identified. The QA team conducted additional medical record reviews of randomly selected residents on 10/20/2025 - 11/17/2025. Nursing leadership reviewed findings in daily morning meetings with all the department heads. The facility continued with weekly medication cart audits by the DON and these audits were implemented as a measure to maintain sustained compliance and were ongoing at the time of the State Agency Recertification Survey with no additional medication errors identified. The surveyor verified and validated onsite through facility documentation review, weekly audit reviews, and interviews. The facility continues with ongoing audits with no concerns identified. The State Survey Agency (SA) corroborated the staff had received education and retraining related to the incident, medication errors, medication administration, following standards of practice, and the 5 rights of medication administration. The education was performed as reported/documented and verified through multiple staff interviews, and observations of medication administration passes conducted throughout the onsite recertification survey. No medication errors were observed during surveyor observations. No medication errors were detected during clinical record reviews of sampled residents. Quality Assurance sign-in sheets were also reviewed and corroborated with the corrective actions reported and the corresponding timeline and facility investigation documents. The facility's Medical Director confirmed participation in the QA meeting of the incident during interview on 12/9/2025.Review of the medical record revealed Resident #99 returned to the facility after an overnight hospitalization observation (9/2/2025) and completed his rehabilitation at the SNF without further incidents. Close monitoring of the resident was documented upon his return and continued until his eventual discharge back to an assisted living on 9/5/2025. At the time of the State Agency survey, Resident #99 remained in stable condition as a resident at the adjacent assisted living center on campus where he lived with his spouse.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure proper infection control practices related to hand hygiene were followed during meal service when 1 staff member failed to offer hand hygiene assistance to 1 resident (Resident #24) of #24 residents observed during meal tray distribution on 1 of 4 hallways.The findings include:Review of the facility's policy titled, Hand Hygiene, revised 6/2025, revealed .Encouragement, remainders, and/or assistance with hand hygiene is provided to residents before meals .Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Need for assistance with personal care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Further review revealed the resident required supervision or touching assistance with eating and partial to moderate assistance with personal hygiene.Review of the comprehensive care plan for Resident #24 revised on 3/10/2025, revealed .need assistance with daily ADL [activities of daily living] care .Hygiene/Oral .need total assistance .Eating .assist resident with [meal] tray set up .During an observation on 10/8/2025 at 12:24 PM, revealed Certified Nursing Assistant (CNA) K carry the meal tray down the 800 hallway. CNA K took the meal tray into Resident #24's room, opened the resident's silverware, picked up Resident #24's drink, opened a straw to place inside the drink, and opened the cover from the plate of food. Resident #24 picked up his fork and began eating his meal. CNA K failed to offer Resident #24 hand hygiene assistance prior to the resident eating the lunch meal.During an interview on 12/8/2025 at 12:57 PM, CNA K stated she failed to offer hand hygiene assistance to Resident #24 prior to the lunch meal service.During an interview on 12/9/2025 at 3:15 PM, the Director of Nursing (DON) stated the staff were to complete hand hygiene before assisting a resident with the meal tray setup and to offer hand hygiene assistance to all residents before serving the meal. The DON confirmed infection prevention and control practices were not maintained during the lunch meal service on 12/8/2025 when CNA K failed to offer Resident #24 hand hygiene assistance prior to the lunch meal service.

Based on review of the facility policy, observation, and interviews, the facility failed to reconcile controlled medications for 3 residents (Residents #86, #13, and #67) of 8 residents reviewed for controlled substance reconciliation. The findings include: Review of the facility's policy titled, Medication Administration, dated 12/2025, revealed .if medication is a controlled substance .sign narcotic book . During an observation and interview beginning on 12/9/2025 at 7:15 AM of the 700 East Medication Cart revealed the following: Registered Nurse (RN) N was asked to review Resident #86's narcotic reconciliation sheet. Review of the Controlled Drug Record (narcotic reconciliation sheet) for Resident #86 revealed .oxyCODONE (opioid used to treat moderate to severe pain) 10/325 MG (Milligram) .Amount Left .8 . Review of Resident #86's narcotic card revealed a count of 7 tablets remaining. RN N was asked about the difference in the number and stated, .she [Resident #86] refused the dose earlier and it needs to be wasted with the supervisor .There are 7 in the package, not 8 .RN N was asked to review Resident #13's narcotic reconciliation sheet. Review of the Controlled Drug Record for Resident #13 revealed .traMADol TAB (Tablet/opioid used to treat moderately severe pain) 50MG .Amount Left .23 .Review of Resident #13's narcotic card revealed a count of 22 tablets remaining. RN N was asked about the difference in the .Amount and stated, .I gave her a dose earlier .I signed them off in the computer but haven't signed them off in the book yet [narcotic reconciliation sheet] . RN N was asked to review Resident #67's narcotic reconciliation sheet. Review of the Controlled Drug Record for Resident #67 revealed .traMADol TAB 50MG .Amount Remaining .6 . Review of Resident #67's narcotic card revealed a count of 5 tablets remaining. RN N was asked about the difference in the number and stated, .I gave her a dose earlier .I haven't written it in the book yet . During an interview on 12/9/2025 at 9:08 AM, the Director of Nursing (DON) confirmed narcotics should be signed out on the narcotic reconciliation sheet as soon as they were administered to a resident

Based on review of the facility policy, review of the facility assessment, review of a facility document, review of resident council minutes, review of the medical record, observations, and interviews, the facility failed to ensure sufficient nursing staff as determined by the acuity of the resident population on 1 of 4 hallways observed. The findings include:Review of the facility policy titled, Procedure: Answering the Call Light, dated 1/2024, revealed .The purpose of this procedure is to respond to the resident's requests and needs .Answer the resident's call light as soon as possible .Review of the facility assessment tool dated 6/16/2025, revealed .Staffing Plan .Staffing ratios and needs are based upon resident census, resident need, and facility acuity [the severity of a resident's illness or condition, indicating the intensity of care needed] .Staffing assignments are based on overall patient [resident] acuity per unit [hallway] .Assignments are .modified to reflect resident needs based on acuity .Review of facility documentation dated 12/11/2025, revealed 9 residents of 18 residents on the 800-west hallway required 2-person assistance. Further review revealed out of the 9 residents, 4 required the use of a hoyer (mechanical patient lift used to safely move individuals who are bedridden or have limited mobility) lift.Review of a Resident Council Meeting Agenda/Minutes form dated 5/14/2025, revealed, .8 [NAME] needs a new CNA, wants 3 total .Review of a Resident Council Meeting Agenda/Minutes form dated 6/19/2025, revealed .needs a 3rd CNA on 8 west .request from Council members [Residents #78 and #35] .Review of a Resident Council Meeting Agenda/Minutes form dated 7/9/2025, revealed .ongoing staffing concerns .8th Floor .West .Review of Resident Council Notes dated 8/2025, revealed .8W [800-west hallway] .Council expressed concern about lack of CNA support .to support Hoyer .needs and .transfers .Review of Resident Council Notes dated 9/2025, 10/2025, and 11/2025, revealed staffing on 8-west was not discussed.Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Left Femur Fracture, and Muscle Wasting and Atrophy.Review of the comprehensive care plan for Resident #23 dated 11/26/2025, revealed .[Resident #23] needs assistance with daily ADL [Activities of Daily Living] care .TRANSFER .need total assistance .BED MOBILITY .need extensive assistance .TOILETING .extensive assistance .incontinent of bladder .bowel .BATHING .extensive assistance .DRESSING .total assistance .Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #23 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Further review revealed the resident required partial/moderate assistance for bathing, toileting hygiene, lower body dressing, and was dependent for personal hygiene.Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Type 2 Diabetes, Morbid Obesity, and Hemiplegia Following Cerebrovascular Disease Affecting Left Nondominant Side.Review of an annual MDS assessment dated [DATE], revealed Resident #35 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was dependent on staff for bathing, toileting hygiene, lower body dressing, and required substantial/maximal assistance with bathing and upper body dressing.Review of the comprehensive care plan for Resident #35 dated 10/31/2025, revealed, .[Resident #35] needs assistance with daily ADL care .need substantial assistance with upper body dressing and lower body dressing needs .total assist .needs substantial/total assist with toileting hygiene .substantial assist of 2 (total) for turning side to side .total assist with use of Hoyer lift .check and change q [every] 2 h [hours] .Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Functional Quadriplegia, Complete Lesion at C5 Level of Cervical Spinal Cord, Spastic Hemiplegia Affecting Left Nondominant Side, Neuromuscular Dysfunction of Bladder, and Need for Assistance with Personal Care.Review of the comprehensive care plan for Resident #37 dated 8/24/2023, revealed .[Resident #37] needs assistance with daily ADL care. Functional quadriplegia .C5 injury in accident. Non ambulatory .need total assistance x [times] 2 person staff support with transfer .hoyer lift be used with use of x2 staff support .catheter .incontinent of bowel .total assistance with 2 person staff support to turn side to side in bed .BATHING .total assistance with 2 person staff support .DRESSING .total assistance with 2 person staff support .TOILETING .dependent on 2 staff members with toileting .Review of a quarterly MDS assessment dated [DATE], revealed Resident #37 scored a 15 on the BIMS which indicated the resident was cognitively intact. Further review revealed the resident was dependent on staff for bathing, toileting/personal hygiene, and upper/lower body dressing.Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes, Quadriplegia, Morbid Obesity, and Need for Assistance with Personal Care.Review of the comprehensive care plan for Resident #78 dated 4/1/2024, revealed .[Resident #78] needs assistance with daily ADL care .dx [diagnosis] .Quadriplegia .TOILETING .total assistance .incontinent of bladder .bowel .BATHING .extensive assistance .DRESSING .Total assistance .TRANSFER .total assistance .2 person .sit to stand [a medical device that helps people who can stand but need assistance to rise from a seated position] lift .BED MOBILITY .total assistance with 2 person staff support .Review of a quarterly MDS assessment dated [DATE], revealed Resident #78 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident was dependent on staff for toileting hygiene, lower body dressing, and required substantial/maximal assistance with bathing and upper body dressing.During an observation on 12/9/2025 at 9:30 AM, Resident #78's (room [ROOM NUMBER] on the west hallway) call light was activated. Further observation revealed the call light remained unanswered after 20 minutes.During an observation and interview on 12/9/2025 at 9:50 AM, revealed resident #78 was seated in a wheelchair in her room. The resident stated she needed to be assisted to the bathroom for a bowel movement. The resident had activated the call light for assistance, and no one had checked to see what she needed. The resident also stated the staff were slow to respond to her call light frequently at various times of the day. Resident #78 stated she was incontinent of urine most of the time and was incontinent of bowel some of the time.During an observation on 12/9/2025 at 9:59 AM (call light activated for 29 minutes), revealed Licensed Practical Nurse (LPN) A answered Resident #78's call light and assisted the resident to the bathroom with a second employee.During an interview on 12/9/2025 at 10:05 AM, Certified Nursing Assistant (CNA) B stated she worked the 800-west hallway and there were 2 CNA's and a nurse daily on day shift (6:00 AM-6:00 PM). There were multiple residents that were a 2-person transfer/assistance and 3 residents (Residents #35, #37, and #78) who required up to 1 1/2 to 2 hours to provide the resident's care. CNA B also stated when 2 CNA's were in a resident's room who required 1 1/2 to 2 hour care, the CNA's were unable to answer other call lights and meet the needs of the other residents timely.During an interview on 12/9/2025 at 10:08 AM, CNA C stated she worked the 800-west hallway and there were 2 CNA's and a nurse daily on day shift. There were multiple residents that were a 2-person transfer/assistance and 3 residents (Residents #35, #37, and #78) who required up to 1 1/2 to 2 hours to provide the needed care. CNA C also stated when 2 CNA's were in a resident's room who required 1 1/2 to 2 hour care, the CNA's were unable to answer other call lights and meet the needs of the other residents timely.During an interview on 12/9/2025 at 10:12 AM, the Director of Nursing (DON) stated she was aware the 800-west hallway had multiple residents that required 2-person transfer/assistance. There were multiple residents who required up to 1 1/2 to 2 hours for the CNA's to provide personal care. The DON also stated she had asked some of the residents to move to another hallway .to spread out the acuity of the residents . and the residents refused to move.During an interview on 12/9/2025 at 10:45 AM, LPN A stated the hallway had multiple high acuity residents. Multiple residents on the 800-west hallway required 2-person transfer/assistance and some required up to 1 1/2 to 2 hours to provide the needed care. There were 2 CNA's and 1 nurse on shift at all times during day shift and when the CNA's were in a resident room who required 2-person staff assistance, other resident call lights were not always answered timely. LPN A also stated Resident #78 was incontinent of bladder and was incontinent of bowel 75% of the time.During an interview on 12/9/2025 at 11:30 AM, Resident #78 stated staff had assisted her to the bathroom and she had not been incontinent of her bowel.During an interview on 12/9/2025 at 2:10 PM, CNA D stated she used to work the 800-west hallway, and the hallway had 2 CNA's and 1 nurse scheduled daily on day shift. There were multiple residents who required 2-person transfer/assistance, and it would take a long time to provide care for some of the residents. CNA D also stated call lights were not always answered and care provided timely when 2 CNA's had to provide care for the 2 person assist residents.During an interview on 12/9/2025 at 2:15 PM, CNA E stated he worked the 800-west hallway at times, and the hallway had 2 CNA's and 1 nurse scheduled daily on day shift. There were multiple residents who required 2-person assistance, and it would take a long time to provide care for some of the residents. CNA E also stated call lights were not always answered and care provided timely when 2 CNA's had to provide care for the 2 person assist residents.During an interview on 12/9/2025 at 2:30 PM, Resident #35 stated she resided on the 800-west hallway in room [ROOM NUMBER]. It would take up to 30-45 minutes for her call light to be answered at times. Resident #35 also stated she was incontinent of bladder and bowel, required 2 staff assistance to change her brief, and did not always have care provided timely.During an interview on 12/9/2025 at 2:48 PM, Resident #23 stated there were times when staff did not respond to her call light timely.During an interview on 12/10/2025 at 7:28 AM, the DON confirmed the 800-west hallway had a high acuity level and staffing needed to be adjusted to meet the needs of the residents timely.During an interview on 12/10/2025 at 7:36 AM, LPN F stated she worked day shift on the 800-west hallway routinely and there were 2 CNA's and a nurse daily on the hallway. There were multiple residents that required 2-person transfer/assistance and 3 residents (Residents #35, #37, and #78) who required up to 1 1/2 to 2 hours to provide the needed care. LPN F also stated call lights were not always answered and care provided timely when 2 CNA's had to provide care for the 2 person assist residents.During an interview on 12/10/2025 at 7:45 AM, Resident #78 stated there were 3 CNA's on the hallway today and the facility needed 3 CNA's every day on day shift.During an interview on 12/10/2025 at 7:50 AM, CNA G stated she worked day shift on the 800-west hallway routinely. There were 2 CNA's and 1 nurse scheduled daily on the hallway. Multiple residents on the hallway required 2-person transfer/assistance and 3 residents (Residents #35, #37, and #78) who required up to 1 1/2 to 2 hours to provide the resident's care. CNA G also stated call lights were not always answered and care provided timely when 2 CNA's had to provide care for the 2 person assist residents.During an interview on 12/10/2025 at 7:55 AM, CNA H stated she worked day shift on the 800-west hallway routinely. There were 2 CNA's and 1 nurse scheduled daily on the hallway. Multiple residents on the hallway required 2-person transfer/assistance and 3 residents (Residents #35, #37, and #78) who required up to1 1/2 to 2 hours to provide the resident's care. CNA H also stated call lights were not always answered and care provided timely when 2 CNA's had to provide care for the 2 person assist residents.During an interview on 12/10/2025 at 8:04 AM, Registered Nurse (RN) I stated 8-west hallway typically had 2 CNA's and 1 nurse scheduled on day shift. The hallway had multiple residents who required 2-person transfer/assistance. RN I also stated there had been times when the call lights were not answered timely due to the high acuity of resident needs.During an interview on 12/10/2025 at 8:15 AM, CNA J stated she worked the 800-west hallway routinely on day shift. There were 2 CNA's and 1 nurse scheduled daily on the hallway. Multiple residents on the hallway required 2-person transfer/assistance and there were multiple residents who required up to 1 1/2 to 2 hours to provide the resident's care. CNA J also stated there were times when she was unable to answer call lights and provide care timely to residents on the hallway.During an interview on 12/10/2025 at 8:30 AM, the Administrator stated she was aware there had been multiple resident complaints regarding staffing concerns on the 800-west hallway. The hallway had multiple residents who required 2-person transfer/assistance and some who required up to 1 1/2 to 2 hours to provide the needed care for the resident. The concerns were discussed (no date given) with corporate administration and there was no resolution. The Administrator confirmed the 800-west hallway had a high acuity and staffing needed to be adjusted.During an interview on 12/10/2025 at 9:50 AM, the Director of Clinical Operations stated she acquired the facility on 11/17/2025. She was made aware by the facility on 12/9/2025 there was a staffing concern on the 800-west hallway. She also stated she talked with corporate administration on 12/9/2025 and was given permission to adjust staffing levels to meet the needs of the high acuity residents.

Based on review of medical records and staff interview, the facility failed to ensure accurate documentation of a resident's meal intake which prevented the facility from determining whether the resident met the criteria for administering the ordered nutritional supplement for 1 resident (Resident #2) of 3 residents reviewed for nutrition.The findings Include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Specified Nutritional Anemia, Dysphagia, History of Subdural Hematoma, and Chronic Migraines.Review of the comprehensive care plan for Resident #2 dated 11/17/2025, revealed .at risk for unintended weight loss related to inadequate intake and dysphagia .provide nutritional supplements as ordered .Review of a Physician's Order for Resident #2 dated 11/20/2025, revealed .Give one container of Jevity [liquid nutrition supplement] if resident eats 50% or less at meals . to be administered three times daily.Review of a significant change in status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact, and was able to feed himself with setup or clean-up assistance. Review of the facility's daily meal intake documentation for Resident #2 dated 12/1/2025 to 12/10/2025, revealed there was a total of 28 meals, the resident consumed between 25-50% for 5 out of 28 meals (lunch on 12/2/2025, breakfast on 12/3/2025, lunch on 12/4/2025, breakfast on 12/8/2025, and lunch on 12/9/2025). The documentation was not specific on whether these intakes were 25% to 49%, which would meet the physician's order criteria for the nutritional supplement, or 50%, which would not meet the physician's order criteria. Further review revealed no documentation of meal intake percentage on 8 out of 28 meals (dinner on 12/1/2025, 12/2/2025, and 12/3/2025; all 3 meals on 12/7/2025, dinner on 12/9/2025, and breakfast on 12/10/2025), preventing the facility from determining whether the resident met the criteria for administering the ordered supplement.Review of the Treatment Administration Record (TAR) dated 12/1/2025 to 12/10/2025, revealed .Give one container of Jevity if resident eats 50% or less at meals . and was to be administered three times daily at 9 AM, 1 PM, and 6 PM. There were 28 meals including breakfast on 12/10/2025, and all entries were signed off by the licensed nurses as N-Treatment Not Administered. Further review revealed the TAR contained no documentation of the reason the nutritional supplement was not administered.Review of the Nursing progress notes for Resident #2 dated 12/1/2025 to 12/10/2025, revealed no documentation for a reason the Jevity supplement was not administered. Review of the medical record revealed Resident #2 had not had any significant weight loss.During an interview on 12/10/2025 at 2:30 PM, the Director of Nursing (DON) stated staff were expected to document intake at every meal and to administer Jevity according to physician orders. The DON confirmed Resident #2's documentation 12/1/2025 to 12/10/2025 for meal intake was incomplete, the Jevity supplement was not administered, and there was no documentation related to why the supplement was not administered.

Based on review of the facility's policy, review of the medical records, observations, and interviews, the facility failed to implement the comprehensive care plan for an orthotic device for 1 resident (Resident #12) and failed to update the care plan for refusal of splint use for 1 resident (Resident #39) of 5 residents reviewed for Activities of Daily Living (ADLs)/Mobility.The findings Include:Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Dysphagia.Review of the medical record revealed Resident #12 was transferred to the hospital on 9/11/2025, returned to the facility the same day with a new diagnosis of a fracture of the right distal fibula (bone in the lower leg toward the ankle), and the resident had a new physician's order for a tall walking boot at all times.Review of the comprehensive care plan for Resident #12 dated 9/12/2025, revealed, .resident to wear boot on her right leg at all times, can be removed during showers only . The care plan did not contain documentation of the right ankle fracture.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact, and required substantial/maximal assistance with putting on/taking off footwear.During observations on 12/8/2025 at 10:30 AM and 2:30 PM, Resident #12 was lying in bed, and the orthotic foot boot was lying on a chair in the corner of the room.During an interview on 12/8/2025 at 2:30 PM, Resident #12 was asked if staff assists her to wear the boot on her foot, and the resident stated, .they don't put that on . but it's not hurting .During observations on 12/9/2025 at 11:00 AM and 4:00 PM, Resident #12 was lying in bed, and the orthotic foot boot was lying on a chair in the corner of the room.During an interview on 12/9/2025 at 4:00 PM, Resident #12 was asked if she wore the foot boot, and the resident stated, .no . When asked if she is supposed to wear the boot on her foot, the resident stated, .I think so .Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including History of a Stroke with Hemiplegia, Weakness, and Contractures of Left Arm, Hand, and Wrist. Review of the comprehensive care plan for Resident #39 dated 3/21/2024, revealed, .needs assistance with daily ADL care .left hand contracture .left wrist/hand splint-to be applied early am around 7 am .gentle stretch of left elbow prior to applying .remove around 3 pm .Review of an annual MDS assessment dated [DATE], revealed Resident #39 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact, was dependent on staff for dressing, and did not reject care.During observations on 12/8/2025 at 10:35 AM and 2:35 PM, Resident #39 was lying in bed, without a splint on her left wrist or hand.During observations on 12/9/2025 at 9:45 AM and 2:05 PM, Resident #39 was lying in bed, without a splint on her left wrist or hand.During an interview on 12/9/2025 at 2:05 PM, Resident #39 was asked if staff assists her to wear the splints on her left arm and hand, and the resident stated, .no, I told them I don't wear those because they hurt .I told [named an Occupational Therapist] .Review of the Treatment Administration Record (TAR) dated 12/1/2025 to 12/10/2025, revealed Resident #39 refused the left wrist/hand splint when staff attempted application.Review of the Nurse's notes 12/1/2025 to 12/10/2025 revealed no documentation Resident #39 refused splint application.During an interview on 12/10/2025 at 2:30 PM, the Registered Nurse/Director of Quality Management (RN/DQM) stated staff were expected to follow the care plan for orthotic use, and confirmed Resident #12 should have her foot boot on at all times. The RN/DQM stated the care plan should be updated when a resident refuses an intervention consistently so further evaluation could be conducted, and confirmed Resident #39's refusal of splints was not reflected in the resident's care plan.

Based on review of the facility policy, review of the medical record, observation, and interview, the facility failed to ensure call lights were within reach for 1 resident (Resident #41) of 18 residents reviewed on the 800-west hallway. The findings include:Review of the facility policy titled, Procedure: Answering the Call Light, dated 1/2024, revealed .The purpose of this procedure is to respond to the resident's requests and needs. The community [facility] should be adequately equipped to allow residents to call for assistance .when the resident is in bed .be sure the call light is within reach of the resident .Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including Anemia, Coronary Artery Disease, Hypertension, Parkinsons, and Depression.Review of the comprehensive care plan for Resident #41 dated 5/19/2025, revealed .[Resident #41] is at risk for impaired communication related to cognitive impairment .[Resident #41] will be able to communicate some of her basic needs effectively .Call light in reach .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment, and required substantial/maximal assistance for personal hygiene, bathing, and toileting.During an observation on 12/8/2025 at 11:45 AM, revealed Resident #41 lying in bed with the call light hanging over the headboard of the bed and was not within reach of the resident. Further observation revealed Resident #41 was holding a chicken salad sandwich and some of the contents had fallen onto the resident's clothing. During an observation and interview on 12/8/2025 at 1:50 PM, revealed Resident #41 lying in bed with the call light hanging over the headboard of the bed and was not within reach of the resident. Resident #41 stated when she needed assistance from the staff, she .pushed a button .During an observation on 12/8/2025 at 4:12 PM, revealed Resident #41 lying in bed with the call light hanging over the headboard of the bed and was not within reach of the resident. During an observation and interview on 12/8/2025 at 4:15 PM, with Licensed Practical Nurse (LPN) F, revealed Resident #41 lying in bed with the call light hanging over the headboard of the bed and was not within reach of the resident. LPN F stated Resident #41 was able to activate the call light when she needed staff assistance. LPN F confirmed the call light was out of Resident #41's reach.During an interview on 12/10/2025 at 9:15 AM, Certified Nursing Assistant (CNA) J stated she provided care for Resident #41 routinely and the resident was able to activate the call light when she needed assistance from the staff.During an interview on 12/10/2025 at 9:20 AM, CNA G stated she provided care for Resident #41 and the resident was able to activate the call light when she needed assistance from the staff.During an interview on 12/10/2025 at 11:02 AM, the Director of Nursing stated it was her expectation for Resident #41 to have her call light in reach at all times.

Based on review of facility policy, observation and interviews, the facility failed to ensure staff promoted resident dignity during dining for 1 resident (Resident #26) of 7 residents observed during dining.The findings Include:Review of the facility's undated policy titled, Tennessee Notices .Nursing Home Resident Rights, revealed .you [the resident] have the right to a dignified existence .a facility environment must treat each resident with respect and dignity and care for each resident in a manner .that promotes maintenance or enhancement of his or her quality of life .Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including History of Stroke with Hemiplegia, Aphasia, and Atrial Fibrillation.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 had severely impaired cognitive skills for daily decision making, and required substantial/maximal assistance with eating. During an observation on 12/8/2025 at 12:20 PM, Licensed Practical Nurse (LPN) O was in the 8th floor dining room, standing up awhile assisting Resident #26 with the lunch meal.During an interview on 12/8/2025 at 12:30 PM, LPN O stated, .I get antsy sitting too long, so I usually stand up if I'm feeding a resident, and we have several feeders [referring to residents who require assistance to eat] so I just kind of bounce around . During an interview on 12/8/2025 at 2:00 PM, the Registered Nurse/Director of Quality Management (RN/DQM) stated standing while assisting the resident to eat and referring to resident's who required assistance with eating as feeders did not maintain resident's dignity. The RN/DQM confirmed staff were expected to maintain resident dignity during meals by sitting at the resident's eye level when assisting residents during dining and should not refer to residents as feeders.

Based on facility policy review, medical record review, observation and interview, the facility failed to implement Enhanced Barrier Precautions (EBP) for 3 residents (Residents #36, Resident #12, and Resident #24) of 7 residents reviewed for indwelling devices. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions in Skilled Nursing Communities, revised 3/2024, revealed .Enhanced Barrier Precautions .infection control intervention .that employs targeted gown and glove use .shall be implemented during high-contact resident care activities .with .indwelling medical devices .regardless of .infection or colonization .during .dressing .bathing . transferring .providing hygiene .changing linens .changing briefs . device care or use .urinary catheter . Medical record review revealed Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Functional Quadriplegia, Complete Lesion of Cervical Spine and Neurogenic Dysfunction of Bladder. Review of the Physician's Order for Resident #36 dated 9/3/2020, revealed .indwelling catheter .for neurogenic bladder . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a suprapubic catheter and an active diagnosis of neurogenic bladder. Review of a comprehensive care plan revised on 8/24/2023, revealed Resident #36 had a suprapubic catheter for a neurogenic bladder. During an interview and observation on 9/23/2024 at 12:05 PM, Resident #36 stated he had an indwelling suprapubic catheter. Observation revealed there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. During an observation on 9/24/2024 at 8:25 AM, Resident #36 had a suprapubic catheter and there was no EBP signage or PPE was available in or outside the resident's room. During an interview on 9/24/2024 at 8:30 AM, Licensed Practical Nurse (LPN) B stated Resident #36 had a suprapubic catheter and she only wore gloves to perform the resident's catheter care. LPN B was unaware of the need to use EBP for suprapubic catheter care. During an interview and observation on 9/24/2024 at 2:24 PM, Resident #36 stated the nursing staff only wore gloves when suprapubic catheter care was performed. The resident was unaware of the need for EBP for suprapubic catheter care. There was no EBP signage or PPE available in or outside the resident's room. During an interview on 9/24/2024 at 2:34 PM, Certified Nursing Assistant (CNA) C stated she only wore gloves while performing catheter care for Resident #36. CNA C was unaware of EBP for suprapubic catheter care. 48100 Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Difficulty Walking and Neuromuscular Dysfunction of the Bladder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairement. Further review revealed the resident had an indwelling catheter and an active diagnosis of neurogenic bladder. Review of a comprehensive care plan revised 2/13/2024, revealed Resident #12 had an indwelling urinary catheter for a neurogenic bladder. During an observation on 9/23/2024 at 2:46 PM, revealed Resident #12 did not have EBP signage or PPE available in or outside the resident's room. During an interview on 9/23/2024 at 2:50 PM, the Registered Nurse (RN) House Supervisor stated Resident #12 had an indwelling catheter and was not placed in EBP. During an interview on 9/23/2024 at 2:54 PM, CNA D stated Resident #12 had an indwelling catheter and was not placed in EBP. CNA D stated when she completed catheter care for Resident #12, she only wore gloves, no additional PPE. Review of the Physician's Orders for Resident #12 dated 9/24/2024, revealed catheter care every shift .change cath [catheter] every month . During an observation on 9/24/2024 at 2:05 PM, revealed Resident #12 did not have EBP signage or PPE available in or outside the resident's room. During an interview on 9/24/2024 at 2:15 PM, CNA E stated Resident #12 had an indwelling catheter and was not placed in EBP. CNA E stated when she completed catheter care for Resident #12, she only wore gloves, no additional PPE. During an interview on 9/24/2024 at 2:45 PM, the Infection Preventionist (IP) stated when EBP are implemented signage is placed to alert the staff on the resident's entry door with a PPE storage hanger for the staff to use. During an observation on 9/25/2024 at 11:15 AM, revealed Resident #12 did not have EBP signage or PPE available in or outside the resident's room. During an interview on 9/25/2024 at 11:20 AM, Resident #12 stated when the staff completed catheter care they wear gloves and do not wear a gown. Resident #12 stated she was never told by anyone at the facility she needed to be in EBP for her indwelling catheter. 35460 Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Coronary Artery Disease and Urinary Retention. Review of the comprehensive care plan revised 8/21/2024, revealed Resident #24 had a suprapubic catheter for a neurogenic bladder. Review of the Physician's Order for Resident #24 dated 8/29/2024, revealed .Catheter care every shift . Review of an admission MDS dated [DATE], revealed Resident #24 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairement. Further review revealed the resident had a suprapubic catheter and an active diagnosis of neurogenic bladder. During an observation on 9/23/2024 at 12:15 PM, revealed Resident #24 had an indwelling catheter. There was no EBP signage or PPE available in or outside the resident's room. During an interview on 9/25/2024 at 8:11 AM, the Infection Preventionist stated residents with indwelling devices should be placed on EBP and confirmed the facility did not develop or implement EBP for Resident #36, Resident #12 and Resident #24 related to their indwelling device usage. During an interview on 9/25/2024 at 10:30 AM, LPN A stated Resident #24 was not on EBP for the suprapubic catheter and she only wore gloves when she provided catheter care. Continued interview revealed LPN A was unaware of EBP for catheter care.

Based on facility policy review, medical record review, observation and interview, the facility failed to develop Enhanced Barrier Precautions (EBP) on the comprehensive care plan for 3 residents (Residents #36, Resident #12 and Resident #24) of 21 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, dated 9/2023, revealed .the comprehensive, person-centered care plan will .describe the services that are the be furnished to attain or maintain the resident's .well-being .incorporate identified problem areas .reflect treatment .reflect currently recognized standards of practice for problem areas and conditions . Medical record review revealed Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Functional Quadriplegia, Complete Lesion of Cervical Spine and Neurogenic Dysfunction of Bladder. Review of the Physician's Order for Resident #36 dated 9/3/2020, revealed .indwelling catheter .for neurogenic bladder . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #36 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a suprapubic catheter and an active diagnosis of neurogenic bladder. Review of a comprehensive care plan revised on 8/24/2023, revealed Resident #36 had a suprapubic catheter for a neurogenic bladder. Further review revealed EBP had not been developed on the care plan. During an interview and observation on 9/23/2024 at 12:05 PM, Resident #36 stated he had an indwelling suprapubic catheter. Observation revealed there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. During an observation on 9/24/2024 at 8:25 AM, Resident #36 had a suprapubic catheter. No EBP signage or PPE was available in or outside the resident's room. During an interview on 9/24/2024 at 8:30 AM, Licensed Practical Nurse (LPN) B stated Resident #36 had a suprapubic catheter and she confirmed only gloves were worn to perform the resident's catheter care. Interview revealed LPN B was unaware of the need to use EBP for suprapubic catheter care. During an interview and observation on 9/24/2024 at 2:24 PM, Resident #36 stated the nursing staff only wore gloves when suprapubic catheter care was performed. The resident was unaware of the need for EBP for suprapubic catheter care. Observation revealed there was no EBP signage or PPE available in or outside the resident's room. During an interview on 9/24/2024 at 2:34 PM, Certified Nursing Assistant (CNA) C stated she only wore gloves while performing catheter care for Resident #36. Interview revealed CNA C was unaware of EBP for suprapubic catheter care. 48100 Medical record review revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Difficulty Walking and Neuromuscular Dysfunction of the Bladder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairement. Further review revealed the resident had an indwelling catheter and an active diagnosis of neurogenic bladder. Review of a comprehensive care plan revised 2/13/2024, revealed Resident #12 had an indwelling urinary catheter for a neurogenic bladder. Further review revealed there was no EBP developed on the care plan. Review of the Physician's Orders dated 9/24/2024, revealed catheter care every shift .change cath [catheter] every month . During an observation on 9/23/2024 at 2:46 PM, revealed Resident #12 did not have EBP signage or PPE available in or outside the resident's room. During an interview on 9/23/2024 at 2:50 PM, the Registered Nurse (RN) House Supervisor stated Resident #12 had an indwelling catheter and was not placed in EBP. During an interview on 9/23/2024 at 2:54 PM, CNA D stated Resident #12 had an indwelling catheter and was not placed in EBP. CNA D stated when she completed catheter care for Resident #12, she only wore gloves, no additional PPE. During an observation on 9/24/2024 at 2:05 PM, revealed Resident #12 did not have EBP signage or PPE available in or outside the resident's room. During an interview on 9/24/2024 at 2:15 PM, CNA E stated Resident #12 had an indwelling catheter and was not placed in EBP. CNA E stated when she completed catheter care for Resident #12, she only wore gloves, no additional PPE. During an interview on 9/24/2024 at 2:45 PM, the Infection Preventionist (IP) stated when EBP implemented there is signage placed to alert the staff on the resident's entry door with a PPE storage hanger for the staff to use. The IP stated for residents with EBP initiated, the facility discuss the information in the daily clinical meeting and the resident's care plan and medical record reflect the need for EBP. During an observation on 9/25/2024 at 11:15 AM, revealed Resident #12 did not have EBP signage or PPE available in or outside the resident's room. During an interview on 9/25/2024 at 11:20 AM, Resident #12 stated when the staff completed catheter care, they wear gloves and do not wear a gown. Resident #12 stated she was never told by anyone at the facility she needed to be in EBP for her indwelling catheter. 35460 Medical record review revealed Resident #24 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, Coronary Artery Disease and Urinary Retention. Review of the comprehensive care plan revised 8/21/2024, revealed Resident #24 had a suprapubic catheter for neurogenic bladder. Further review revealed EBP was not developed on the care plan. Review of the Physician's Order for Resident #24 dated 8/29/2024 revealed .Catheter care every shift . Review of an admission MDS assessment dated [DATE], revealed Resident #24 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairement. Further review revealed the resident had a suprapubic catheter and an active diagnosis of neurogenic bladder. During an observation on 9/23/2024 at 12:15 PM, Resident #24 had an indwelling catheter. There was no EBP signage or PPE available in or outside the resident's room. During an interview on 9/25/2024 at 8:11 AM, the Infection Preventionist stated residents with indwelling devices should be placed on EBP and confirmed the facility did not develop or implement EBP for Resident #36, Resident #12, and Resident #24 related to their indwelling urinary device usage. During an interview on 9/25/2024 at 10:30 AM, LPN A stated Resident #24 was not on EBP for the suprapubic catheter and she only wore gloves when she provided catheter care. Continued interview revealed LPN A was unaware of EBP being required for catheter care.

Based on facility policy review, medical record review, observations and interviews, the facility failed to provide a homelike environment for 2 residents (Resident #12 and Resident #7) of 83 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, Quality of Life-Homelike Environment, dated 1/2024, revealed .the characteristics of the community that reflect a .homelike environment .these characteristics include .cleanliness and order . Medical record review revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Difficulty Walking and Neuromuscular Dysfunction of the Bladder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation in room [ROOM NUMBER], on 9/23/2024 at 2:45 PM, 2 pieces of blue tape, to the bottom trim baseboard, on the wall adjacent to the entry door were seen. Upon further observation, the bottom trim baseboard was coming apart from the wall with gouges of various sizes, in the paint and dry wall. During an interview on 9/23/2024 at 2:46 PM, Resident #12 stated she was unsure how long the tape had been covering the gouges in the dry wall. Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Dementia, Hypertension and Asthma. Review of an entry MDS assessment dated [DATE], revealed Resident #7 scored a 0 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation in room [ROOM NUMBER], on 9/23/2024 at 2:47 PM, multiple tears of various sizes, in the paint and dry wall behind the headboard of Resident #7's bed were seen. During an interview on 9/25/2024 at 10:43 AM, the Administrator confirmed room [ROOM NUMBER] and room [ROOM NUMBER] did not reflect a homelike environment for Resident #12 and Resident #7. The Administrator stated the impairments to the walls in room [ROOM NUMBER] and 502 needed repairs.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure the medical record was complete for 1 resident (Resident #4) of 15 residents reviewed for complete medical records. The findings include: Review of the facility policy titled, Change in a Resident's Condition or Status, revised 2/2022, revealed .The nurse will record in the resident's medical record information relative to changes in the resident's medical .condition or status . Review of the facility policy titled, Falls, revised 7/2023, revealed .this procedure .provide guidelines for evaluation of a resident in the event a fall occurred .The Licensed Nurse shall document the fall in the resident's clinical record . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Dementia and General Anxiety Disorder. The resident was discharged on [DATE]. Review of a comprehensive care plan for Resident #4 dated 10/17/2023, revealed .[Resident #4] has potential for further falls r/t [related to] history of falls prior to admission . Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The resident required partial to moderate assistance for activities of daily living (ADLs). Review of Resident #4's medical record revealed no documentation of a fall on 1/25/2024. Review of the facility investigation report for Resident #4 dated 1/27/2024, revealed the resident had an unwitnessed fall on 1/25/2024 that was not documented in the medical record when it occured. The investigation stated .Upon entering the room, [Resident #4] was sitting with his back against his chest [furniture] with his legs spread open. One foot on the floor, and the other foot on his floor mat. He denied hitting his head or another part of his body. His son showed up shortly afterwards .notified .the DON and the Administrator . During a telephone interview on 8/5/2024 at 4:14 PM, Licensed Practical Nurse (LPN) A stated she did a skin check for Resident #4 and found a skin tear on the resident's left forearm. The wound had a dressing on it, but the skin tear had not been documented in the resident's medical record. The LPN stated she was told by a staff member the resident had fallen, and the resident had reported he had a recent fall. The LPN stated she reported the finding to management but could not remember to whom she had reported the incident. During an interview on 8/5/2024 at 5:05 PM, the Quality Nurse stated an agency nurse, Registered Nurse (RN) B, failed to report and document a fall for Resident #4. The facility administration was alerted to the fall by an Environmental Services (EVS) employee after a new skin injury was discovered, and an injury of unknown origin investigation was initiated. The facility completed a thorough investigation of the fall, and the agency nurse was terminated. During an interview on 8/6/2024 at 11:21 AM, EVS C stated she did not remember the exact date, but she was in the hall outside Resident #4's room and observed the resident sitting on the side of his bed. She knew he was not supposed to be up without assistance, so she went to get the nurse. The EVS staff member stated .I heard a commotion and peeked back in to see [Resident #4] had stumbled against his clothes closet, but he was still standing . EVS C told Resident #4 to be still; she was getting help. She then went to get the nurse, and when she and RN B returned, the resident was sitting on his buttocks by the clothes closet. During an interview on 8/7/2024 at 8:17 AM, the DON stated it was her expectation nursing staff chart a resident fall in the medical record at the time of occurrence. The DON confirmed that the nurse did not chart Resident #4's fall on 1/25/2024 in the medical record and had not followed the facility's policy.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure discontinued narcotics were removed from the inventory after discontinued for 1 resident (Resident #11) of 4 residents reviewed for narcotic administration. The facilities failure to timely remove discontinued drugs from inventory resulted in discontinued medications documented as withdrawn from stock but not accounted for in the medical record. The findings include: Review of the facility policy titled, Discarding and Destroying Medications, revised 12/2019, revealed .All unused controlled substances should continue to be counted each shift with the active controlled substances until properly disposed of .Unused controlled substance cards and log sheets should be marked with a red X to denote they are no longer to be used .Disposal of controlled substances must take place after discontinuation of use by the resident . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Mood Disorder with Depressive Features, Unspecified Gait Abnormalities, Muscle Weakness and Cognitive Communication Deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 6 on the Brief Interview of Mental Status (BIMS) assessment which indicated severe cognitive impairment. Review of a physician's order for Resident #11 dated 3/15/2024, revealed the resident was prescribed Oxycodone Acetaminophen (Percocet, a narcotic for pain) 5/325 milligram tablets, one tablet by mouth every 4 hours as needed for pain. The medication was filled with 12 tablets supplied by the pharmacy on 3/15/2024. Review of the Individual Controlled Substance Count Sheet, corresponding Medication Administration Record (MAR) and Pain Assessments revealed Resident #11 had not required use of or administered the pain medications between 3/15/2024 and 3/24/2024. Review of the MAR and Physician Order Summary report for 3/2024, revealed Percocet for Resident #11 was discontinued on 3/24/2024. Review of the Individual Controlled Substance Count Sheet revealed 2 doses of Resident #11's Percocet were documented as withdrawn from inventory for administration to Resident #11 on 3/29/2024 at 9:00 PM and on 3/30/2024 at 5:00 AM by Registered Nurse (RN) G (5 days after the medication was discontinued and was to have been disposed of). Review of the MAR revealed no documentation the medications were administered to Resident #11 by RN G. Review of the facility investigation and witness statements dated 3/30/2024, revealed on the morning of 3/30/2024, the oncoming nurse, Licensed Practical Nurse (LPN) H, reported to the Director of Nursing (DON) she had concerns related to RN G's statements made to her during shift change report. LPN H noted Resident #11's Percocet supply on the cart had been accessed by RN G the night before, and 2 doses of Percocet were documented as withdrawn for administration to Resident #11. LPN H reported to the DON that she questioned RN G about the matter, and RN G informed LPN H Percocet was withdrawn and given to address Resident #11's complaints of pain due to Migraine Headache. LPN H assessed Resident #11 immediately after shift change, and Resident #11 reported she had not requested pain medications for any reason the night before and did not have any pain. Resident #11 reported she did not recall seeing RN G in her room at all the night before. Further review of the facility investigation showed the facility attempted repeatedly to contact RN G for investigation without success despite several voice messages. The facility notified RN G's employer they needed to speak to her about narcotic count irregularities. RN G nor her employer returned the attempted phone calls. During an interview on 8/6/2024 at 9:50 AM, LPN H reported she had cared for Resident #11 regularly for several years and she became suspicious during shift report on 3/30/2024 after she was informed by RN G Percocet had been given for migraine. LPN H reported she had cared for Resident #11 for over 3 years, knew Resident #11 very well and to her knowledge, Resident #11 had no history of migraine. LPN H also reported Resident #11 refused narcotics prescribed for fracture pain in the past and preferred to use over the counter Tylenol instead. LPN H reported she had cared for Resident #11 daily after recent surgery and Resident #11 had refused any pain medications offered her and had stated the skin cancer removals did not cause her discomfort (This was corroborated by review of the MAR and corresponding nursing notes dated 3/15/2024-3/28/2024). LPN H reported she questioned Resident #11 after shift change report and Resident #11 reported she had not experienced Migraines the night prior, had not asked for any medication and did not recall seeing RN G in her room at all the night before. LPN H stated despite Resident #11's cognitive limitations, Resident #11 was able to make needs known and LPN H considered Resident #11 a reliable informant when it came to expressions of pain or unmet needs. During an interview on 8/6/2024 at 5:12 PM, the Director of Nursing (DON) reported she led the facility investigation. The DON reported the discontinued medication was to have been removed from the medication cart on 3/24/2024, and the medication had not been removed timely per her expectations. The DON reported Percocet was removed from Resident #11's stock on the medication cart on the morning of 3/30/2024 and destroyed. The DON reported RN G documented Percocet as withdrawn from inventory for use but had not documented administration of the medication anywhere in the record. Continued interview revealed the DON reported those findings, when taken into context with Resident #11's statements which indicated she had not requested pain medications or recalled seeing RN G in her room the night before, led the DON to conclude it was likely the Percocet was diverted. The DON stated she made multiple attempts to contact RN G to discuss allegations over several days and neither the employer nor RN G responded to allegations or cooperated with the facility investigation. The DON confirmed based upon its own investigation, the facility determined had discontinued Percocet been removed from stocks and destructed timely, the incident would not have occurred.

Based on facility policy review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #6) of 15 residents reviewed. The findings include: Review of the facility's policy titled, MDS Assessment, revised 12/2017, revealed .Residents of our skilled nursing communities will have a MDS Assessment completed in accordance with CMS [Centers for Medicare and Medicaid Services] guidelines as outlined in the RAI Manual .MDS Assessments are based on information from resident, family, physician, caregivers, and/or clinical assessment .MDS Assessments are used by the Interdisciplinary Assessment Team to develop a plan of care .Coding of the MDS item sets will be completed in accordance with the RAI guidelines . Review of the RAI Manual 3.0 dated 10/2023 revealed .Number of Falls Since Admission/Entry or Reentry or Prior Assessment .Review nursing home incident reports and medical record .for falls and level of injury . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Bipolar Disorder, Weakness, Vascular Dementia, and Adult Failure to Thrive. Review of the comprehensive care plan revised 12/27/2023, for Resident #6 revealed, .[Resident #6] has potential for falls . Intervention added to include .use wedge (pillow, blanket) to provide support . Review of the Nurse's Notes for Resident #6 dated 12/27/2023, revealed Resident #6 was found on the floor beside the bed.CNA [certified nurse assistant] found resident on floor beside bed . The resident was transported to the emergency department for further evaluation and treatment. Review of a quarterly MDS assessment for Resident #6 dated 1/25/2024, revealed no falls documented since the prior assessment. During an interview on 8/7/2024 at 10:25 AM, the Interim MDS Coordinator, confirmed Resident #6 had experienced a fall on 12/27/2023 and confirmed the quarterly MDS assessment dated [DATE] was inaccurate for Resident #6.

Based on facility policy review, facility investigation documentation, and interviews, the facility failed to report allegations of abuse to include injuries of unknown origin, to Adult Protective Service (APS) for 13 resident investigations (Residents #2, #19, #38, #39, #3, #37, #42, #43, #68, #69, #70, #71, and #72) of 26 resident investigations reviewed. The findings include: Review of the facility's policy titled, Abuse Prevention, dated 6/22/2022, showed .Injury of Unknown Source .source of the injury was not observed by any person or the source of the injury could not be explained by the resident .will investigate and report any allegations of abuse within timeframes as required .report alleged violations involving .including injuries of unknown source .to the state agency, adult protective services . Review of the facility's policy titled, Abuse Investigation and Reporting, dated 11/2023, showed .reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment .and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies .All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to .Adult Protective Services .Alleged violations .will be reported .Abuse or Serious Bodily Harm - Immediately but not later than 2 hours .If the allegation violation involves abuse or results in serious bodily injury .No Serious Bodily Injury .As soon as practical, but not later than 24 hours .If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury . Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Paraplegia, Spinal Stenosis, Hypertension, Muscle Weakness, Abnormalities of Gait and Mobility, Osteoporosis, Restless Legs Syndrome, and Atherosclerotic Heart Disease, and Age-Related Cognitive Decline. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 was cognitively intact. Resident #2 required extensive assistance of one person for bed mobility, transfers, walk in room, dressing, and toilet use. Resident #2 was unsteady with balance during transitions and walking. The resident required a wheelchair for mobility. Review of the facility's investigation documentation showed the facility was contacted by Resident #2's daughter on 11/28/2023 around 4:00 PM reporting a bruise to Resident #2's right lower extremity. The facility began an investigation and notified the state agency of the allegation on 11/28/2023 at 6:37 PM. Further review showed evidence the State Agency had been notified but no evidence of APS notification of the allegation. Review of a written statement from the Administrator dated 12/6/2023, showed .Allegation of Resident #2's bruise of unknown origin .No APS report . During an interview on 12/6/2023 at 2:26 PM, the Administrator confirmed she had not notified APS of the injury of unknown origin for Resident #2. The Administrator confirmed the injury of unknown origin should have been reported to APS. 48100 Resident #19 was admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar, Abnormalities of Gait, Adjustment Disorder with Anxiety, Delusional Disorder, and Epilepsy. Review of an annual MDS assessment dated [DATE], showed Resident #19 had memory problems, was rarely understood, had a mood problem of being easily annoyed, had presence of physical behavioral symptoms directed towards others (hitting, kicking), required partial moderate assistance with bed mobility, required supervision with transfers, required substantial maximal assistance with dressing, not steady with surface to surface transfers or walking, incontinent of bowel and bladder function. Review of a Skin Evaluation assessment dated [DATE], showed two bruises were observed to the right knee. Review of the facility investigation of Resident #19's bruises to the right knee on 11/25/2023, showed evidence the State Agency had been notified of an injury of unknown origing, but no evidence of APS notification of the allegation. During an interview on 12/5/2023 at 1:32 PM, the Director of Nursing (DON) stated on 11/25/2023 she received a call from Licensed Practical Nurse (LPN) #1 regarding new bruising observed to Resident #19's right knee. The DON stated due to the potential of an unknown injury source, she reported the incident to the state agency and initiated an investigation. The DON stated she notified the Administrator and Executive Director (ED) after LPN #1 reported the incident. The DON stated she did not notify APS. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Cerebral Infarction, Morbid Obesity, Weakness, and Hemiplegia. Review of an annual MDS assessment dated [DATE], showed Resident #38 was cognitively intact. Resident #38 required extensive 1 person assistance with bed mobility, transfers, dressing, and toilet use. Resident #38 required limited 1 person assistance with personal hygiene and was frequently incontinent of bowel and bladder. Review of the facility's investigation documentation showed Resident #38 made an allegation of neglect on 11/25/2023. Further review showed evidence the State Agency had been notified, but no evidence of APS notification of the allegation. During an interview on 12/5/2023 at 1:14 PM, the DON stated on 11/25/2023, she received a call from LPN #1 regarding Resident #38 stating she was not given the call light and had yelled for over an hour. The DON stated due to the resident being upset about the event, she reported the allegation of neglect to the state agency and initiated an investigation. The DON stated she did not notify APS. Resident #39 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypothyroidism, Delusional Disorder, Anxiety, and Weakness. Review of an annual MDS assessment dated [DATE], showed Resident #39 had severe cognitive impairment. Resident #39 exhibited rejection of care behaviors. Resident #39 required substantial/moderate assistance with bed mobility, dressing, and personal hygiene. Resident #39 was not steady with surface-to-surface transfers and was incontinent of bowel and bladder. Review of a Nursing Progress Note dated 11/25/2023, showed .bilateral wrist discolorations .resident unable to recall what caused them. Asked resident if anyone has harmed her and she shook her head and said no. She denies pain . Review of the facility's investigation documentation showed Resident #39 had injuries of unknown origin which involved bruising to the bilateral wrists on 11/25/2023. Further review showed evidence the State Agency had been notified of an injury of an unknown origin, but no evidence of APS notification of the allegation. During an interview on 12/5/2023 at 1:24 PM, the DON stated on 11/25/2023 she received a call from LPN #2 regarding new bruising observed to Resident #39's bilateral wrists. The DON stated due to the suspicious location of the bruising and unknown injury source, an investigation was initiated and was reported to the state agency. The DON stated she did not notify the APS agency. During an interview on 12/6/2023 at 1:10 PM, the Administrator stated she could not find any evidence that APS had been notified regarding Resident #19's bruising to the right knee, Resident #38's allegation of neglect/abuse, and Resident #39's bruising to the bilateral wrists. The Administrator confirmed the APS agency had not been notified for the facility reported incidents. 45837 Resident #3 was admitted to the facility on [DATE] with diagnoses including Epilepsy, Unspecified Dementia, Arthritis, History of Falling and Muscle Weakness. Review of an annual MDS assessment dated [DATE] showed Resident #3 resident was cognitively intact and had verbal behaviors directed toward others. The resident required 2 person assistance by staff to bathe and dress. Review of facility investigation documentation showed Resident #3 had an injury of unknown origin, and an abuse allegation was made and investigated when a bruise was found on the resident's left inner thigh. The report was submitted by the DON on 11/25/2023 at 6:58 PM. Further review showed evidence the State Agency had been notified of the injury of an unknown origin and allegation of abuse, but no evidence of APS notification of the allegation. Resident #37 was admitted to the facility on [DATE] with diagnoses including Fracture of Unspecified Pubis, Epilepsy, and Abnormality of Gait and Mobility. Review of the admission MDS assessment dated [DATE] showed Resident #37 had moderate cognitive impairment. The resident was functionally independent and required set-up assistance with eating. Review of facility investigation documentation dated 11/2/2023 showed Resident #37 was the alleged victim of an alleged perpetrator talking harshly to her. Further review showed evidence the State Agency had been notified of the allegation of verbal abuse, but no evidence of APS notification of the allegation. Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Nonrheumatic Mitral Valve Prolapse, Muscle Weakness and Personal History of Urinary Tract Infection. Review of a 5-day MDS assessment dated [DATE] showed Resident #42 was cognitively intact. The resident required partial assistance from staff with sit-to-stand and chair-to-chair transfers. Review of facility investigation documentation dated 11/24/2023 showed the state agency was notified of an allegation of neglect when Resident #42 had a fall with a staff member present. Further review showed evidence the State Agency had been notified of the allegation of neglect, but no evidence of APS notification of the allegation. Resident #43 was admitted to the facility on [DATE] with diagnoses including Unspecified Sequelae of Cerebral Infarction, Type 2 Diabetes Mellitus, Aphasia and Gout. Review of the discharge MDS assessment dated [DATE] showed Resident #43 had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living due to bilateral lower extremity impairment. The resident was at risk for skin problems, and measures were taken of pressure reducing device for chair and bed and pressure injury care. Review of facility investigation documentation dated 11/6/2023 showed the state agency was notified of an injury of unknown origin for Resident #43 for a bruise on the resident's arm. Further review showed evidence the State Agency had been notified of the injury of unknown origin, but no evidence of APS notification of the allegation. During an interview on 12/11/2023 at 2:50 PM, the Administrator confirmed there were no reports to APS after the facility reported allegations of injury of unknown origin, abuse and neglect for Residents #3, #37, #42, and #43. 40606 Resident #68 was admitted to the facility on [DATE] with diagnoses including: Unspecified Convulsions, Dementia with Mood Disturbance, Atrial Fibrillation, Gout, and Hepatic Encephalopathy. Review of the quarterly MDS assessment dated [DATE] showed Resident #68 was moderately cognitively impaired. The resident required assistance of 2 staff members with activities of daily living (ADL's). Review of Resident #68's current care plan dated 10/20/2023, showed .Gout: has Carpal Tunnel Syndrome .is at risk for complications from blood thinning medication .Eliquis .Monitor/Observe bruising . Review of the facility's investigation documentation dated 11/4/2023 at 12:23 PM, showed Resident #68 had complained of wrist pain. Further review showed evidence the State Agency had been notified but no evidence of APS notification of the allegation. Resident #69 was admitted to the facility on [DATE] with diagnoses including: Parkinson's Disease, Encounter for Orthopedic Aftercare, Fracture of Left Femur, Muscle Weakness, and Ataxic Gate. Review of the quarterly MDS assessment dated [DATE] showed Resident #69 was severely cognitively impaired. The resident required assistance of 1 staff member with activities of daily living (ADL's). Review of the facility's investigation documentation dated 11/23/2023 at 6:27 PM, showed the Private Sitter reported to facility nurse that Resident #69's Left wrist was painful and swollen. Further review showed evidence the State Agency had been notified but no evidence of APS notification of the allegation. Resident #70 was admitted to the facility on [DATE] with diagnoses including: Group Vitamin B Deficiency, Anxiety Disorder, Macular Degeneration, Need for assistance with Personal Care, and Colostomy Status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #70 was cognitively intact. The resident required supervisory assistance of 1 staff member with activities of daily living (ADL's). Resident #71 was admitted to the facility on [DATE] with diagnoses including: Cerebral Infarction, Attention and Concentration Deficit, Cognitive Communication Disorder, Essential Hypertension, and Hyperlipidemia. Review of the quarterly MDS assessment dated [DATE] showed Resident #71 was cognitively intact. The resident required assistance of 1 staff member with activities of daily living (ADL's). Review of the facility's investigation dated 11/5/2023 at 9:00 AM, showed Resident #70 and Resident #71 had a verbal altercation, were redirected, and separated by the staff. Further review showed evidence the State Agency had been notified but no evidence of APS notification of the allegation. Resident #72 was readmitted to the facility on [DATE] with diagnoses including Hemiplegia, Dysphagia, Cognitive Communication Deficit, Muscle Weakness, and Dementia. Review of the quarterly MDS assessment dated [DATE] showed Resident #72 was severely cognitively impaired. The resident required assistance of 1-2 staff members with activities of daily living (ADL's). Review of the facility's investigation dated 11/6/2023 at 2:45 PM, showed staff noted a skin tear to Resident #72's left arm, resident and staff unaware of how it happened. Further review showed evidence the State Agency had been notified but no evidence of APS notification of the allegation. During an interview on 12/12/2023 at 2:47 PM, the DON confirmed the allegations of abuse, neglect, and injury of unknown origin was not reported to Adult Protective Services (APS). The DON stated she was unaware those allegations were to be reported to the entity separately as well as to the State Agency.

Based on facility policy review, observation, and interviews, the facility failed to ensure investigations were completed for allegations of abuse and injuries of unknown origin for 4 resident investigations (Resident #1, #19, #38, and #39) of 24 resident investigations reviewed for abuse including injuries of unknown origin. The findings include: Review of the facility's policy titled, Abuse Prevention, dated 6/22/2022, showed Abuse .the willful infliction of injury .with resulting physical harm, pain, or mental anguish .Injury of Unknown Source .source of the injury was not observed by any person or the source of the injury could not be explained by the resident .will investigate and report any allegations of abuse within timeframes as required .report alleged violations involving .including injuries of unknown source .to the state agency, adult protective services . Review of the facility's policy titled, Abuse Investigation and Reporting, dated 11/2023, showed .reports of resident abuse .injuries of unknown source .shall be promptly reported to local, state, and federal agencies .and thoroughly investigated by community management .conclusions of investigations will also be reported .Administrator (ADM) or designee will assign the investigation to an appropriate individual .The individual conducting the investigation will, at a minimum .review the completed documentation forms .Interview any witnesses to the incident .Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview other residents to whom the accused employee provides care or services .Witness reports will be obtained in writing .Upon conclusion of the investigation, the investigator will record the results of the investigation .Administrator or his/her designee .will provide the appropriate agencies .with a written report of the findings of the investigation within 5 working days of the occurrence of the incident . Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Encephalopathy, Anxiety Disorder, Major Depressive Disorder, Macular Degeneration, Osteoarthritis, Bilateral Hearing Loss, Cognitive Communication Deficit, and Polyneuropathy. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was cognitively intact. Resident #1 was highly hearing impaired and used a hearing aide. The resident usually understood others. Resident #1 had severely impaired vision with no corrective lenses. Review of Resident #1's Care Plan dated 4/12/2023, showed .HX [History] Episodes of behaviors toward staff .polyneuropathy . Review of Resident #1's Care Plan dated 10/9/2023 showed, .impaired vision related to hx [history] of macular degeneration. Resident is legally blind .impaired communication related to being very hard of hearing and legally blind .I use .amplifier .mood state problem related to dx [diagnosis] of anxiety and depression .impaired behavior related to episodes of refusal of personal care, yelling and hitting out at staff. Irritable when things not done exactly as she wishes. Very anxious .due to lack of vision and hearing . Review of the facility's investigation of Resident #1 showed the facility reported an allegation of physical abuse to the state agency on 11/24/2023 at 2:06 PM. The Administrator became aware of the allegation on 11/24/2023 at 12:45 PM from Resident #1's daughter. The alleged perpetrator was identified as Certified Nursing Assistant (CNA) #2. It was noted that Resident #1's daughter reported .that the CNA was a couple of days ago rough with her enough to cause pause and she asked her to stop but the CNA did not .Resident states no injury .Resident's daughter reported to Administrator who went immediately to interview resident who alleged CNA was forceful causing pain in providing care and did not stop when requested to do so . The facility's investigation documentation showed no evidence that staff interviews had been completed until 12/6/2023 (12 days after the allegation was made). Review of the facility investigation documentation of Resident #1's interview dated 11/24/2023, showed .Pt [patient] states 'she was Mean, Mean, Mean!' .She [Resident #1] was pushed + [and] grabbed aggressively by CNA (Night shift) grabbed ankles tightly. Hurt. (Pt has neuropathy) .Kept telling CNA to stop. CNA ignored pt's request to stop .'She seemed like she took great pleasure in being mean + rough [with] me' . Review of facility's 5 day follow up in the Incident Reporting System dated 12/1/2023, showed .Summary of interview(s) with witnesses(es), what the individual observed or knowledge of the alleged incident or injury .na [not applicable] .Summary of interview(s) with the alleged perpetrator .n [no] . Summary of interview(s) with staff responsible for oversight and supervision of the location where the alleged victim resides .na .Summary of interview(s) with staff responsible for oversight and supervision of the alleged perpetrator, if staff or resident .na . During an interview on 12/4/2023 at 3:30 PM, the Social Services Director (SSD) stated she was asked by the DON to speak with Resident #1 on 11/27/2023, because Resident #1's daughter had reported to the Administrator .I believe Thanksgiving day .but I'm not exactly sure of the date . that a CNA had been harsh with Resident #1 and had hurt her during care. The SSD spoke with Resident #1 on 11/27/2023 and the resident stated that a CNA was harsh, rough, not gentle, and had hurt her during care. Resident #1 was unable to name the CNA or give a description of the CNA in question. The SSD stated she reported Resident #1's interview to the Administrator and the Director of Nursing (DON) immediately after the conversation and they assumed the CNA Resident #1 referred to was CNA #2 based off reports from other residents alleging CNA #2 had been rude and was short with them during care. The SSD stated she had followed up with the resident daily after the allegation and Resident #1 had no change in behaviors and did not want to continue talking about it. During a telephone interview on 12/5/2023 at 8:04 AM, CNA #2 stated she did not recall Resident #1 and was unaware of any time a resident stated she had hurt them during care. CNA #2 stated if a resident had reported that she was hurting them while providing care, she would have stopped and notified the nurse. The CNA stated she had not been made aware of any allegations of mistreatment of a resident at the facility and had not been contacted by the facility about any resident allegations. During an interview on 12/5/2023 at 8:51 AM, the Administrator stated Resident #1's daughter notified her on 11/24/2023, that Resident #1 told her during a phone call, that a CNA had been mean and hateful to her while providing care and caused her pain. Resident #1 stated she had asked the CNA to stop but the CNA did not stop. Resident #1's daughter was unable to tell the Administrator who the CNA was or a specific date the incident occurred. The Administrator immediately went to speak to Resident #1 after the conversation with Resident #1's daughter. The Administrator stated it was difficult to interview Resident #1 because Resident #1 was very hard of hearing and had severe visual impairment. Resident #1 told the Administrator that a CNA was rough while providing care and had caused pain in the resident 's legs. The resident asked the CNA to stop because the CNA was hurting the resident, but the CNA did not stop. Resident #1 reported that the CNA was black based off her voice but was unable to name or describe the CNA. Resident #1 reported to the Administrator that the incident happened .a couple of days before . but was unable to give a time. The Administrator stated, .I will be honest we just immediately assumed it was [CNA #2's first name] . based off customer service complaints received by other residents. The Administrator confirmed she was unable to verify CNA #2 was the CNA Resident #1 spoke of, because the resident was unable to give a specific date, time, name, or description of the CNA. The Administrator stated the facility had attempted to reach CNA #2 via telephone to discuss the allegations, but there was no documentation to show the attempts. During a telephone interview on 12/5/2023 at 12:37 PM, Licensed Practical Nurse (LPN) #3 stated she was a regular caregiver for Resident #1 on night shift. LPN #3 stated Resident #1 had become confused over the last month which was new for the resident. Resident #1 had neuropathy in the bilateral lower extremities and was very sensitive to even the slightest touch to the bilateral lower extremities. LPN #3 stated Resident #1 had never made any allegations regarding staff members hurting her. LPN #3 had not been contacted by the facility regarding Resident #1's allegations. During an observation on 12/5/2023 at 12:51 PM, Resident #1 was lying in bed. The resident wore a headset and a device connected to the headset to amplify sound and was listening to something that could be heard by the surveyor. Resident #1 was unable to tell that this surveyor had entered her room. This surveyor attempted to speak with the resident through the resident's hearing assistive device and the microphone provided by the facility. Multiple attempts were made to communicate with Resident #1 without success. During an interview on 12/5/2023 at 2:24 PM, the Administrator stated it was her expectation that allegations of abuse were conducted by the abuse coordinator. Abuse investigations were to include an interview with the resident, interviews with residents with BIMS of 8 or above, skin assessment of residents with BIMS below 8, interviews with all staff on the unit or those who may have knowledge of the event, and interviews with any potential witnesses. The Administrator confirmed no staff interviews were conducted for Resident #1's abuse allegation because the alleged perpetrator was believed to be CNA #2 based off other reports from other residents. The Administrator confirmed a complete and thorough investigation had not been conducted for Resident #1's abuse allegation. During a telephone interview on 12/5/2023 at 3:50 PM, Resident #1's daughter stated Resident #1 told her during a phone call on an unknown date that 2 staff members had entered her room and were rough with her while providing care. Resident #1 stated she had told the 2 staff members they were hurting her legs, and had asked them to stop, but they did not stop. Resident #1 is deaf and blind and had been having increased confusion prior to the incident. Resident #1 was unable to name or describe the staff members. Resident #1's daughter reported the incident to the Administrator. 48100 Resident #19 was admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar, Abnormalities of Gait, Adjustment Disorder with Anxiety, Delusional Disorder, and Epilepsy. Review of an annual MDS assessment dated [DATE], showed Resident #19 had memory problems, was rarely understood, had a mood problem of being easily annoyed, and exhibited physical behavioral symptoms directed towards others (hitting, kicking). Resident #19 required partial moderate assistance with bed mobility and supervision with transfers. Resident #19 required substantial/maximal assistance with dressing and was not steady with surface to surface transfers or walking. Resident #19 was incontinent of bowel and bladder. Review of Resident #19's comprehensive care plan revised 10/23/2023, showed memory problems, needs assistance with Activities of Daily Living (ADL) care, episodes of behaviors (cussing, hitting), mood state problem, refusing care, and seizure disorder. Review of a Skin Evaluation assessment dated [DATE], showed new bruising was observed to Resident #19's right knee. Review of the facility's investigation documentation showed new bruising was noted to Resident #19's right knee on 11/25/2023. Further review showed no evidence resident or staff interviews had been completed related to the bruising on unknown origin. During an observation on 12/5/2023 at 9:15 AM, Resident #19 was lying in bed with bedside table adjacent to the resident's bed. Resident #19 rolled over in bed, with knees protruding from the mattress and the right knee (same knee with the bruising) almost bumped the metal base to the bedside table. During an interview on 12/5/2023 at 10:01 AM, Registered Nurse (RN) #1 stated she was familiar with Resident #19 and was aware of her right knee bruising. RN #1 stated at the time the bruising was observed, she could not recall any event that would have caused the bruising. RN #1 stated Resident #19 was combative with care and would get up unassisted to walk around. During an interview on 12/5/2023 at 10:12 AM, CNA #1 stated she routinely provided care for Resident #19 and was aware of the bruising to the right knee. CNA #1 stated she could not recall any event that would have caused the bruising to Resident #19 right knee. During an interview on 12/5/2023 at 1:32 PM, the Director of Nursing (DON) stated on 11/25/2023 she received a call from LPN #1 regarding new bruising observed to Resident #19's right knee. The DON stated due to the potential of an unknown injury source, she reported the incident to state agency and initiated an investigation. DON stated the notified the Administrator after the nurse reported incident. The DON stated she was out of town during the initial reporting of the incident and the nurses on the floor were responsible for conducting staff and resident interviews with cognitively impaired resident skin checks. The DON stated the Administrator or ED was responsilble for overseeing the investigation was completed. The DON stated the the facility was unable to substantiate any abuse or neglect, but could not identify how the bruising occurred. The DON stated she was unsure if the staff and resident witness statements had been completed. During an interview on 12/5/2023 at 5:40 PM, LPN #1 stated she reported right knee bruising to the DON after a routine skin check was completed on Resident #19. LPN #1 stated she was unsure how bruising occurred. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Cerebral Infarction, Morbid Obesity, Weakness, and Hemiplegia. Review of an annual MDS assessment dated [DATE], showed Resident #38 was cognitively intact. Resident #38 required extensive 1 person assistance with bed mobility, transfers, dressing and toilet use. Resident #38 required limited 1 person assistance with personal hygiene and was frequently incontinent of bowel and bladder. Review of Resident #38 comprehensive care plan revised 11/1/2023, showed the resident needed assistance with daily ADL care, had altered elimination due to episodes of incontinence and impaired mobility. Review of the facility's investigation documentation of Resident #38 abuse/ neglect allegation (call-light had not been accessible and was upset) on 11/25/2023, showed no evidence resident/staff interviews had been completed. During an observation and interview on 12/5/2023 at 9:45 AM, Resident #38 was sitting up in wheelchair with call light in reach. Resident #38 stated CNA #2 had assisted her to bed and placed her call light on her chest prior to leaving the room. Resident #38 stated when she sneezed or coughed, her call light fell from her chest to her left side on the bed (her paralyzed side). Resident #38 stated when the call light fell from her chest, she could not reach it and she started to yell for CNA #2 to return. Resident #38 stated after she yelled out CNA #2 returned to her room to place her call light in reach. During an interview on 12/5/2023 at 1:14 PM, DON stated on 11/25/2023 she received a call from LPN #1 regarding Resident #38 stating she could not reach her call light and had yelled out for it. The DON stated due to the resident being upset about the event, she reported the incident to the state agency and initiated an investigation. The DON stated she notified the Administrator and the Executive Director (ED) after the nurse reported the incident. The DON stated she was out of town during the initial reporting of the incident and the nurses on the floor were responsible for conducting staff and resident interviews. The DON stated a specific agency employee was named in the allegation and was not working the day the allegation occurred. The DON stated the investigation showed the last day CNA #2 (agency CNA) worked was 11/21/2023 and was further blocked from picking up any other shifts due to the complaint. The DON stated the agency corporation was notified of the complaint allegation towards CNA #2 and received confirmation from them she would not return. The DON stated CNA #2 was called numerous times to discuss the allegation and could not be reached. DON stated the Administrator or ED was responsible for overseeing the investigation was completed. The DON was unsure if witness statements were completed. During an interview on 12/5/2023 at 5:40 PM, LPN #1 stated she reported via telephone to the DON that Resident #38 stated she was not given the call light and had yelled out for it. LPN #1 stated the resident was visibly upset about the event however the resident could not recall the exact day it happened. Resident #38 remembered the staff member's name and stated it was CNA #2. Review of a Witness Statement dated 12/6/2023 (11 days after the allegation was made), showed Nurse #1 worked the night of 11/21/2023 with CNA #2 and had assisted CNA #2 with Resident #38's care. Nurse #1 stated she heard no concerns from any of the residents. Resident #39 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypothyroidism, Delusional Disorder, Anxiety, and Weakness. Review of an annual MDS assessment dated [DATE], showed Resident #39 had severe cognitive impairment and exhibited rejection of care behaviors. Resident #39 required substantial/moderate assistance with bed mobility, dressing, and personal hygiene. Resident #39 was not steady with surface-to-surface transfers and was incontinent of bowel and bladder. Review of Resident #39's comprehensive care plan revised 10/24/2023, showed memory problems, needs assistance with daily ADL care, resident will refuse to have incontinent brief changed, irritability, pessimism, mood state problem, behavioral outbursts at times, refuses personal care and medications, and risk for skin related injuries. Review of a Nursing Progress Note dated 11/25/2023, showed .bilateral wrist discolorations .resident unable to recall what caused them. Asked resident if anyone has harmed her and she shook her head and said no. She denies pain . Review of the facility's investigation documentation showed new bruising was noted to Resident #39's bilateral wrists on 11/25/2023. Further review showed showed no evidence resident or staff interviews had been completed. During an interview on 12/5/2023 at 9:47 AM, Resident #39 stated she could not recall how the bruising occurred to the bilateral wrists. Resident #39 stated no one had hurt her or abused her. During an interview on 12/5/2023 at 10:05 AM, Registered Nurse (RN) #1 stated she was familiar with Resident #39 and was aware of the bruising to the resident's bilateral wrists. RN #1 stated at the time the bruising had been observed, she could not recall any event that specifically caused the bruising. RN #1 stated the resident was combative with care and rested her hands underneath her bedside table frequently after eating. During an interview on 12/5/2023 at 10:15 AM, CNA #1 stated she was aware of Resident #39's bruising to her bilateral wrists. CNA #1 stated at the time the bruising was observed, she could not recall any event that specifically caused the bruising as the resident is combative with care and rests her hands underneath her bedside table frequently after eating. During an interview on 12/5/2023 at 1:24 PM, the Director of Nursing (DON) stated on 11/25/2023 she received a call from LPN #2 regarding new bruising observed to Resident #39's bilateral wrists. The DON stated due to the suspicious location of bruising and unknown injury source, she reported the incident to state agency and initiated an investigation. The DON stated she notified the Administrator and ED after the nurse reported the incident. The DON stated she was out of town during the initial reporting of the incident and the nurses on the floor were responsible for conducting staff and resident interview with skin checks. The DON stated no specific employee or person of interest was identified in the incident. The DON stated the Administrator or ED was responsible for overseeing the investigation was completed appropriately. The DON stated the facility was unable to identify how the bruising occurred. The DON stated she was unsure if the staff or resident witness statements was completed. During an interview on 12/5/2023 at 5:44 PM, LPN #2 stated she reported Resident #39's bruising to the DON via telephone. LPN #2 stated she had no idea on how the bilateral wrist bruising occurred. During an observation on 12/6/2023 at 12:45 PM, Resident #39 was lying in bed with bedside table across her abdominal area. Resident #39 had her bilateral hands/ forearms folded against her stomach and was tucked underneath the bedside table after finishing lunch. During an interview on 12/6/2023 at 3:20 PM, the Interim ED/Director of Operations (DOO) stated the witness statements had not been completed on 11/25/2023 (day the facility reported incidents occurred). The Interim ED/DOO stated it was the facility's expectation to ensure a thorough and complete investigation had been conducted, staff and resident witness statements would be completed as soon as possible after an alleged event. The Interim ED/DOO confirmed the facility failed to ensure resident/ staff witness statements had been completed for the facility reported incidents for Resident #19, #38, and #39

Based on facility policy review, facility document review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to assess and monitor concerns with reporting allegations of abuse, injury of unknown origin, misappropriation, and neglect for 15 resident investigations (Residents #1, #2, #19, #38, #39, #3, #37, #42, #43, #64, #68, #69, #70, #71, and #72) of 26 resident investigations reviewed. The facility failed to maintain an effective QAPI program that was successful in identifying, prioritizing and implementing strategies related to ensuring incident investigations were thorough and complete as well as the reporting to all entities required. The QAPI program failed to ensure systems and processes were implemented facility wide and consistently followed by staff. The findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement (QAPI) Program, dated 8/2023, revealed, .This community shall maintain an ongoing, comprehensive, data-driven, community-wide Quality Assurance and Performance Improvement (QAPI) program that focuses on outcomes of quality of care and quality of life goals .QAPI Supportive Actions .Gathering and using QAPI data in an organized and meaningful way .Prioritizing identified quality issues based on safety, quality, rights, choice, respect and frequency of occurrence, and determining which will be the focus of PIP's [Performance Improvement Projects] .Planning, conducting, documenting and monitoring PIP's until substantial compliance is determined by the QAPI committee . Review of the medical records and facility incident investigations for 14 residents (Residents #1, #2, #19, #38, #39, #3, #37, #42, #43, #68, #69, #70, #71,and #72) revealed allegations of abuse, injury of unknown origin, misappropriation, and neglect were reported to the State Agency, the allegations were not reported to APS (Adult Protective Services) as required. Refer to F-609. Review of the medical records and facility incident investigations of 4 residents (Resident #19, #38, and #39) of 24 resident investigations reviewed for abuse including injuries of unknown origin revealed the facility failed to ensure a complete and thorough investigation was conducted. Refer to F-610. Review of QAPI minutes for 10/2023 and 11/2023, revealed .State Agency reportable incidents and Survey Management concerns . were reviewed, no documentation to support allegations of abuse, injury of unknown origin, misappropriation, and neglect was conveyed to all appropriate entities. The facility had reported the allegations to the State Agency and failed to notify APS. During an interview on 12/12/2023 at 2:00 PM, the Director of Nursing (DON) stated she was not aware that allegations that are reported as abuse and neglect are also to be reported immediately to APS. The QAPI committee failed to identify the facility's lack of knowledge related to reporting of abuse, neglect and injury of unknown origin. During an interview on 12/13/2023 at 8:45 AM, the Administrator confirmed the facility's QAPI program was ineffective and the facility's QAPI committee failed to identify the allegations of abuse, neglect, misappropriation, and injury of unknown origin were to be reported to APS and failed to identify the allegations had not been reported. The Administrator stated the facility waited to address issues until the monthly meeting occurred .need more eyes are on the processes .

Based on interview, record review, and review of the facility's Administrator's and Director of Nursing's (DON) Job Descriptions, the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility. During an abbreviated survey, five Immediate Jeopardies were identified, with the highest scope and severity (S/S) of a L and four standard level tags were cited with the highest S/S being an F. The facility failed in the areas of 42 CFR 483.10 Notification of Change (F580), 42 CFR 483.12 Free from Misappropriation (F602), 42 CFR 483.25 Quality of Care (F684), 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657), 42 CFR 483.70 Resident Records-Identifiable Information (F842), 42 CFR 483.25 Bed Rails (F700), 42 CFR 483.25 Respiratory Care (F695), 42 CFR483.21 Comprehensive Care Plans/Services Meet Professional Standards of Quality (F658), and 42 CFR 483.25 Accidents (F689). The facility's failure to ensure it was administered in a manner that enables it to use its resources effectively and efficiently has caused or was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was identified on 09/28/23 at 42 CFR 483.70 Administration (F835) and was determined to exist on 07/30/23. The facility was notified of the Immediate Jeopardy on 09/28/23 at 8:30 PM. The Administrator was notified of the Immediate Jeopardy on 09/28/23 at 8:30 PM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of the Administrator's Job Description, effective 06/11/23, revealed Job Summary: Oversees the operational effectiveness of assigned facility. Responsibilities: Oversees the development and implementation of policies, procedures and strategies related to assigned facility. Ensures that facility is in compliance with federal, state, and local regulations. Monitors care delivery to determine changes that may be needed to improve outcomes and service standards. Reviews data to identify performance improvement opportunities. Develops, implements, and monitors operating budgets for areas of responsibility. Directs and coordinates activities of all medical, nursing, and administrative staff and services . Review of the DON's Job Description, effective date 07/10/22 revealed, Job Summary: Directs services, workflow and resources for assigned long-term care nursing area. Responsibilities. Develops departmental goals and objectives consistent with medical, administrative, legal, and ethical requirements of the long-term care health delivery system. Directs forecasting, planning, developing, organizing, implementing, directing, and evaluating all clinical services and programs to ensure high quality resident care. Plans, organizes, and directs all activities related to staffing, including hiring, orienting, evaluating, and continuing education initiatives. Prepares and monitors budget(s) and ensures that assigned nursing area operates within allocated funds. Coordinates and directs internal and externally-driven audits. Monitors admissions, discharges, and transfers to assure appropriate care and compliance with State and/or Federal regulations. Complexity of Work: Within scope of job, requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision . (Refer to F580, F602, F657, F658, F684, F689, F695, F700, F835, and F842) The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-835 continues at a scope and severity F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure six of six residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for bowel movement monitoring received the necessary care and treatment in accordance with professional standards of practice. On 07/30/23, R7 was transferred to the hospital after becoming entrapped in between his mattress and grab bar. While receiving treatment, it was discovered that R7 had a fecal impaction. Record review revealed there were no documented bowel movements for R7 for five days leading up to the fecal impaction diagnosis. Additional record reviews revealed the facility's systemic failure of ensuring residents' bowel movements were monitored to prevent constipation. The facility's systemic failure has the potential to affect all residents who resided at the facility. The facility's failure to ensure residents received quality of care and treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/27/23 and was determined to exist on 07/30/23, in the area of S483.25 Quality of Care F684 at a scope and severity (S/S) of a L. The Administrator was notified of the Immediate Jeopardy on 09/27/23 at 4:55 PM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: 1. Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident to always be incontinent of bowels. Review of R7's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/01/23 through 06/03/23, 06/16/23 through 06/18/23, 06/22/23 through 06/24/23, 06/30/23 through 07/04/23, 07/26/23 through 07/30/23, 08/04/23 through 08/07/23, 08/17/23 through 08/21/23, 08/29/23 through 08/31/23, and 09/09/23 through 09/12/23. Review of R7's Medication [Administration] Record (MAR), dated June 2023 and provided by the facility revealed the resident's physician ordered the following bowel regimen medications to prevent constipation, Miralax (laxative) 17 gram/dose oral powder .by mouth every day as needed for constipation. Milk of Magnesia (laxative) 400 mg/5mL [milligram/milliliter] or suspension .by mouth every day as needed for constipation if no BM [bowel movement] x 2 [for two] days; diagnosis/reason = Constipation . Dulcolax (laxative) 10mg rectal suppository .every day as needed for constipation if no bm x 3 days . and Fleet Enema 19 gram-7 gram/118 mL- 1 rectal every day as needed for constipation unrelieved by suppository; diagnosis/reason = constipation unrelieved by suppository . Review of R7's readmission Physician's Orders, dated 08/04/23, provided by the facility revealed R7 was ordered the following Milk of Magnesia 400mg/5mL oral suspension-2400mg/30ml by mouth every day as needed for constipation if no BM x 2 days ., Miralax 17 gram/dose oral powder- 17g [grams] by mouth everyday as needed for constipation, Dulcolax 10 mg rectal suppository- 10mg every day as needed for constipation if no bm x 3 days, and Fleet Enema 19 gram-7 gram/118 mL - 1 rectal every day as needed for constipation unrelieved by suppository. Review of R7's MARs, dated June 2023, July 2023, August 2023, and September 2023, provided by the facility revealed R7 was not administer any of the as needed medications for constipation for the dates when the resident went three days or longer without a documented bowel movement. Review of R7's Hospitalists Discharge Summary, dated 08/04/23 revealed .In the emergency room , CT scan of .abdomen/pelvis .Other pertinent findings include rectal distention concerning for fecal impaction .Hospital course by problem .Active Problems .Fecal impaction (HCC) .Constipation. Noted to have significant stool burden/fecal impaction on initial CT of the abdomen. Will start aggressive bowel regimen including enemas .Would continue aggressive bowel regimen after discharge .Hospital Summary .Follow-up Issues: Would recommend ongoing aggressive bowel regimen .Radiology Results: .CT Abdomen/Pelvis with IV Contrast .Findings: .Stomach and bowel: Stomach decompressed. Small bowel loops unremarkable. There is significant diverticulosis throughout the colon without evidence for diverticulitis. There is significant rectal fecal material present with distention up to 8 cm .Impression: .2. Rectal distention from significant amount of colonic fecal material, correlate for constipation for possible fecal impaction . During an interview on 09/26/23 at 2:31 PM, R7's Attending Physician (AP) 1 stated when reviewing R7's bowel monitoring documentation for the last week of July 2023 where there were several days with no documented bowel movement, and just now finding out the resident was diagnosed with a fecal impaction at the hospital, this was very distressing to her. AP1 also stated the PRN (as needed) medications were ordered for the purpose of ensuring the resident did not become constipated. AP1 further stated the facility should have implemented the PRN medications that she had ordered for R7. During an interview on 09/26/23 at 5:33 PM, Registered Nurse (RN) 3 stated he was not sure what the facility's protocol was; however, it was a nursing practice if a resident goes two consecutive days without having a bowel movement, then the nurse should notify the resident's physician. RN3 stated if a resident was to go multiple days without having a bowel movement, it could cause issues such as a bowel obstruction, pain, constipation, or an impaction. RN3 stated impactions were usually extremely painful. When asked how he would know if a resident had not had a bowel movement in two or more days, RN3 stated he was not for sure, and the facility had never told him that he needed to be going back and looking at Certified Nurse Aids (CNAs) documentation. During an interview on 09/26/23 at 6:10 PM, the Director of Nursing (DON) stated CNAs were to document each shift if their assigned residents had a bowel movement or not. When asked who was responsible for pulling the residents' bowel movement documentation, the DON stated there was no procedure in place directing what nurses or on what shifts the no bowel movement report was to be run. The DON also stated it was important the residents' bowel movements were tracked because going without a bowel movement for several days could cause multiple issues that could then lead to major health issues. 2. Review of R4's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of R4's quarterly MDS, with an ARD of 07/05/23, provided by the facility revealed the facility assessed the resident as always continent of bowels. The surveyor requested R4's documentation of physician orders, daily bowel movement charting, and MARs; however, the facility never provided the requested documentation prior to leaving the building. 3. Review of R8's Significant Change in Status MDS, with an ARD of 08/25/23 revealed the resident was admitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R8 as being occasionally incontinent of bowels. Review of R8's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/15/23 through 06/17/23, 07/29/23 through 08/01/23, 08/17/23 through 08/19/23, 08/25/23 through 08/29/23, and 08/31/23 through 09/04/23. Review of R8's current Physician Orders, provided by the facility revealed the resident was ordered the following bowel regimen medications Dulcolax 5 mg tablet, delayed release - 10 mg rectal every day as needed for constipation and Fleet Enema 19 gram-7 gram/118 mL- 1 Rectal every day as needed for constipation. Review of R8's MARs, dated June 2023, July 2023, August 2023, and September 2023, provided by the facility revealed R8 was not administer any of the as needed medications for constipation for the dates when the resident went three days or longer without a documented bowel movement. 4. Review of R20's admission MDS with an ARD of 01/24/23 revealed the resident was admitted to the facility on [DATE]. Review of R20's quarterly MDS, with an ARD of 06/14/23, provided by the facility revealed the resident was readmitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R20 as being frequently incontinent of bowels. Review of R20's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 07/05/23 through 07/07/23, 07/14/23 through 07/16/23, 08/20/23 through 08/25/23, 08/30/23 through 09/01/23, 09/08/23 through 09/14/23, 09/18/23 through 09/20/23, and 09/22/23 through 09/24/23. Review of R20's current Physician Orders, provided by the facility revealed the resident was ordered the following bowel regimen medications Dulcolax 5 mg tablet, delayed release - 10 mg rectal every day as needed for constipation and Fleet Enema 19 gram-7 gram/118 mL- 1 Rectal every day as needed for constipation. Review of R20's MAR, dated June 2023, provided by the facility revealed R20 was ordered the following bowel regimen medications, Colace Cap [capsule] 100MG CAPS-100 mg by mouth every 12 hours for constipation; diagnosis/reason = constipation, Milk of Magnesia -30ml as needed 30 ml daily as needed for constipation Continued review of the MAR revealed there was no documented evidence R20 was administered any of the as needed medications for constipation for the dates when the resident went three days or longer without a documented bowel movement. R20's MARs for July 2023, August 2023, and September 2023 were requested; however, they were not received before the survey team exited the building and were not received after leaving the building. During an interview on 09/27/23 at 11:45 AM, R20 stated he has gone up to five days without having a bowel movement. The resident stated he has only told the nurse one time because it was bothering him. R20 also stated the nurses or CNAs have not asked him about his bowel movements or he would have told them how many days he goes without a bowel movement. 5. Review of R21's admission MDS with an ARD of 10/27/22 revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, with an ARD of 07/21/23, provided by the facility, revealed the resident was readmitted to the facility on [DATE]. Continued review of the MDS revealed the facility assessed R21 as being always continent of bowels. Review of R21's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/23/23 through 06/25/23, 07/10/23 through 07/12/23, 07/14/23 through 07/22/23, and 08/21/23 through 08/23/23. Review of R21's MARs dated June 2023, July 2023, August 2023, and September 2023, provided by the facility, revealed R21 was ordered the following bowel regimen medications, Milk of Magnesia -30ml as needed 30 ml daily as needed for constipation, Dulcolax 10 mg rectal suppository every day as needed if no BM x3 days, for constipation and Fleet Enema 19 gram- 7 gram/118 mL- 1 rectal every day as needed if unrelieved [sic] by Dulcolax suppository for constipation. Continued review of the MARs revealed R21 was not administered any of the medications when he did not have a documented bowel movement within three days. 6. Review of R22's undated Profile Face Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R22's quarterly MDS, with an ARD of 06/29/23, revealed the facility assessed the resident as always being incontinent. Review of R22's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/24/23 through 06/26/23, 08/06/23 through 08/10/23, and 09/07/23 through 09/09/23. Review of R22's current Physician's Orders, provided by the facility revealed the resident was ordered the following bowel regiment medications, Dulcolax 10 mg rectal suppository- 10mg rectal every day as needed for constipation, Milk of Magnesia 400 mg/5 mL oral suspension give 30 mls-2400mg/30mls by mouth ever day as needed for constipation, polyethylene glycol POWD [powder] 17GM/SCOOP .every day as needed for constipation, and Fleet Enema 19 gram-7 gram/118mL- 1 rectal every day as needed for constipation. Review of R22's MARs, dated June 2023, July 2023, August 2023, and September 2023, provided by the facility revealed no documented evidence the resident was administered any of the as needed medications when there were not documented bowel movements for three or more days. During an interview on 09/27/23 at 3:38 PM, CNA 3 she would assume alert and oriented residents would tell her without her asking if they had a bowel movement. The CNA stated she checks on incontinent residents every two hours and would document in the computer if there was a bowel movement. CNA3 also stated if she did not get her charting completed by the end of her shift, she would inform the CNA for the next shift and the CNA would agree to chart for her. Continued interview with CNA3 revealed she rarely had time to chart bowel movement documentation because she was usually so busy answering call lights. Review of the facility's policy titled, Clinical Protocol: Bowel (Lower Intestinal Tract) Disorders, revised December 2017, revealed .Monitoring and Follow-Up .A. The associates and physician will monitor the individual's response to interventions and overall progress; for example .frequency and consistency of bowel movements . Review of the facility's undated Standing PRN Orders, document provided by the facility revealed, .Constipation: (always notify the provider of each additional step that is required) .If no BM for 48 hours, begin with: 1. Miralax 17GM PO [by mouth] QD [every day] + Colace 100mg PO Q12 [every 12 hours] .After 96 total hours since last BM: Choose from following options: 1. Magnesium hydroxide (MOM [milk of magnesium]) 400mg/5ml. Dose: 30 ml/day PO until BM, then D/C [discontinue] .Do not exceed more than 3 doses of the above medication. Please call provider . The survey team requested the facility provide the nursing practice the facility followed/referenced, specifically related to bowel management. The facility provided an untitled and undated facility letterhead document which read, This Facility uses the following: [NAME] Nursing Practice [[NAME] Manual of Nursing Practice]. The document did not reference an edition number nor any other information. The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-684 continues at a scope and severity F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on observation, interview, record review, and review of a facility document, the facility failed to ensure services were provided to meet acceptable professional standards for six out of six sampled residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for accidents, bowel monitoring, and supplemental oxygen therapy, out of a total sample of 35. On 07/30/23, R7 was found entrapped between the grab bar and mattress and sustained multiple fractures to his ribs. The nurse on duty assigned to R7 failed to complete a thorough assessment of R7 and failed to accurately report the incident to the resident's physician. Additionally, the facility failed to ensure R7 received supplemental oxygen therapy per the physician orders. R7's Physician's Orders were for R7 to have oxygen administered at two liters per minute (lpm) to keep his saturations above 90% for hypoxia (low level of oxygen). On 09/26/23, R7's oxygen concentrator was not working properly. The resident's oxygen saturation dropped to 83%. The facility determined that when the humidifier bottle was changed out, the cap was not correctly/fully applied and was not allowing oxygen to flow. Also, the Director of Nursing (DON) stated she assessed R7's oxygen saturation on 09/26/23; however, the DON did not document the assessment and did not document the incident in the resident's medical record. The facility also failed to have a system in place for bowel management to ensure nursing staff were monitoring residents' bowel movements. When R7 was transferred to the hospital for treatment related to the entrapment, it was discovered R7 had a fecal impaction which required an aggressive bowel regimen as treatment. Through record review a total of six residents (R4, R7, R8, R20, R21, and R22) were found not to have documentation of bowel movements. There was intermittent documentation that residents went at a minimum of 48 hours and up to five days without documentation of any bowel movements. The facility's failure to ensure acceptable professional standards of care has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/28/23 and determined to exist on 07/30/23 in the area of 42 CFR S483.21(b) Comprehensive Care Plans, (i) Meet professional standards of quality F658 at the highest scope and severity (S/S) of a L. The Administrator was notified of the Immediate Jeopardy on 09/28/23 at 8:30 PM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: 1. Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, repeated falls, pulmonary fibrosis, and sleep apnea. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident that a brief interview for mental status (BIMS) score could not be completed. The facility assessed R7 to have long-term and short-term memory problems, and the resident was severely impaired in cognitive skills for daily decision making. Continued review the resident's MDS revealed the facility assessed R7 to require extensive assistance of two staff persons for bed mobility, transfers between surfaces, and toilet use. a. Review of R7's Interdisciplinary Note, dated 07/30/23 at 7:12 AM, completed by Licensed Practical Nurse (LPN) 11 and provided by the facility revealed Patient found this am at 4am by CNA [Certified Nurse Aide], she immediately alerted nurse and found patient to be rolled off right side of bed with rt [right] arm/chest wedged in by side rail with bil [bilateral] legs folded under him. On assessment, patient responsive, but unable to explain to this nurse what had occurred. Myself and CNA assisted patient back bed and on further assessment, found red areas on right forearm and rib cage under breast, surface abrasions to rt hip and lower back. Abrasion to hip, cleaned and covered d/t [due to] scant amount of serous fluid present. VS [vital signs] 128/70 [blood pressure], hr [heart rate] 74, [respirations] 18 temp [temperature] 97.0 O2 [oxygen saturation] 96 ra [room air]. Supervisor notified as well as MD [physician] and patients [sic] responsible party. Neuro's [neurological checks] initiated and at baseline. Bed was in lowest position; patient has alarm mat but it was on left side of bed and staff wasn't alerted. Will continue to monitor. Review of an untitled Communication Record document provided by the facility revealed the first time a physician was notified after R7's entrapment on 07/30/23 at 4:00 AM, was on 07/30/23 at 8:10 AM, four hours after the incident occurred. The documented communication read, [LPN11 or Registered Nurse (RN) 3] nurses with [facility name], state the patient [R7] has an abrasion on his hip, hit his right arm and chest. The patient is not complaining of pain . Continued review revealed a second communication on 07/30/23 at 8:30 AM, completed by the on-call physician read, .Reports pt [patient] was slumped over side of bed and accidentally rolled of (sic) this AM. He sustained some abrasions on his, R [right] arm, and chest. Denies there was any bleeding .Instructed to sent to ED [emergency department] if VS [vital signs] become unstable or patient begins to bleed uncontrollably. Will inform [R7's Attending Physician]. There was no documented evidence the nurse reported the details of the entrapment. Review of R7's Hospitalists Discharge Summary, dated 08/04/23, provided by the facility revealed .Patient presents after a fall. He has a history of advanced dementia .Patient was apparently trying to get out of bed this morning around 4 AM. He has a handrail on the bed that he sometimes uses to help pivot. Apparently his hand became caught in the rail and then slid to the floor. He sustained injuries to his right hand, abdomen, and hip. He also has abrasions around his neck (possibly secondary to the oxygen tubing) .When patient's caregiver came to evaluate the patient today, she was concerned regarding the level of injuries and request to be brought to the emergency room for evaluation .In the emergency room , CT scan of brain/cervical spine/chest/abdomen/pelvis demonstrated nondisplaced anterior left fifth through seventh rib buckle type fractures and age-indeterminate nondisplaced fracture sequela of the right sixth rib. ER provider requested admission given rib fractures and risk for pneumonia . During an interview on 09/25/23 at 5:33 PM, RN3 stated he came on shift on 07/30/23 at approximately 5:45 AM. The RN stated he could not locate the nurse [LPN11] for the floor to do shift communication. RN3 stated he notified the nursing supervisor at 6:10 AM that he could not locate the nurse and needed shift report. Continued interview revealed after LPN11 was located and came to give him the shift report, she informed him that R7 had fallen and reported the resident had no substantial injuries, just some scratches and bruises on the ribs. RN3 stated being his first day out of orientation, he notified the nursing supervisor of the fall. RN3 further stated the day shift nursing supervisor and LPN11 entered into R7's room and he started medication pass. RN3 also stated he was later called to R7's room and told by R7's Care Connections Case Manager (CCCM) she wanted the resident sent to the hospital. She showed him the injuries and he was shocked because the resident had multiple injuries that were very visible. During an interview on 09/26/23 at 2:31 PM, R7's Attending Physician (AP) 1 stated during this interview with the surveyor was the first she had heard that R7 was wedged between the mattress and the grab bar on his bed. When listening to the nurses note dated 07/30/23 at 7:12 AM read to her by this surveyor, AP1 stated hearing the words wedged and bilateral legs under him was really distressing for her to hear. AP1 stated knowing those details, the resident should have been sent out to the emergency room sooner than he was. During an interview on 09/27/23 at 6:30 PM, LPN11 stated at approximately 4:00 AM on 07/30/23, CNA2 came to her medication cart and told her R7 was on the floor. Continued interview revealed LPN11 directly went to R7's room and discovered the right side of the resident's chest and his right arm were wedged in between the grab bar and his mattress. LPN11 stated R7's knees were barely touching the fall mat. LPN11 also stated R7 was wedged so tightly, the grab bar could not be lowered, there was no room to get a Hoyer lift, and the use of a gait belt would not have been safe. LPN11 stated she got a bedsheet and made a sling, slipped it under the resident, where she and the CNA got the resident unwedged and put him back into his bed. LPN11 further stated she had to push on the resident's mattress while pulling him to get him out of the grab bar. LPN11 stated her and RN4 later determined the resident's mattress edge failed by deflating and combined with R7's weight that was how he became wedged. LPN11 also stated by the time they got the resident back into bed, assessed, and started her paperwork, she did not see any serious injury, so she continued administering residents their medications and it did not seem emergent. The LPN stated no one ever followed up with her on the incident. Complete review of R7's Electronic Medical Record (EMR) revealed no documented evidence of an accurate assessment of R7's injuries as noted per the hospital discharge summary. b. Review of R7's Significant Change in Status MDS with an ARD of 08/16/23 revealed the facility assessed the resident as receiving oxygen therapy. Review of R7's current Physician Orders, located in the resident's EMR under order's tab revealed an order dated 08/04/23 of Oxygen at 2 liters/minute [per minute] to keep sats [saturations] above 90%. 2L [liters] inhalation every 12 hours for hypoxia . During an observation and interview on 09/25/23 at 1:56 PM, R7 was sitting at the dining room table with a peer. The resident was being administered supplemental oxygen via nasal canula. RN3 was asked to observe R7's oxygen concentrator and to verify how many liters per min was the resident's concentrator set at. RN3 stated the concentrator was set to 1.5 lpm. When asked who was responsible for setting the lpm on the concentrator, RN3 stated both nurses and CNAs were responsible for ensuring it was set correctly. During an observation and interview on 09/25/26 at 4:23 PM, R7 was lying in his bed, with his Continuous Positive Airway Pressure (CPAP/machine that keeps breathing airways open) on, being connected to his oxygen concentrator. RN3 who was present during the observation verified the concentrator was set to 1.5 lpm. RN3 stated during the observation, he realized the concentrator should have been set to 2 lpm and immediately corrected the concern. RN3 also stated it was important R7's oxygen be administered per his physician's order to ensure his oxygen saturation was maintained at 90% or greater. During an interview on 09/26/23 at 3:20 PM, R7's CCCM approached surveyor and stated at approximately 2:15 PM today, herself and a care connections nurse came to visit R7. The CCCM stated R7 was sitting in the common area in his wheelchair when the care connections nurse noticed R7's humidifier bottle was not bubbling like normal. The CCCM and care connection nurse assessed the nasal canula and they did not feel any air flowing, so they got a cup of water to put the nasal canula in and verified there was no oxygen flow. The CCCM stated they immediately took the resident's oxygen saturation, and it was 83%. At that point, the nurse was not visibly available, so she went to the Director of Nursing (DON's) office and reported the concern. The CCCM further stated the DON obtained a pulse oximeter from the nurse's station and checked R7's oxygen saturation and it was still at 83%. The CCCM stated the DON immediately obtained a portable oxygen tank and within a few minutes, the resident's saturations rose to 90%. The interview also revealed the resident was more confused than usual, could not form words, tired looking, and was moving his arms around slowly with no purpose. The CCCM stated the Administrator informed her that she determined the oxygen concentrator's humidifier bottle was the reason oxygen was not flowing. Specifically, the Administrator told her when the bottle was changed out, the cap did not puncture the bottle to allow for air flow. Observation on 09/27/23 at 4:37 PM revealed R7's oxygen concentrator was set at 2.5 lpm. During an interview on 09/28/23 at 11:27 AM, RN3 stated on 09/26/23 at around 2:30 PM, while at the nurse's station he learned that R7's oxygen saturation was in the 80s. RN3 also stated the DON explained to him that the resident was not receiving the oxygen because the cap of the humidifier bottle did not puncture the bottle like it should have when it was changed out. During an interview on 09/27/23 at 12:17 PM, the DON stated on 09/26/23, R7's oxygen was not being administered as ordered. The DON stated when she arrived to the floor the resident was confused more than normal. The DON also revealed she assessed R7's oxygen saturation and it was in the mid-80s; however, the DON stated she had not fully investigated the concern and did not know if she documented the assessment. Continued interview revealed she obtained a portable oxygen tank from the crash cart, and administered the oxygen to the resident and his saturations came back up. The DON stated she determined that whoever changed the humidifier bottle on the concentrator did not ensure when screwing the cap on the bottle that it punctured the bottle so oxygen could flow. When asked who was the staff person that changed the humidification bottle out, the DON stated she had not investigated that yet. The DON further stated it was a full bottle, so it had to have been changed recently. During an interview on 09/28/23 at 2:34 PM, AP1, who was R7's attending physician stated she was at the facility during the concern with R7's saturations being in the 80s on 09/26/23. AP1 stated she did not assess the resident but mentioned to the nurse that putting him in bed and applying his CPAP may be needed because the resident's carbon dioxide level may have built up. Continued interview revealed it was important R7's oxygen be administered as ordered to keep his saturation above 90%. AP1 stated she wanted his oxygen saturation 90% or above because if it is below 90% for a long period of time, the resident may not get enough oxygen to the organs of his body. c. Review of R7's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/01/23 through 06/03/23, 06/16/23 through 06/18/23, 06/22/23 through 06/24/23, 06/30/23 through 07/04/23, 07/26/23 through 07/30/23, 08/04/23 through 08/07/23, 08/17/23 through 08/21/23, 08/29/23 through 08/31/23, and 09/09/23 through 09/12/23. Review of R7's Hospitalists Discharge Summary, dated 08/04/23 revealed .In the emergency room , CT scan of .abdomen/pelvis .Other pertinent findings include rectal distention concerning for fecal impaction .Hospital course by problem .Active Problems .Fecal impaction (HCC) .Constipation. Noted to have significant stool burden/fecal impaction on initial CT of the abdomen. Will start aggressive bowel regimen including enemas .Would continue aggressive bowel regimen after discharge .Hospital Summary .Follow-up Issues: Would recommend ongoing aggressive bowel regimen .Radiology Results: .CT Abdomen/Pelvis with IV Contrast .Findings: .Stomach and bowel: Stomach decompressed. Small bowel loops unremarkable. There is significant diverticulosis throughout the colon without evidence for diverticulitis. There is significant rectal fecal material present with distention up to 8 cm .Impression: .2. Rectal distention from significant amount of colonic fecal material, correlate for constipation for possible fecal impaction . 2.Review of R4's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE]. The surveyor requested R4's documentation of physician orders, daily bowel movement charting, and MARs; however, the facility never provided the requested documentation prior to leaving the building. 3. Review of R8's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/15/23 through 06/17/23, 07/29/23 through 08/01/23, 08/17/23 through 08/19/23, 08/25/23 through 08/29/23, and 08/31/23 through 09/04/23. 4. Review of R20's admission MDS with an ARD of 01/24/23 revealed the resident was admitted to the facility on [DATE]. Review of R20's quarterly MDS, with an ARD of 06/14/23, provided by the facility revealed the resident was readmitted to the facility on [DATE]. Review of R20's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 07/05/23 through 07/07/23, 07/14/23 through 07/16/23, 08/20/23 through 08/25/23, 08/30/23 through 09/01/23, 09/08/23 through 09/14/23, 09/18/23 through 09/20/23, and 09/22/23 through 09/24/23. During an interview on 09/27/23 at 11:45 AM, R20 stated he has gone up to five days without having a bowel movement. The resident stated he had only told the nurse one time because it was bothering him. R20 also stated the nurses or CNAs have not asked him about his bowel movements or he would have told them how many days he goes without a bowel movement. 5. Review of R21's admission MDS with an ARD of 10/27/22 revealed the resident was admitted to the facility on [DATE]. Review of R21's quarterly MDS, with an ARD of 07/21/23, provided by the facility, revealed the resident was readmitted to the facility on [DATE]. Review of R21's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/23/23 through 06/25/23, 07/10/23 through 07/12/23, 07/14/23 through 07/22/23, and 08/21/23 through 08/23/23. 6. Review of R22's undated Profile Face Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R22's Daily Charting . from 06/01/23 through 09/28/23, provided by the facility revealed the following documentation of the resident not having a bowel movement and/or no documented evidence of a bowel movement for three consecutive days or longer: 06/24/23 through 06/26/23, 08/06/23 through 08/10/23, and 09/07/23 through 09/09/23. During an interview on 09/26/23 at 5:33 PM, RN3 stated he was not sure what the facility's protocol was; however, it was a nursing practice if a resident goes two consecutive days without having a bowel movement, then the nurse should notify the resident's physician. During an interview on 09/26/23 at 6:10 PM, the DON stated CNAs were to document each shift if their assigned residents had a bowel movement or not. When asked who was responsible for pulling the residents' bowel movement documentation, the DON stated there was no procedure in place directing what nurses or on what shifts the no bowel movement report was to be run. The DON also stated it was important the residents' bowel movements were tracked because going without a bowel movement for several days could cause multiple issues that could then lead to major health issues. The facility was asked for a policy related to professional standards and an untitled and undated facility letterhead document revealed This Facility uses the following: [NAME] Nursing Practice [[NAME] Manual of Nursing Practice]. The document did not reference an edition number nor any other information. Refer to F684, F689, and F695 The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-658 continues at a scope and severity F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on observations, interviews, record reviews, and review of the facility's policies, the facility failed to ensure residents were free from accidents and hazards for one of three resident (Resident (R) 7) reviewed for accidents out of a sample of 35. On 07/30/23, R7 was discovered entrapped between his low air loss mattress and the grab bar attached to his bed. The resident sustained multiple fractures to his right and left ribs. Additionally, the facility failed to complete a timely and thorough investigation into the incident. An Immediate Jeopardy was identified on 09/26/23 and was determined to exist starting on 07/30/23, in S483.25(d) F689: Accidents. The Administrator was notified on 09/26/23 at 3:45 PM of the failure to prevent accidents and hazards for R7. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, and repeated falls. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident that a brief interview for mental status (BIMS) score could not be completed. The facility assessed R7 to have long-term and short-term memory problems, and the resident was severely impaired in cognitive skills for daily decision making. Continued review the resident's MDS revealed the facility assessed R7 to require extensive assistance of two staff persons for bed mobility, transfers between surfaces, and toilet use. Review of R7's Care Plan Historical Copy, dated 06/29/23, provided by the facility revealed . [resident's name] has memory problems, impaired decision-making skills, and impaired ability to comprehend. Dx [diagnosis] dementia . [resident's name] needs assistance with daily ADL [activities of daily living] care .I need extensive [assistance] x1 [of one] person staff support with bed mobility . [resident's name] has potential for falls d/t [due to] dementia and limited mobility. Needs assistance with transfers and mobility. Hx [history] of falls. Poor safety awareness .Fall mats bilateral sides of bed .Fall mat with call light activation in place when resident in bed . The care plan did not include any interventions related to the resident using grab bars. Review of R7's Interdisciplinary Note, dated 07/30/23 at 7:12 AM, completed by Licensed Practical Nurse (LPN) 11 and provided by the facility revealed Patient [R7] found this am [morning] at 4am by CNA [Certified Nurse Aide], she immediately alerted nurse and found patient to be rolled off right side of bed with rt [right] arm/chest wedged in by side rail with bil [bilateral] legs folded under him. On assessment, patient responsive, but unable to explain to this nurse what had occurred. Myself and CNA assisted patient back bed and on further assessment, found red areas on right forearm and rib cage under breast, surface abrasions to rt hip and lower back. Abrasion to hip, cleaned and covered d/t [due to] scant amount of serous fluid present. VS [vital signs] 128/70, hr [hear rate] 74, 18 [respirations] temp [temperature] 97.0 O2 [oxygen saturation] 96 ra [room air]. Supervisor notified as well as MD [physician] and patients [sic] responsible party. Neuro's [neurological checks] initiated and at baseline. Bed was in lowest position, patient has alarm mat but it was on left side of bed and staff wasn't alerted. Will continue to monitor. Review of R7's Interdisciplinary Note dated 07/30/23 at 11:43 AM, completed by Registered Nurse (RN) 3 and provided by the facility revealed Case manager came to visit and assess patient after fall. Case manager requested for patient to be sent out for xrays and evaluation. Called 911 with nonemergency transport to [hospital name]. Supervisor notified. Review of the Incident Witness Statement Form, dated 07/30/23, completed by LPN11 and provided by the facility revealed .Patient [R7] was on edge of bed [with] bil knees on fall mat [sic]. his [sic] upper rt side was up against handrail. He was assessed, Alert [sic] and talking. Assisted back into bed with further assessment completed . Review of the Incident Witness Statement Form, dated 07/30/23, completed by CNA2 and provided by the facility revealed .upon on [sic] doing my final round I entered [R7's Name] room and he had slid out of his bed on the right side. I made sure he was breathing and notified the nurse [LPN11's Name] . Review of R7's Hospitalists Discharge Summary, dated 08/04/23, provided by the facility revealed .Patient presents after a fall. He has a history of advanced dementia .Patient was apparently trying to get out of bed this morning around 4 AM. He has a handrail on the bed that he sometimes uses to help pivot. Apparently his hand became caught in the rail and then slid to the floor. He sustained injuries to his right hand, abdomen, and hip. He also has abrasions around his neck (possibly secondary to the oxygen tubing) .When patient's caregiver came to evaluate the patient today, she was concerned regarding the level of injuries and request to be brought to the emergency room for evaluation .In the emergency room , CT scan of brain/cervical spine/chest/abdomen/pelvis demonstrated nondisplaced anterior left fifth through seventh rib buckle type fractures and age-indeterminate nondisplaced fracture sequela of the right sixth rib. ER provider requested admission given rib fractures and risk for pneumonia . Review of the Safety Event Manager [facility incident report], with a completion date of 08/29/23, revealed .When did the event occur? 07/30/2023-04:00 [4:00 AM]. Who was the affected party? [R7's Name] .Was a physician or provider contacted in response to this event? Yes .07/30/2023- 07:30 [7:30 AM] .Briefly describe what happened. Patient found at side of bed on fall mat. How would you categorize this event? Falls & Slips .What was the cause of the fall? Accidental fall .Was any device, equipment, or software involved? No [inaccurate. Grab bar installed on the resident's bed]. What were the outcomes related to the event? No clinical outcome or consequences [Inaccurate. Resident sustained multiple rib fractures]. What was the severity of the event? Moderate: Event reached the person and caused moderate harm and required moderate intervention or care .Investigation Summary .resident transfers with pivot and x1 [times one] staff, w/c [wheelchair] for mobility. Resident was noted to have c/o [complaint of] pain and abrasions to his back/chest area on dayshift 7/30-resident sent out to ER [emergency room ] per care manager's wishes-noted with L [Left] rib fractures 5-7 .In your opinion, what led to this event? resident [sic] attempted to get up unassisted/rolled out of the edge of bed. Give us your recommendations on what needs to be done as a result of this event. Scoop air mattress added, room rearranged with different bed placement, movement of the call alerting fall mat to the right side of the bed . The report was signed by the Administrator on 08/29/23 which indicated the investigation was completed 29 days after the incident occurred on 07/30/23. Additionally, the investigation did not include any information regarding the resident being entrapped in between the mattress and grab bar. Additionally, the Administrator's investigation did not include any information related to any abrasions around R7's neck as noted in the resident's hospital discharge summary. During an observation on 09/25/23 at 8:50 AM of R7's room, the resident's bed had a low air loss scoop mattress with bilateral grab bars. The left side of the bed was pushed all the way against the wall. During an observation and interview on 09/25/23 at 2:10 PM, Maintenance (MT) 1 measured the space/gap between R7's low air loss scoop mattress and the grab bar attached to the resident's right side of the bed. MT verified the gap was 4-5 inches and that was with him pressing some weight on the mattress. MT stated if the resident was to roll over to the edge of the low air loss scoop mattress, that would be the reason it would create a gap. MT also stated if the mattress was not a low air loss mattress, then there would be no gap created. Observation on 09/25/23 at 3:30 PM revealed R7 was lying in bed, rolled on his left side. During an interview on 09/25/23 at 4:45 PM, R7's Care Connections Case Manager (CCCM) stated she came into the facility to check on the resident after she received notification he [R7] had rolled out of bed. The CCCM stated R7 had abrasions around his neck, his chest and abdomen were bruised, and the resident had deep abrasions on his inner legs. During an interview on 09/25/23 at 5:33 PM, RN3 stated he came on shift on 07/30/23 at approximately 5:45 AM. RN3 stated he could not locate the nurse [LPN11] for the floor to do shift communication. RN3 stated he notified the nursing supervisor at 6:10 AM that he could not locate the nurse and needed shift report. Continued interview revealed after LPN11 was located and came to give him the shift report, she informed him that R7 had fallen and reported the resident had no substantial injuries, just some scratches and bruises on the ribs. RN3 stated being his first day out of orientation, he notified the nursing supervisor of the fall. RN3 further stated the day shift nursing supervisor and LPN11 entered into R7's room and he started medication pass. RN3 also stated he was later called to R7's room and told by R7's CCCM she wanted the resident sent to the hospital. She showed him the injuries and he was shocked because the resident had multiple injuries that were very visible. During an interview on 09/25/23 at 6:07 PM, when asked about resident's injuries and the nurse's note indicating he was wedged [entrapped], the Assistant Director of Nursing (ADON) stated she would not have thought that a grab bar would pose a risk. The ADON also stated this was a hazy area because the facility could not determine if R7 fell to the floor and then if attempting to get himself back up in the bed if that was when he became wedged or was it when he was attempting to get out of the bed. During an interview on 09/25/23 at 7:06 PM, RN4, who was the day shift nursing supervisor on 07/30/23 stated she was contacted by RN3 because he could not locate LPN11 to complete shift report. Continued interview with RN4 revealed when she received her shift report from the nightshift nursing supervisor, R7's fall was not reported. RN4 stated when she located LPN11, the LPN informed her that R7 had fallen during her shift but did not report include any details that the resident was wedged between the mattress and the grab bar. RN4 further stated she and LPN11 went to R7's room to lay eyes on him; however, she did not complete an assessment due to LPN11 informing her that she completed an assessment and treated minor abrasions. RN4 stated later that morning, she received a call from RN3 that R7's CCCM was demanding he be sent out because of the visible injuries. During an interview on 09/26/23 at 2:03 PM, the Administrator stated R7 was not assessed for the use of the grab bars. The Administrator also stated every resident bed at the facility had grab bars and they did not complete any assessments for any of the residents at the facility. The Administrator confirmed she did not complete a documented investigation until 08/29/23; however, she did not give a reason why it was not completed until then. During an interview on 09/26/23 at 2:31 PM, R7's Attending Physician (AP) 1 stated during this interview with the surveyor was the first she had heard that R7 was wedged between the mattress and the grab bar on his bed. When listening to the nurses note dated 07/30/23 at 7:12 AM read to her by this surveyor, AP1 stated hearing the words wedged and bilateral legs under him was really distressing for her to hear. AP1 stated knowing those details, the resident should have been sent out to the emergency room sooner than he was. During an interview on 09/27/23 at 3:44 PM, the Administrator stated all the mattresses in the facility were from Direct Supply and were a Panaca brand. The Administrator stated all the beds in the facility were Invacare C7 brand. Continued interview revealed the beds, and the mattresses were two different brands; however, they were compatible with one another. When asked if she was aware the manufacturer's manual for the Invacare C7 bed recommends to only use Invacare brand mattresses to prevent the risk of death or injury, the Administrator stated she was not aware of this. The Administrator also stated she was the person responsible for the purchasing of beds and mattresses. The Administrator stated she contacts the supplier, tells them what size mattresses and beds the facility needs, then the supplier makes the recommendation of what mattresses and beds would work together. During an interview on 09/27/23 at 6:30 PM, LPN11 stated at approximately 4:00 AM on 07/30/23, CNA2 came directly to her medication cart and told her R7 was on the floor. Continued interview revealed LPN11 directly went to R7's room and discovered the right side of the resident's chest and his right arm were wedged in between the grab bar and his mattress. LPN11 stated R7's knees were barely touching the fall mat. LPN11 also stated R7 was wedged so tightly, the grab bar could not be lowered, there was no room to get a Hoyer lift, and the use of a gait belt would not have been safe. LPN11 stated she got a bedsheet and made a sling, slipped it under the resident, where she and the CNA got the resident unwedged and put him back into his bed. LPN11 further stated she had to push on the resident's mattress while pulling him to get him out of the grab bar. LPN11 stated her and RN4 later determined the resident's mattress edge failed by deflating and combined with R7's weight that was how he became wedged. LPN11 also stated by the time they got the resident back into bed, assessed, and started her paperwork, she did not see any serious injury, so she continued administering residents their medications and it did not seem emergent. The LPN stated no one ever followed up with her on the incident. LPN11 also stated this was the scariest situation she had dealt with in her [AGE] years of nursing. Review of the Invacare bed user manual titled, Invacare [NAME] CS Series, revealed the user manual was for the CS7 bed model. Continued review of the manual revealed on page 19, DANGER! Risk of Death, Injury, or Adverse Health Consequences .Fall hazard exists due to use of Non-Invacare mattresses. Non-Invacare mattresses are potentially incompatible with Invacare beds. To avoid injury, ensure that only Invacare mattresses are used with Invacare beds at all times . Further review of the user manual revealed on page 18, DANGER! Risk of Death, Injury, or Damage. Patient entrapment from the use of bed side rails may cause injury or death. To Avoid patient entrapment: The Invacare mattress MUST fit firmly against the bed frame AND bedside rails to prevent patient entrapment. Follow the manufacturer's instructions .DANGER! Risk of Death, Injury, or Damage. Conditions such as .dementia, sleeping problems, and incontinence can significantly impact a patient's risk of entrapment .Monitor patients with these conditions frequently . Review of page 45 revealed .Bed Rails and Positioning Devices. DANGER! Risk of Death, Injury, or Damage. Patient entrapment from the use of bed side rails may cause injury or death. To avoid patient entrapment: The Invacare mattress MUST fit firmly against the bed frame AND bed side rails to prevent patient entrapment .Periodically monitor gaps between the bed, mattress, and/or bed rail. Where gaps occur, patient entrapment is possible, and the mattress should be replaced. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of entrapment . Review of the facility's policy titled, Accidents and Incidents-Investigation and Reporting revised January 2020, revealed .Accidents or incidents involving residents shall be investigated and reporting completed, per state and federal requirements .A. The nurse should promptly initiate and document investigation of the accident or incident. B. The following information shall be included in the investigation, as applicable: 1. The date and time the accident or incident took place; 2. The nature of the injury; 3. The circumstances surrounding the accident or incident; 4. Where the accident took place; 5. The name(s) of witnesses and their accounts; 6. The resident's account of the incident; 7. The time the resident's Health Care Provider was notified, as well as the time the Healthcare Provider responded and his or her instructions; 8. The date/time the resident representative was notified and by whom . Review of the facility's policy titled, Falls, revised July 2023, revealed, .The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall .2. If a resident sustains a fall, or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated . The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-689 continues at a scope and severity D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on interview, record review, review of the Hospitalists Discharge Summary, and review of the facility's policy, the facility failed to revise the Comprehensive Care Plan with newly identified problem areas and with new interventions for one of 35 sampled residents (Resident (R) 7). On 07/30/23, R7 was transferred to the hospital after he was discovered entrapped between his mattress and a grab bar attached to his bed. When R7 was readmitted to the facility on [DATE], his care plan was not revised to include updated interventions related to his entrapment. Additionally, while being treated at the hospital for the entrapment incident, it was discovered that R7 had a fecal impaction. After receiving the Resident's hospital discharge summary upon the resident's readmission to the facility, the facility failed to revise the resident's care plan to include the newly identified bowel problem. The facility's failure to ensure R7's Comprehensive Care Plan was revised as indicated has caused or is likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy was identified on 09/28/23 and was determined to exist on 08/04/23, in the area of 42 CFR S483.21 F657 Comprehensive Person-Centered Care Plans at the highest scope and severity (S/S) of J. The facility was notified of the Immediate Jeopardy on 09/28/23 at 10:15 AM. The facility was notified that an acceptable plan of removal had not been submitted and the Immediate Jeopardy was ongoing. Findings include: Review of R7's undated Profile Face Sheet, provided by the facility revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dementia, difficulty in walking, and repeated falls. Review of R7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/07/23, provided by the facility, revealed the facility assessed the resident that a brief interview for mental status (BIMS) score could not be completed. The facility assessed R7 to have long-term and short-term memory problems, and the resident was severely impaired in cognitive skills for daily decision making. Continued review the resident's MDS revealed the facility assessed R7 to require extensive assistance of two staff persons for bed mobility, transfers between surfaces, and toilet use. Review of R7's Care Plan Historical Copy, dated 06/29/23, provided by the facility revealed . [resident's name] has memory problems, impaired decision-making skills, and impaired ability to comprehend. Dx [diagnosis] dementia . [resident's name] needs assistance with daily ADL [activities of daily living] care .I need extensive [assistance] x1 [of one] person staff support with bed mobility . [resident's name] has potential for falls d/t [due to] dementia and limited mobility. Needs assistance with transfers and mobility. Hx [history] of falls. Poor safety awareness .Fall mats bilateral sides of bed .Fall mat with call light activation in place when resident in bed . The care plan did not include any interventions related to the resident using grab bars. Review of R7's Interdisciplinary Note, dated 07/30/23 at 7:12 AM, completed by Licensed Practical Nurse (LPN) 11 and provided by the facility revealed Patient found this am at 4am by CNA [Certified Nurse Aide], she immediately alerted nurse and found patient to be rolled off right side of bed with rt [right] arm/chest wedged in by side rail with bil [bilateral] legs folded under him. On assessment, patient responsive, but unable to explain to this nurse what had occurred. Myself and CNA assisted patient back bed and on further assessment, found red areas on right forearm and rib cage under breast, surface abrasions to rt hip and lower back. Abrasion to hip, cleaned and covered d/t scant amount of serous fluid present. VS [vital signs] 128/70, hr [hear rate] 74, 18 [respiration] temp [temperature] 97.0 O2 [oxygen saturation] 96 ra [room air]. Supervisor notified as well as MD [physician] and patients [sic] responsible party. Neuro's [neurological checks] initiated and at baseline. Bed was in lowest position, patient has alarm mat but it was on left side of bed and staff wasn't alerted. Will continue to monitor. Review of R7'sInterdisciplinary Note, dated 07/30/23 at 11:43 AM, revealed Case manager came to visit and assess patient after fall. Case manager requested for patient to be sent out for xrays and evaluation. Called 911 with nonemergency transport to [name of hospital] . Review of R7's Hospitalists Discharge Summary, dated 08/04/23, provided by the facility revealed .Patient presents after a fall. He has a history of advanced dementia .Patient was apparently trying to get out of bed this morning around 4 AM. He has a handrail on the bed that he sometimes uses to help pivot. Apparently his hand became caught in the rail and then slid to the floor. He sustained injuries to his right hand, abdomen, and hip. He also has abrasions around his neck (possibly secondary to the oxygen tubing) .When patient's caregiver came to evaluate the patient today, she was concerned regarding the level of injuries and request to be brought to the emergency room for evaluation .In the emergency room , CT scan of brain/cervical spine/chest/abdomen/pelvis demonstrated nondisplaced anterior left fifth through seventh rib buckle type fractures and age-indeterminate nondisplaced fracture sequela of the right sixth rib. ER [emergency room ] provider requested admission given rib fractures and risk for pneumonia .In the emergency room , CT scan of .abdomen/pelvis .Other pertinent findings include rectal distention concerning for fecal impaction .Hospital course by problem .Active Problems .Fecal impaction (HCC) .Constipation. Noted to have significant stool burden/fecal impaction on initial CT of the abdomen. Will start aggressive bowel regimen including enemas .Would continue aggressive bowel regimen after discharge .Hospital Summary .Follow-up Issues: Would recommend ongoing aggressive bowel regimen .Radiology Results: .CT Abdomen/Pelvis with IV Contrast .Findings: .Stomach and bowel: Stomach decompressed. Small bowel loops unremarkable. There is significant diverticulosis throughout the colon without evidence for diverticulitis. There is significant rectal fecal material present with distention up to 8 cm [centimeters] .Impression: .2. Rectal distention from significant amount of colonic fecal material, correlate for constipation for possible fecal impaction . Review of R7's Care Plan, initiated on 08/04/23 (resident's readmission), provided by the facility revealed .Falls. [R7's Name] has potential for falls d/t dementia and limited mobility. Needs assistance with transfers and mobility. Hx of falls. Poor safety awareness . Newly identified interventions included .room/bed rearranged .scoop air mattress .call light alerting fall mat to right side of bed . All of the newly identified interventions had a start date of 08/29/23, 25 days after R7 was readmitted to the facility; however, R7's Care Plan was not revised to include his entrapment. Additionally, R7's Care Plan was not revised to include the newly identified problem of constipation/impaction. During an interview on 09/27/23 at 2:16 PM, the Director of Nursing (DON) stated the MDS department would have been the ones responsible for updating R7's Care Plan after his readmission. The DON also stated the Care Plan directs the care that needs to be provided to the resident; however, the Care Plan was a resource and should be reviewed, but for what care the resident needed to receive, the nursing staff would go by the nursing 24-hour report. When asked if the resident's bowel problem should have been care planned, the DON stated she reviewed R7's hospital discharge summary; however, it was an oversight that the resident had an impaction. Had this issue been caught, it should have been added to R7's Care Plan. During an interview on 09/27/23 at 2:27 PM, the MDS Coordinator (MDSC) stated R7's Care Plan should have been revised prior to 08/29/23 since he was readmitted on [DATE]. The MDSC verified R7's Care Plan did not include any problem and/or interventions specifically related to his entrapment. The MDSC stated even though R7's bowel impaction was resolved while he was admitted to the hospital, this should have been included on his Care Plan upon readmission to the facility. The MDSC also stated she reviewed R7's Hospital Discharge Summary upon his readmission to the facility, but the impaction issue was an oversight. The MDSC further stated it was important R7's Care Plan would have been revised to ensure he received the appropriate plan of care. Review of the facility's policy titled, Care Plans-Comprehensive Person-Centered, revised October 2021, revealed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, that are identified through evaluation and assessment, is developed and implemented for each resident .I. The comprehensive, person-centered care plan will: .8. Incorporate identified problem areas .N. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. O. The Interdisciplinary Team must review and update the care plan: 1. When there has been a significant change in the resident's condition; .3. When the resident has been readmitted to the community from a hospital stay . The IJ was effective from 9/26/2023 - 10/10/2023. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/28/2023. The corrective actions were validated onsite by the surveyors on 10/9/2023 and 10/11/2023 through review of the root cause analysis, in-services conducted, and staff interviews on all shifts and the following: AOC removal plan dated 9/28/2023 was verified onsite 10/11/2023 at 2:30 PM: -QAPI meeting was conducted on 10/1/2023 to determine root cause. -Review of the ADhoc QAPI meeting minutes showed on 10/1/2023 a QAPI meeting was held to discuss implementation of a plan to implement person centered care plan for each resident for bowel regimen, monthly review of completed Resident at risk forms, falls, and BM audit results and trends will be completed by DON and/or designee and reported to the facility's QAPI Committee which consist of Medical Director, Administrator, DON, ADON, QA Director, Pharmacist, Social Services, Activities, Dietician, Therapy Director, and MDS Coordinator for next three months then reevaluated to determine if further monitoring is indicated. -Verification of staff training, and education was obtained by interviews and documentation. The nurses were trained by the Director of Clinical Operations and or designee by 10/2/2023 or prior to working next scheduled shift on bed safety policy, oxygen administration procedure, clinical protocol-bowel procedures and care plan-comprehensive person centered. Verified by the signatures of the nurses on the training sheet and by interview with nurses confirmed had received the training as indicated in their AOC. -Resident #4, #7, #8, #20, #21, and #22 assessed for constipation and reviewed for daily BM documentation and placed on Bowel Regimens and monitored daily. Monitors were reviewed by the DON or designee, for deficiencies. -Reviewed and verified the BM log and audits have been completed and evaluated as indicated in the AOC. -15-minute check have been completed daily for residents with handrail to beds. 2-hour Safety rounding had been completed on Resident #7 for appropriate positioning while in bed-invoice was obtained from the facility for the new air mattress purchases. All residents with handrails received 2-hour safety rounding (Resident #7 and Resident #34). -Working with Direct Supply and the bed frame manufacturer to obtain the appropriate mattresses. Order placed 10/6/2023. The facility's noncompliance of F-657 continues at a scope and severity D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility protocol review, medical record review, review of facility falls investigations, and interview, the facility failed to develop and implement interventions to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility policy, Care Plans - Comprehensive Person-Centered revised 5/2017 revealed .The comprehensive, person-centered care plan will .Incorporate identified problem areas .Reflect currently recognized standards of practice for problem areas and conditions .Identifying problem areas and their causes, and developing interventions .are the endpoint of an interdisciplinary process .Care planning interventions are chosen only after careful data gathering, proper sequencing of events .and relevant clinical decision making .The Interdisciplinary Team must review and update the care plan .When the desired outcome is not met .When the resident has been readmitted to the community from a hospital stay; and at least quarterly . Medical record review revealed Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Safety Event Entries (facility investigation conducted post falls) dated 7/6/17, 7/7/17 (2 of 3 falls on this date), 8/24/17, 9/3/17, and 9/4/17, revealed the resident sustained [REDACTED]. Continued review revealed the resident sustained [REDACTED]. Review of a Safety Event Entry dated 7/7/17 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular (ankle) fx (fracture) . Medical record review of the care plan dated 7/7/17 revealed the care plan was not revised or updated to reflect new interventions to prevent falls after the falls on 7/7/17. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 7/8/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 9/5/17 revealed the care plan was updated on 9/5/17 to include .Falls .Resident re-education to call for assistance with transfers post fall 7/8/17 .start date 9/5/17 . Continued review revealed the care plan was not updated until 60 days after the fall occured. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Safety Event Entry dated 8/7/17 revealed the resident had an unwitnessed fall in her room on this date. Medical record review of the care plan dated 4/17/17 revealed the care plan was not revised to include a new intervention to prevent falls after the fall on 8/7/17. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/13/17 revealed the resident had an unwitnessed fall and was sent to the hospital for evaluation. Medical record review of the care plan dated 8/21/17 revealed the care plan had not been revised to include a new fall intervention after the resident's fall on 8/13/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a Safety Event Entry dated 8/18/17 revealed the resident sustained [REDACTED]. Medical record review of the care plan dated 8/23/17 revealed .Falls .at risk for falls r/t (related to) hx (history) of falls with fx (fracture) . Continued review revealed the care plan was not revised to reflect new interventions after returning to the facility from a hospitalization . Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed Resident #6 had alarms ordered previously for fall prevention on 6/14/17. Continued interview confirmed the resident was discharged to the hospital on [DATE], and the alarm was discontinued at that time. Further interview confirmed the facility failed to revise the resident's care plan when she returned from the hospital, and the current care plan was not accurate. Continued interview confirmed the care plans for Residents #3, #4, #5, and #7 were not revised to include new interventions to prevent further falls after the post-falls investigations had been completed. The facility's failure resulted in Resident #7 sustaining a fractured ankle (tibula). Refer to F-323

Based on facility protocol review, medical record review, review of facility falls investigations, interview, and observation, the facility failed to provide supervision to prevent falls for 5 residents (#7, #3, #4, #5, and #6), of 7 residents reviewed for falls, of 69 residents assessed as at risk for falls. The facility's failure resulted in a fractured ankle (harm) for Resident #7. The findings included: Review of the facility protocol, Falls Clinical Protocol, dated 12/2016 revealed .Treatment/Management .the associate and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of consequences of falling. If underlying causes cannot be readily identified or corrected, associates will try various relevant interventions, based on assessment of the nature or category of falling .Monitoring and follow-up .The community associates will monitor and document the individuals response to interventions intended to reduce falling .If the individual continues to fall, the nursing associate and physician will re-evaluate the situation and .will re-evaluate the continued relevance of current interventions . Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating the resident had severe cognitive impairment. Continued review of the functional status revealed the resident required limited assistance for toileting and dressing and supervision for bed mobility, transfer, ambulation and personal hygiene. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls, and .A Score of 5 or greater = (equals) High Risk . Medical record review of a nurses note dated 7/6/17 at 3:39 PM, revealed .Witnessed fall at 1530 (3:30 PM) Resident tripped on the carpet as she was walking toward her room No s/s (signs or symptoms) or c/o (complaints of) pain or discomfort .Walker was being used for assistance . Review of a Safety Event Entry (entries for falls investigations) dated 7/6/17 revealed .Witnessed fall. Resident was using walker for assistance to her room but tripped on the carpet. No injuries noted .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation was completed. Continued review revealed no other new interventions were implemented after the fall to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 8:25 AM revealed .Witnessed fall from standing position with walker to couch then slid off edge to floor .no visible injury . Review of a Safety Event Entry dated 7/7/17 8:36 AM, revealed .Resident attempting to sit on couch from standing position, sat on edge of couch and slid to floor .Location where the event occurred? Reception Area .No Harm .Event increased the need for monitoring or evaluation . Continued review revealed no documentation the increased monitoring or evaluation had been completed, and there were no other new interventions implemented to prevent future falls. Medical record review of a nurse's note dated 7/7/17 at 12:09 PM revealed .Resident having extreme agitation. Found walking down hall with no pants on. Nonsensical word salad (incoherent jumble of words), crying, received order .to administer 1 mg (milligram) lorazepam (anti-anxiety medication, same as Ativan) IM (intramuscular) q 6h PRN (every 6 hours as needed). First dose administered at this time . Medical record review of a nurses note dated 7/7/17 at 1:55 PM, revealed .Resident fell in bathroom. All clothes had been removed and she soiled herself. Gotten up off the floor with a gait belt and assist x 3 (with 3 persons) .Left ankle xray (swollen and painful) .Additional dose of 1 mg Ativan (anti-anxiety medication) IM also given at this time . Medical record review revealed no interventions were implemented after the fall on 7/7/17 to prevent future falls. Medical record review of a nurses note dated 7/7/17 at 3:59 PM, revealed .Resident found on floor by her bed. Third fall this shift .Resident is now in wheelchair at the nurse's station . Review of a Safety Event Entry dated 7/7/17 at 4:06 PM revealed .Resident found on floor beside her bed. 3rd fall this shift. 2nd fall occurred 4 hours prior in the bathroom. Resident was naked and had urinated on herself at that time. Unknown why she fell the third time. She is unable to articulate .What type of injury(s) was sustained? Fracture (Major) . Medical record review of a nurses note dated 7/7/17 at 4:44 PM revealed .Call received from Dr (physician) .stating .resident has a left tibular fx (fracture) .1640 (4:40 PM)- resident transported by EMS (emergency medical services) . Medical record review of a nurses note dated 7/7/17 at 11:59 PM, revealed .Resident arrived back from hospital via EMS .No new orders given. Resident has boot on broken ankle and is now resting in bed . Medical record review revealed no new interventions to prevent further falls had been implemented after the third fall on 7/7/17 at 4:06 PM. Medical record review revealed the resident was hospitalized from [DATE] to 7/13/17, and again on 8/4/17 to 8/24/17. Continued review revealed Resident #7 was readmitted to the facility on [DATE]. Medical record review of a falls risk assessment dated [DATE] revealed a score of 14 (score of 5 or higher indicates High Risk). Review of a Safety Event Entry dated 8/24/17 at 5:08 PM revealed .Witnessed fall. Resident was attempting to transfer without assistance . Medical record review revealed no new interventions were implemented after the fall on 8/24/17 to prevent future falls. Review of a Safety Event Entry dated 9/3/17 at 4:32 PM revealed .Resident attempting to stand from wheelchair, with non-weight bearing status d/t (due to) LLE (left lower extremity) fracture .fell to floor .denies injuries . Continued medical record review revealed no new interventions were implemented after the fall to prevent future falls. Review of a Safety Event Entry dated 9/4/17 at 3:57 PM revealed . Unwitnessed fall. Resident attempted to ambulate/transfer without assistance . Continued medical record review revealed no new interventions were implemented to prevent future falls. Interview with the Quality Director on 9/7/17 at 11:30 AM, in the conference room, confirmed Resident #7 had suffered a fractured ankle as a result of the 2nd fall that occurred on 7/7/17. Continued interview confirmed no new interventions were implemented after the fall to address safety concerns, and Resident #7 continued to have falls on 8/24/17, 9/3/17, and 9/4/17, with no new interventions implemented to prevent falls. Continued interview confirmed the facility failed to adequately assess the safety needs and implement interventions to prevent falls for Resident #7, which resulted in harm to the resident. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required limited assistance of 1 for bed mobility, transfers, and ambulation in the room and hallway. Review of a Safety Event Entry dated 5/18/17 at 12:44 PM, revealed .unwitnessed fall. Resident assisted to her w/c (wheelchair) x 3 staff .No Injury . Medical record review of a Falls assessment dated [DATE] revealed score of 4, indicating the resident was a low risk for falls. Medical record review revealed no new interventions were implemented to prevent future falls after the fall on 5/18/17. Medical record review of an Interdisciplinary Note dated 7/8/17 revealed .Resident was in the sitting position without her 02 (oxygen) when this nurse arrived. Resident had fallen on the floor while attempting to use her potty chair unassisted .small abrasions on the 1st and 2nd toe on the left foot and to the 2nd toe on the right foot . Review of Resident #3's Care Plan revealed, .Resident reeducation to call for assistance with transfers post fall 7/8/17 . Continued review revealed the intervention was implemented on 9/5/17, two months after the resident's fall, and no other new interventions were implemented in a timely manner. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing and toilet use and the resident used a wheelchair for mobility. Continued review revealed the resident had a history of [REDACTED]. Review of a Safety Event Entry dated 8/7/17 revealed .Was informed by .Rehab Tech that resident was in (on) the floor .W/C (wheelchair) was on it's side .no injuries noted . Medical record review of a Falls assessment dated [DATE] revealed a score of 8, indicating the resident was a high risk for falls. Medical record review revealed no interventions were implemented after the fall on 8/7/17 to prevent future falls. Observation of Resident #4 on 9/7/17 at 11:30 AM, revealed the resident seated in a wheelchair in the resident's room with her daughter visiting. Attempted interview was unsuccessful as the resident was unable to answer questions. Medical record review revealed Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility and transfers. Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 9, indicating the resident was a high risk for falls. Review of the Safety Event Entry dated 8/13/17 revealed .Writer .heard alarm start sounding and went .to residents room .resident lying on the floor on right side .alert and oriented x 2 (oriented to person and place) stated that she was trying to get up and walk to BR (bathroom) (resident does not walk) .large pumpknot noted to right side of forehead, skin tears x 2 to LUE (left upper extremity), red area around eye .order received to transfer to ED (emergency department) for evaluation and treatments . Medical record review of an Interdisciplinary Note dated 8/13/17 revealed .@ (at) 250 (2:50) pm Resident returned to facility .Large purple/red area noted to right side face . Medical record review revealed no new interventions were implemented after the fall on 8/13/17 to prevent future falls. Medical record review revealed Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed the resident had short and long term memory impairment and severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for bed mobility, transfer, and required extensive assistance of 1 staff for locomotion using a wheelchair or walker. Medical record review of a CT Scan (type of xray) report dated 7/14/17 revealed .There is diffuse bone demineralization . Medical record review of a Falls Risk assessment dated [DATE] revealed a score of 8, indicating the resident was at high risk for falls. Medical record review of an Interdisciplinary Note dated 8/18/17 at 10:50 AM, revealed .Resident noted to be on back .resident was attempting to ambulate from her w/c when her leg buckled and she fell on to the floor . Review of a Safety Event Entry dated 8/18/17 revealed The resident stood up from her w/c, her leg buckled and she fell on to the floor. Her left leg was deformed and she was sent to the ER (emergency room ) . Medical record review of an xray report dated 8/18/17 revealed .displaced fracture of the proximal left femur .Underlying generalized demineralization . Medical record review revealed no new interventions were implemented after the fall on 8/18/17, or after Resident #6 returned to the facility on [DATE], to prevent future falls. Interview with the Director of Quality on 9/8/17 at 8:20 AM, in the conference room, confirmed the facility failed to follow the falls protocol to identify and implement pertinent interventions to prevent future falls for Residents #7, #3, #4, #5, and #6. The facility's failure resulted in a fractured ankle for Resident #7.

Based on medical record review, review of facility documentation, interview, and observation, the facility failed to prevent a fall for one resident (#153), resulting in Harm to the resident, and failed to provide the appropiate number of staff assistance for transfers for one resident (#104) of 6 residents reviewed for falls of 29 residents sampled. The findings included: Medical record review revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident had cognitive impairment, memory problems, and required extensive assistance with transfers and ambulation. Medical record review of a nurse's note dated 6/27/15 revealed, .called to resident's room at 1:20 AM by CNA (certified nursing assistant). Resident found lying on her R (right) side on floor next to bed .unable to answer what happened or if she hit head .call made to Dr (doctor) .to update on resident condition. Order received to send to .hospital .for evaluation and treatment . Review of the facility documentation of the fall dated 6/27/15 revealed interventions were in place at the time of the fall and included a low bed and nonskid socks. Medical record review revealed Resident #153 was readmitted back to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's plan of care dated 7/4/15 revealed .need 2 person staff assistance with transfers .support with transfer with use of Hoyer lift (type of total dependence non weight bearing lift) . Medical record review of the Physical Therapy Evaluation and Plan of Treatment with a start date of 7/5/15 revealed, .Transfers= (equals) Total Dependence w/o (without) attempts to initiate unable to perform sit to stand despite max (maximum) assist of 2 .patient will require use of total dependence lift for OOB (out of bed transfer) . Medical record review of a nurse's note dated 7/6/15 revealed, .@ (at) 1130 (11:30 AM) CNA and this nurse was transferring resident to restroom using the sit-to-stand lift (type of weight bearing lift) .Encouraging resident to bear weight on her right leg and toe touch with the left. Resident was cooperative and then suddenly said no and let go of the lift crossing her hands losing her balance in the lift. CNA and (charge nurse) assisted resident by lowering her to the floor .Assisted resident back to wheelchair x3 (with 3) staff members and then assisted resident to bed with assist from PT (Physical Therapy) department . Medical record review of a nurse's note dated 7/7/15 at 1:11 AM revealed, .Assessment of surgical site shows severe redness and warmth to 2 staples on left hip .Middle site has 2 inch surrounding area that is hard and red. Will alert day shift nurse of need to call surgeon in AM (morning) . Medical record review of a nurse's note dated 7/7/15 at 10:13 AM, revealed, .On assessment of surgical site distal from hip is red, hard, swollen, 2 inches by 2 inches .Md (Medical Doctor) called and informed. With new orders to apply warm compresses to area for 20 minutes .will continue to monitor . Medical record review of a Physicians telephone order dated 7/8/15 revealed, .x-ray to left hip and femur .pain . Medical record review of a mobile image of the left hip dated 7/8/15 revealed, .Findings: screw threads projecting beyond the superior margin of the femoral neck and appearing to impinge upon the lateral aspect of the acetabulum .Impressions: Recurrent fracture of the femoral neck versus malposition dynamic screw of the femoral neck .notified Dr .wants to see resident on .7/10/15 . Medical record review of a nurse's note dated 7/10/15 at 10:34 AM revealed, .Left for Dr. appointment at 1015 (10:15 AM) . Medical record review of a Hospital Consultation Report dated 7/10/15 revealed .recently fell .status [REDACTED].left femur and was admitted to the hospital today for revision to a total hip arthroplasty on that side . Medical record review of the Hospital Discharge summary dated 7/12/15 revealed discharge [DIAGNOSES REDACTED]. status [REDACTED]. History of recent hip fracture. status [REDACTED]. Interview and medical record review of the plan of care with the MDS coordinator on 10/21/15 at 1:20 PM, in the MDS office, confirmed the resident was to have a Hoyer lift for transfer. Interview and review of the physical therapy evaluation and plan of treatment with the Physical Therapist on 10/21/15 at 1:27 PM, in the therapy room, confirmed the resident required a total dependence lift for transfers. Telephone interview with Licensed Practical Nurse (LPN) #3 on 10/21/15 at 1:12 PM, revealed the LPN did not look at the resident's plan of care prior to transfering the resident. Continued interview revealed the LPN used a sit-to stand lift instead of the Hoyer lift identified for use with the resident by therapy and nursing staff. Interview with the Medical Director on 10/21/15 at 12:48 PM, in the conference room, confirmed the resident's fall could have caused the re-injury to the resident's hip. Interview with the Interim Director of Nursing (DON) on 10/21/15 at 2:10 PM, in the DON office, confirmed the facility failed to prevent a fall, resulting in harm to the resident, by not using the appropriate lift for transfer of the resident. Medical record review revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission nurse's note dated 8/12/15 revealed, .resident requires max (maximum) assist with all ADLs (activities of daily living) . Medical record review of the Admission MDS dated [DATE] revealed the resident scored an 8 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility, transfer, dressing, and personal hygiene. Further review revealed the resident was only able to stabilize with the assistance of staff, and had limitation in range of motion in upper and lower extremities. Review of facility documentation dated 8/30/15 revealed Resident #104 had reported to the facility the resident had requested assistance with toileting on the evening of 8/29/15. Continued review revealed the resident stated CNA #1 had responded to the resident's request for assistance with getting to the toilet. Further review revealed the CNA had transferred the resident from the bed to a wheelchair, from the wheelchair to the toilet, and then back to the resident's bed. Further review revealed the resident stated the CNA then .rushed me in the w/c (wheelchair) into the room and he dumped me into my bed . Continued review revealed the resident struck her head on the side rail of the bed during the transfer from the wheelchair back to the bed. Further review revealed the resident was not injured during the transfer. Review of a witness statement signed and dated on 9/1/15 by CNA #1 revealed the CNA had transferred the resident without the assistance of another staff member. Medical record review of the resident's nursing care plan, last updated on 10/2/15, revealed .needs assistance with daily ADL care; she is new admission to facility .I need 2 staff support with transfer .I need max assistance with mobility. I need 2 staff support with mobility .I need 2 staff support with bed mobility .I need 2 staff support with toileting . Medical record review of Resident ADL/Daily Care List (Certified Nurse Assistant care plan) last updated on 10/2/15, revealed .Transfers and Ambulation/Mobility: Gait Belt, Resident requires max assist for transfers x (times) 2 assist . Interview with Resident #104 on 10/20/15 at 8:17 AM, in the resident's room, revealed the resident had called for assistance with getting to the toilet on the evening of 8/29/15. Continued interview revealed CNA #1 had transferred the resident from the bed to the wheelchair, had taken the resident to the toilet, and then transferred the resident back to the bed. Continued interview revealed the resident felt as if CNA #1 had .acted like he did not know what he was doing, stepped on my feet . and had caused the resident to become fearful she was going to fall during the transfer. Further interview revealed when the CNA had transferred the resident back to the bed the CNA had .dumped . the resident in the bed causing the resident to hit her head on the side rail. Further interview confirmed CNA #1 had transferred the resident without the assistance of another staff person. Observation on 10/20/15 at 4:20 PM, in the resident's room, revealed CNA #2 was preparing to transfer Resident #104 from the resident's bed to the resident's wheelchair to assist in getting to the toilet. Continued observation revealed CNA #2 took the resident to the bathroom and had assisted the resident from the wheelchair to the toilet by herself. Interview with LPN #5 on 10/20/15 at 4:25 PM, in the 7 West Nurse Station, revealed the CNAs were kept informed of the level of assistance a resident required for transfers through reviewing the resident's ADL/Daily Care List care plan or by asking the nurses. Continued interview revealed Resident #104 was documented as requiring the use of 2 staff members for transfers. Further interview revealed the LPN had been present on 8/30/15 when the resident had complained regarding CNA #1 transferring the resident without assistance to the toilet and back to bed. Continued interview confirmed CNA #1 had transferred the resident without the assistance of another staff person. Continued interview confirmed CNA #2 transferred the resident without assistance of another staff person on 10/20/15 at 4:20 PM. Interview with the Interim DON on 10/21/15, at 1:41 PM, in the Conference Room, revealed CNAs were required to read and acknowledge they have read the resident's ADL/Daily Care List which instructs CNAs on the level of assistance needed for transfers. Continued interview confirmed Resident #104 was documented on both the nursing and CNA care plan as requiring the use of 2 staff members for transfers. Continued interview confirmed the resident had required the assistance of 2 people for transfers on both 8/30/15 and on 10/20/15. Further interview confirmed both CNA #1 and CNA #2 had failed to provide the required level of assistance during transfers.

Based on facility policy review, medical record review, review of facility documentation, interview, and observation, the facility failed to follow the care plan for transfers for two residents (#153 and #104) of 6 residents reviewed for falls of 29 residents sampled, resulting in Harm to resident #153. The findings included: Review of the facility Fall Management policy, revised 9/20/13, revealed .Prevention .2. Those residents identified, as being at risk for falls will have individualized interventions added to their plan of care to decrease the risk of injury related to a fall . Medical record review revealed Resident #153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident had cognitive impairment, memory problems, and required extensive assistance with transfers and ambulation. Medical record review of a nurse's note dated 6/27/15 revealed, .called to resident's room at 1:20 AM by CNA (certified nursing assistant). Resident found lying on her R (right) side on floor next to bed .unable to answer what happened or if she hit head .call made to Dr (doctor) .to update on resident condition. Order received to send to .hospital .for evaluation and treatment . Review of the facility documentation of the fall dated 6/27/15 revealed interventions were in place at the time of the fall and included a low bed and nonskid socks. Medical record review revealed Resident #153 was readmitted back to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's plan of care dated 7/4/15 revealed .need 2 person staff assistance with transfers .support with transfer with use of Hoyer lift (type of total dependence non weight bearing lift) . Medical record review of the Physical Therapy Evaluation and Plan of Treatment with a start date of 7/5/15 revealed, .Transfers= (equals) Total Dependence w/o (without) attempts to initiate unable to perform sit to stand despite max (maximum) assist of 2 .patient will require use of total dependence lift for OOB (out of bed transfer) . Medical record review of a nurse's note dated 7/6/15 revealed .@ (at) 1130 (11:30 AM) CNA and this nurse was transferring resident to restroom using the sit-to-stand lift (type of weight bearing lift) .Encouraging resident to bear weight on her right leg and toe touch with the left. Resident was cooperative and then suddenly said no and let go of the lift crossing her hands losing her balance in the lift. CNA and (charge nurse) assisted resident by lowering her to the floor .Assisted resident back to wheelchair x3 (with 3) staff members and then assisted resident to bed with assist from PT (Physical Therapy) department . Medical record review of a nurse's note dated 7/7/15 at 1:11 AM revealed, .Assessment of surgical site shows severe redness and warmth to 2 staples on left hip .Middle site has 2 inch surrounding area that is hard and red. Will alert day shift nurse of need to call surgeon in AM (morning) . Medical record review of a nurse's note dated 7/7/15 at 10:13 AM, revealed, .On assessment of surgical site distal from hip is red, hard, swollen, 2 inches by 2 inches .Md (Medical Doctor) called and informed. With new orders to apply warm compresses to area for 20 minutes .will continue to monitor . Medical record review of a Physicians telephone order dated 7/8/15 revealed, .x-ray to left hip and femur .pain . Medical record review of a mobile image of the left hip dated 7/8/15 revealed, .Findings: screw threads projecting beyond the superior margin of the femoral neck and appearing to impinge upon the lateral aspect of the acetabulum .Impressions: Recurrent [MEDICAL CONDITION] neck versus malposition dynamic screw of the femoral neck .notified Dr .wants to see resident on .7/10/15 . Medical record review of a nurse's note dated 7/10/15 at 10:34 AM revealed, .Left for Dr. (doctor) appointment at 1015 (10:15 AM) . Medical record review of a Hospital Consultation Report dated 7/10/15 revealed .recently fell .status [REDACTED].left femur and was admitted to the hospital today for revision to a total hip arthroplasty on that side . Medical record review of the Hospital Discharge summary dated 7/12/15 revealed discharge [DIAGNOSES REDACTED]. status [REDACTED]. History of recent [MEDICAL CONDITION]. status [REDACTED]. Interview and medical record review of the plan of care with the MDS coordinator on 10/21/15 at 1:20 PM, in the MDS office, confirmed the resident was to have a Hoyer lift for transfer. Continued interview revealed the MDS coordinator coordinates with physical therapy when developing the plan of care. Interview and review of the physical therapy evaluation and plan of treatment with the Physical Therapist on 10/21/15 at 1:27 PM, in the therapy room, confirmed the resident required a total dependence lift for transfers. Telephone interview with Licensed Practical Nurse (LPN) #3 on 10/21/15 at 1:12 PM, revealed the LPN did not look at the resident's plan of care prior to transfering the resident. Continued interview revealed the LPN used a sit-to stand lift instead of the Hoyer lift identified for use with the resident by therapy and nursing staff. Interview with the Medical Director on 10/21/15 at 12:48 PM, in the conference room, confirmed the resident's fall could have caused the re-injury to the resident's hip. Interview with the Interim Director of Nursing (DON) on 10/21/15 at 2:10 PM, in the DON office, confirmed the facility's failure to follow the resident's care plan and use the appropriate lift for transferring the resident, resulted in harm to the resident. Medical record review revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an admission nurse's note dated 8/12/15 revealed, .resident requires max (maximum) assist with all ADLs (activities of daily living) . Medical record review of the Admission MDS dated [DATE] revealed the resident scored an 8 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired. Continued review revealed the resident required extensive assistance of 2 persons for bed mobility, transfer, dressing, and personal hygiene. Further review revealed the resident was only able to stabilize with the assistance of staff, and had limitation in range of motion in upper and lower extremities. Review of facility documentation dated 8/30/15 revealed Resident #104 had reported to the facility the resident had requested assistance with toileting on the evening of 8/29/15. Continued review revealed the resident stated CNA #1 had responded to the resident's request for assistance with getting to the toilet. Further review revealed the CNA had transferred the resident from the bed to a wheelchair, from the wheelchair to the toilet, and then back to the resident's bed. Further review revealed the resident was not injured during the transfer. Review of a witness statement signed and dated on 9/1/15 by CNA #1 revealed the CNA had transferred the resident without the assistance of another staff member. Medical record review of the resident's nursing care plan, last updated on 10/2/15, revealed .needs assistance with daily ADL care; she is new admission to facility .I need 2 staff support with transfer .I need max assistance with mobility. I need 2 staff support with mobility .I need 2 staff support with bed mobility .I need 2 staff support with toileting . Medical record review of Resident ADL/Daily Care List (Certified Nurse Assistant care plan) last updated on 10/2/15, revealed .Transfers and Ambulation/Mobility: Gait Belt, Resident requires max assist for transfers x (times) 2 assist . Interview with Resident #104 on 10/20/15 at 8:17 AM, in the resident's room, revealed the resident had called for assistance with getting to the toilet on the evening of 8/29/15. Continued interview revealed CNA #1 had transferred the resident from the bed to the wheelchair, had taken the resident to the toilet, and then transferred the resident back to the bed. Continued interview revealed the resident felt as if CNA #1 had .acted like he did not know what he was doing, stepped on my feet . and had caused the resident to become fearful she was going to fall during the transfer. Further interview confirmed CNA #1 had transferred the resident without the assistance of another staff person. Observation on 10/20/15 at 4:20 PM, in the resident's room, revealed CNA #2 was preparing to transfer Resident #104 from the resident's bed to the resident's wheelchair to assist in getting to the toilet. Continued observation revealed CNA #2 took the resident to the bathroom and had assisted the resident from the wheelchair to the toilet by herself. Interview with LPN #5 on 10/20/15 at 4:25 PM, in the 7 West Nurse Station, revealed the CNAs were kept informed of the level of assistance a resident required for transfers through reviewing the resident's ADL/Daily Care List care plan or by asking the nurses. Continued interview revealed Resident #104 was documented as requiring the use of 2 staff members for transfers. Continued interview confirmed CNA #1 had transferred the resident without the assistance of another staff person. Continued interview confirmed CNA #2 transferred the resident without assistance of another staff person on 10/20/15 at 4:20 PM. Interview with the Interim DON on 10/21/15, at 1:41 PM, in the Conference Room, revealed CNAs were required to read and acknowledge they have read the resident's ADL/Daily Care List which instructs CNAs on the level of assistance needed for transfers. Continued interview confirmed Resident #104 was documented on both the nursing and CNA care plan as requiring the use of 2 staff members for transfers. Continued interview confirmed the resident had required the assistance of 2 people for transfers on both 8/30/15 and on 10/20/15. Further interview confirmed both CNA #1 and CNA #2 had failed to follow the care plan during transfers.

Based on medical record review, review of facility investigation, review of facility in-service, and interview, the facility failed to provide supervision and safe assistance to prevent a fall for one resident (#1) of eight residents reviewed. The facility's failure to ensure resident #1 was supervised and safe assistance was provided when turning the bedridden resident resulted in a fall from the bed with multiple bodily injuries and sudden death on [DATE]. The facility's failure placed resident #1 in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Administrator and Chief Nursing Officer were informed of the Immediate Jeopardy in the Conference Room on February 20, 2013, at 1:35 p.m. Substandard Quality of Care was cited under tag F-323 at a scope and severity level of a "J." The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Advanced Directive for Health Care, dated February 11, 2011, signed by the resident (as declared by two different witnesses), revealed, "...I, (resident), have made this document to set forth my treatment instructions...in case of my incapacity. As a student of the Holy Scriptures I direct that NO TRANSFUSIONS of whole blood, red cells, white cells, platelets, or plasma be given me under any circumstances, even if the health care providers believe that such are necessary to preserve my life...I give no one...any authority to disregard or override my instructions set forth herein. Family members, relatives, or friends may disagree with me, but any such disagreement does not diminish the strength or substance of my refusal of blood or other instructions..." Medical record review of a hospital History and Physical dated [DATE], revealed the resident was transferred and admitted to the hospital and treated for [REDACTED]. Medical record review of a Physician's Progress Note dated [DATE], at 3:52 p.m., revealed the resident was discharged from the hospital back to the nursing home on [DATE]. Continued review of a Physician's Progress Note dated [DATE], revealed the resident stated to have "contemplated long and has come to a decision after discussion with friends, counselor, brother, social worker, and after (resident's) care plan meeting with (nursing home) staff. (Resident) wishes for...goals to be changed to 'DNR (Do Not Resuscitate)-Comfort Care.' (Resident) does not wish to be transferred to the hospital for life-threatening conditions...wants us (nursing home) to treat...pain and anxiety and have (a) goal of 'comfort' as foremost." Medical record review of Physician order [REDACTED]. "Other instructions" on the POST revealed, "DO NOT HOSPITALIZE." Medical record review of a Significant Change in Status Minimum Data Set (MDS), dated [DATE], revealed a cognition score of thirteen (thirteen-fifteen cognitively intact). Continued review revealed the resident was totally dependent and required the physical assistance of two or more staff for bed mobility and toilet use. The resident's weight measured 429 pounds. Medical record review of the Resident Kardex (Certified Nursing Assistant (CNA) Care Plan), dated [DATE], revealed, "...The following interventions are to be provided to the resident as a part of his/her individual plan of care...Toileting (Please Circle)..." Continued review revealed the required circled intervention for toileting (still current at the time of the fall) was "Assist of 2 (two staff)." Medical record review of the MDS's dated [DATE], and [DATE], revealed the resident's cognition had improved to a score of fifteen but; remained totally dependent and continued to require the physical assistance of two or more staff. The resident's body weight revealed 469 pounds and 476 pounds, respectively. Medical record review of the Physician's Recapitulation Orders, dated [DATE] through [DATE], revealed, "...Aranesp (stimulates the production of red blood cells for chronic kidney disease-associated anemia), inject...200 mcg (micrograms), sub-q (subcutaneous; under the skin), every week..." Continued review revealed the resident's hemoglobin (a lab test to determine the blood's ability to carry oxygen throughout the body) was to be obtained routinely, every week. If the hemoglobin was equal to, or greater than ten, the Aranesp was to be held. Medical record review of the hemoglobin tests obtained [DATE], through [DATE], revealed hemoglobin levels ranged from 7.8 to 9.1 (normal range 12XXX,[DATE].0). Review of a facility investigation dated [DATE], revealed, at approximately 6:00 a.m., the resident "fell off the bed during am (a.m.) care." The "Type of Injury" section with check boxes had the following injuries checked, "...abrasion (scraped)...bruise...laceration (cut)...pain...other." The documentation after "other" included "neurochecks." The resident's reported pain was ten, on a scale of one-to-ten, with ten being the worse. Continued review revealed, "...res (resident) lost grip of side rails and continued momentum over the side of the bed..." Review of a Root Cause Analysis (no date) revealed, "...What steps...contributed to...the event? Associate usually performed this duty alone...What human factors were relevant to the outcome? One CNA assisting the resident during rounds. Resident stated that '(CNA #1) moves me kind of fast'...Are there any other factors that have directly influenced this outcome? Resident's wt (weight) was 430# (pounds)..." Review of a written witness statement dated [DATE], by (CNA #1), revealed, "...I went to change (resident) for morning rounds before I would leave. Told (resident) to lift (resident's) hip to turn (resident). I took and push (pushed) (resident) to (resident's) side. Then before I knew it (resident) was going over. I try (tried) to stop (resident) but (resident) kept on going over and it was to (too) late..." Review of a written witness statement dated [DATE], by Registered Nurse (RN) #1, revealed, "...'As told by res after the fall'...(CNA #1) was drying me. (CNA #1) moves and turns me kinda (kind of) fast. As (CNA #1) was turning me and I was holding onto the rail (side rail). My hand slipped off the rail. Because I was already moving I fell off the bed. I hit my head. I know my leg hit something because I had a lot (a lot) of pain to my leg, the right one (right leg)..." Medical record review of a Nursing Progress Note dated [DATE] (2012), by RN #1 revealed the following: 610 (6:10 a.m.), "I was alerted to a 'big problem on 6th (sixth) floor.' I arrived to the 6th floor to observe (resident) laying on the floor of (resident's) room. Floor was wet with liquid cl (clear)/yellow and some red. Res (resident's) L (left) thigh was lying on top of (roommate's) bedside table. Table was removed for resident's comfort. Res is alert x (times) 3 (three) but very anxious...called (Local) Fire Depart (department) to assist with moving (resident) up off the floor. I called (physician)...to let (physician) know of ,[DATE] (three-to-four) inch laceration to R (right) lateral calf and res refusal to go to hospital. Res neurological intact during assmt (assessment). While waiting for (fire department) lac (laceration) to RLE (right lower extremity) cleaned & (and) dressed." 630 (6:30 a.m.), "1st (first) EMS (Emergency Medical Services) crew arrived-they called a 2nd (second) crew in to help with lifting the res up." 715p (7:15 a.m.), "Res rolled onto tarp and lifted to bed c (with) assist (assistance) of 10 (ten). Res positioned in bed. Tarp removed." 740 (7:40 a.m.), "Bath given to res. Large bruise noted to R thigh, abrasion & bruise noted to R elbow & RFA (right forearm). Abrasion noted to ABD (abdomen). Absion (abrasion) & bruis (bruise) to R hip/buttock (hip and buttock) area-Abrasion noted to L lateral torso (the part of the body to which the head, arms, and legs are attached)...to axilla..XXX,[DATE] (three-to-four) laceration to RLE laterally. Lac cleaned & covered c exerform (xeroform; gauze), ABD pad & wrapped c Kerlix (gauze roll)..." 815 (8:15 a.m.), "Spoke with (Physician office)...bringing a suture kit...(physician) will be here about 9A (9:00 a.m.)." Medical record review of a Physician's Progress Note dated [DATE], revealed the resident had a fall in the early morning. Injuries included bruises to the right thigh; a three and one-half to four inch laceration on the right lateral lower extremity; numerous abrasions on the shoulder (right or left not identified), axillary region (right or left not identified), abdomen, and right hip. The resident was complaining of pain in the thigh (right or left not identified), and revealed, "I cannot move my leg." The resident complained of nausea and retching (unproductive effort to vomit); and was anxious due to the fall and laceration. The laceration was cleaned, locally (edges of the laceration) anesthetized (numbed), and eight sutures were placed. Medical record review of the Physician's Telephone Orders dated [DATE], revealed the following orders: 1. X-ray of the right thigh, leg, and foot; 2. Clean incision (laceration) on right leg daily with normal saline; apply kerlix and xeroform dressing daily and PRN (as needed); 3. Augmentin (antibiotic), 500 milligrams, by mouth, three times daily for five days. Medical record review of the Medication Administration Record, dated [DATE] through [DATE], revealed the following: 1. The laceration was cleaned and dressed as ordered, for wound care; 2. Ativan, 0.5 milligrams, was administered by mouth, at 6:45 a.m., for anxiety; 3. Augmentin was started (at 8:00 a.m.), for prevention of infection; 4. Hydrocodone/Acetaminophen, 5 milligrams-325 milligrams, was administered by mouth, at 8:00 a.m., for pain. Medical record review of the X-ray reports dated [DATE], at 1:00 p.m., revealed two radiologic reviews (x-rays) of the right femur, right tibia and fibula, and the right foot, with the following impressions: 1. Femur, "...no gross (visible) acute displaced fractures..." 2. Tibia and fibula, "...no acute displaced fractures..." 3. Foot, "...no gross acute fractures of the foot...Prominent soft tissue swelling..." Medical record review of a routine weekly hemoglobin lab report dated [DATE], collected at 8:40 a.m., revealed a result of 6.4, (a 2.3 drop from the previous hemoglobin of 8.7 obtained on [DATE]). Medical record review of a Physician's Telephone Order dated [DATE], at 4:00 p.m., revealed orders for a Stat (immediately) repeat of the hemoglobin and to call the Physician with the results. Medical record review of a Nursing Progress Note dated [DATE], at 11:15 p.m., revealed, "...Rcvd (received) call from (hospital) lab...critical value...(hemoglobin)...4.6...Observed res at that time non responsive, resp (respiration) was observable. Called family...to notify...this occurred at 8:10 p.m. Difficult to obtain vs (vital signs), b/p (blood pressure) ,[DATE], pulse 51. LM (left message) with answering service for MD (Medical Doctor). Re: (regarding)...hemoglobin. CNA called for the nurse 8:20 p.m., to observe 0 (no) resp. Supervisor called to room. Family arrived in facility approx (approximately) 9:50 p.m. & was made aware of res passing..." Medical record review of a lab report dated [DATE], revealed the repeat hemoglobin result was 4.6, which was a further drop of 1.8 from the previous hemoglobin of 6.4 obtained earlier at 8:40 a.m. Medical record review of the Record of Death revealed the [AGE] year old resident's date and time of death were on [DATE], at 8:25 p.m. The immediate cause of death revealed, "Sudden death due to questionable internal bleeding secondary to fall." Review of facility in-service, ADL (Activities of Daily Living) Assistance and Kardex, dated [DATE] through [DATE], revealed, "...Explained the ADL coding...what each care level meant in the terms of type of assistance provided and the amount of staff needed for the assistance...Explained the new kardex system. Instead of looking in the care plan book a Kardex notebook will be located at each nurse's station for each hall...The Kardex book will contain an information sheet on each resident to provide the level of assistance needed in ADL's...check this book prior to assisting any resident. This will begin [DATE], (2011)..." Interview with CNA #1 on February 12, 2013, at 5:30 p.m., in the conference room, confirmed, "...I went into the resident's (#1) room to change (provide incontinence care)...(resident) just before the end of the shift. (Resident) was a big woman and I had to take both of my hands and push (resident) hard, with a lot of force, because resident was so big." As CNA #1 described "pushing" the resident, CNA #1 held both hands up, and with the palms of both hands facing forward, demonstrated a pushing gesture using both hands. "I didn't ask anybody to help me...I did it by myself (turned the resident)...When I pushed (resident) over, I couldn't see the opposite side of (resident) because (resident) was so big...when (resident) was turned, (resident) went over so hard and fast, I couldn't stop (resident)...As (resident) went over, (resident) hit (resident's) head on the night stand...there was a huge knot on her forehead (CNA #1 reached up and touched the right side of CNA #1's forehead)...I think the right side of (resident's) forehead...(resident) landed on the bottom (metal base of the table) of the over-the-bed table...there was blood on the floor from a gash on (resident's) right lower leg, and it was (resident's) bad leg...the one that hurt (resident) all the time. I should have had someone helping me. Before I went out to get help, I made sure (resident) was breathing. (CNA #5) was in a nearby room...I hollered (called out loud) '(CNA #5)!'...because I knew (CNA #5) wasn't far from me...(CNA #5) came in and I stayed with (resident) while (CNA #5) went to get the nurse...(RN #1), Licensed Practical Nurse (LPN #3), (CNA #5), and myself were looking at (resident) trying to figure out how we were going to get (resident) off of the over-the-bed table...(RN #1), (CNA #5), and me pulled (resident) over as (LPN #3) pulled the over-the-bed table from under (resident)...We were talking to (resident)...(resident) was in pain...(LPN #3) got (resident) some Ativan to help (resident) calm down...(resident) said (resident) couldn't breathe...I guess it was an anxiety attack...(resident) calmed down with the Ativan. By this time the fire department was there...The fire department was looking for a lift to get (resident) back into the bed...They had to use a rug from downstairs, like a big mat you use to wipe your feet on. First they used a bed pad, rolling (resident) side-to-side until it (bed pad) was under (resident)...then went [DATE], and lifted (resident) up and over until they got (resident) onto the rug...Once on the rug, the fire department got (resident) onto the bed...(Physician) told me it was an accident that ended bad...I was responsible...I pushed (resident) over...I couldn't see that (resident) had lost (resident's) hand grip...I couldn't see (resident's) hand...(resident) was so big..." Continued interview revealed CNA #1 denied knowing the resident required the assistance of two for toileting and "Nobody in-serviced (educated) me or gave me any disciplinary action." Interview with Resident Assessment Information Coordinator (RAIC) #1 on February 13, 2013, at 10:30 a.m., in the conference room, confirmed the resident was a total assist with turning, toileting, and transferring, and required the assistance of two or more staff. "The information was on the care plan and the kardex (a reference for resident-specific information related to nursing care); and the kardex is CNA-based. All CNA's were trained and required to use the kardex for resident specific information." Interview with RN #1 on February 13, 2013, at 11:15 a.m., in the conference room, confirmed, "On the morning of [DATE], I was called (RN #1 was on seventh floor; resident was on sixth floor), and told that (resident) was on the floor, and had fell from the bed. I assessed (resident's) neurological status...was alert, and oriented x3 (to person, place, time)...no neurological distress or changes. There was bloody fluid in the floor...was a cut on the (resident's) leg that was bleeding...right lateral calf (side area between knee and ankle)...The fire department was notified for assistance." RN #1 reviewed the Nursing Progress Notes and witness statement, written by RN #1, and confirmed the following injuries were observed by RN #1 from the resident's fall: 1. Left lateral torso-abrasion going into the axilla (armpit); 2. Abdomen-(belly)-abrasion; 3. Right hip and buttock area-abrasion and bruising; 4. Right lateral lower extremity (leg)-three-to-four lacerations; 5. Right thigh (upper leg), anterior (front)-large bruise; 6. Right elbow and forearm (part of arm between elbow and hand)-large bruise; 7. Right lateral calf-three-to-four inch laceration Continued interview with RN #1 confirmed RN #1 was aware the resident was a total assist and defined "total assist" as "required the assist of two or more staff." RN #1 confirmed to have observed only one CNA providing assistance to the resident, prior to the resident's fall. "I have seen one CNA assisting the resident...The CNA's knew not to provide ADL's with one CNA...but some did...It was not safe for the resident to be assisted by only one CNA..." Continued interview with RN #1 confirmed, "I did not report the CNA's non-compliance with the resident's required assistance to the Chief Nursing Officer (CNO), or Administrator...I didn't report it to anyone...I didn't do any disciplinary action or in-servicing was provided in response to the CNA's who were non-compliant with the resident's required assistance of two..." RN #1 confirmed the facility failed to ensure the resident received supervision and assistance to prevent the fall on [DATE]. Interview with the Physician on February 13, 2013, at 2:30 p.m., in the conference room, confirmed the Physician had completed a fell owship in Geriatric Medicine, and had provided Physician services to the resident for over one and one-half years. "The resident was chronically anemic secondary to Chronic Kidney Disease, and was being treated with Aranesp, which required routine weekly monitoring of the resident's hemoglobin. The resident's hemoglobin historically ranged between 8XXX,[DATE].0; with one occasion of a false-low. On ([DATE]), the day of the fall, (resident) had a routine hemoglobin, which came back critically low, with a result of 6.4. Due to the previous false-low, I ordered a Stat repeat (of the hemoglobin). The repeat (blood specimen) was difficult for the nurses to obtain from the resident, but once successfully obtained, the result remained critically low...even lower at 4.6. I discussed (resident's) Advanced Directives with (resident). (Resident) refused to go to the hospital after the fall, and continued to refuse to go with the critically low hemoglobin results...This drop in the hemoglobin indicated internal bleeding...There is normally not a 'two-point drop' in an approximate ten-hour period; there would have to be a significant bleed for that much of a drop (in the hemoglobin)...With the resident's size, the bleed was not obvious..." Continued interview with the Physician confirmed, "...Due to the resident's obese and debilitated condition, it was not safe to turn or clean (resident) with one CNA; at least two were needed. While the resident was comorbidly obese...this accident (fall) was separate from (resident's) disease processes. The immediate cause of (resident's) death was due to the accident, not (resident's) diagnoses." Interview with CNA #4 on February 13, 2013, at 3:50 p.m., in the conference room, confirmed, "I routinely cared for (resident) and periodically, I reviewed the (resident's) care plan and kardex...I knew the resident was a total assist with two people, to turn and clean; but there were days I did it by myself, and there were days I got other CNA's to help with (resident)..." Interview with CNA #5 on February 13, 2013, at 3:50 p.m., in the conference room, confirmed, "...I knew (resident was a two-person assist...I knew it was not safe to do (resident) by myself but, I did. If (resident's) bed needed changing, I always got another person to help because you would not be able to reach across the bed; it was too big and you would run yourself to death going from side-to-side. It was quicker if two did it (changed the bed). We had the kardex and care plan...I knew it took two people but I just thought I could get it done by myself and move on. Continued interview with CNA #5 confirmed, "On the morning of the fall ([DATE]), I was in a room beside of (resident's) room...I heard the loudest noise and I thought, 'God, I hope nobody fell out of bed.' About that time, (CNA #1) came rushing through the door (where CNA #5 was)...screaming, '(CNA #5)! (Resident) fell out of bed!' (Resident) was on the floor; (CNA #1) stayed with (resident) while I got help...I called upstairs and said, 'We need somebody down here now! We've got a resident in an incident and need somebody NOW!' (Resident) looked pitiful lying there. (RN #1) came down. EMS and the fire department responded to the call for help. The fire department had to help us get (resident) up...we got (resident) onto a bed pad and little-by-little, we were able to get (resident) onto a floor mat. Once on the mat, at least ten firemen, maybe more, lifted the resident to the bed. (Resident's) leg was messed up...cut...there was blood...we just had to get (resident) up...it was awful...it was pitiful." Interview with RN #2 on February 13, 2013, at 8:00 p.m., in the conference room, confirmed RN #2 routinely provided the care and services, and supervision of (resident). "(Resident) went 'down-hill' in 2011...had declined and required the assistance of two people. I was quite surprised...shocked...when I found out (resident) had fallen (on [DATE]), when only one CNA had attempted to assist (resident) with care. I didn't realize or even think it could be done, and obviously, it shouldn't have." Continued interview with RN #1 confirmed, "It was not safe for one to assist (resident) in turning, incontinence care...the potential for harm was so much greater." Interview by telephone with RN #3 on February 14, 2013, at 12:52 p.m., confirmed, "I was the previous CNO, at the time of (resident's) fall (on [DATE]). (Resident) was a two-person assist with turning and incontinence care and (resident's) assist level was on the kardex...'assist of two.' I recall this because it was a very serious event...we investigated it thoroughly..." Continued interview with RN #3 confirmed no one, to include (RN #1), had reported observing any CNA's who were non-compliant regarding using the required assistance with (resident). Interview by telephone with LPN #3 on February 14, 2013, at 6:42 p.m., confirmed LPN #3 provided assistance to the resident and nursing staff, after the resident's fall from the bed on [DATE]. (Resident's) leg was bleeding badly...(resident) was in a lot of pain and was anxious. (Resident) refused to go to the hospital...I gave (resident) anxiety and pain medication, and it helped...(resident) calmed down and slept. As the day went on, (resident) declined...it was a steady decline from the point of the fall until (resident) died . (Resident) was a two-person assist. This was all because the CNA (#1) failed to obtain the assistance of another person; and used the inappropriate turning technique, by turning (resident) in the opposite direction of the CNA (#1) (instead of toward CNA #1)..." A second interview with CNA #1 on February 15, 2013, at 12:15 p.m., in the conference room, confirmed, "I was 'blurry' in my recall of the incident with assisting (resident) with incontinence care on [DATE]. I've had time to think about it, and my memory is now clear. I was trained in orientation to use the kardex to find the care and assist needs the residents' needed, including (resident). I was trained to always turn the resident toward me, never to turn away from me. I knew (resident) was needed the assist of two people...I just felt like I could do (resident) by myself. There was staff here to help me, and they would have if I had asked them; but I just didn't ask them. When I was changing (resident) (on [DATE]), (resident) was too big for me to pull (resident) to me. I had to push (resident) to get (resident) over and to be on the side where (resident's) bottom was to clean it. When I pushed (resident) over, I took my hands off of (resident) to get the brief ready; then I proceeded to clean (resident). It was at this point I noticed (resident) was going over (falling out of the bed). (Resident) was in an over-sized bed and it was impossible for me to get around the bed to break (resident's) fall. (Resident) was too big for me to see over (resident's) body and see that (resident's) hand was not on the side rail. Continued interview with CNA #1 confirmed, "I was never meaning to lie to you about this. It has been seven months and I had to re-think it. I was caught off-guard when I talked to you Tuesday night (February 12, 2013). I've had time to think about it and I wanted to clear this up." Interview with the CNO on February 15, 2013, at 2:00 p.m., in the conference room, confirmed the CNO began working for the facility in 1998, and has since held various positions, to include: MDS Coordinator, Quality Assurance Coordinator, Quality Assurance Director; and most current, CNO. "I personally trained (CNA #1) on using the kardex in November of 2011." Continued interview with the CNO confirmed, "I was the Quality Assurance Director at the time of the resident's fall (on [DATE]). I was aware of the fall and completed a root-cause analysis, which identified (CNA #1) failed to ensure the assist of two people when turning and providing incontinence care to the resident. (RN #1) was required to ensure any nursing staff who failed to provide the assistance required for (resident) was disciplined; and was required to ensure reporting of the non-compliance to administration (CNO especially), to ensure education and follow-up...this did not happen..." The CNO confirmed the facility failed to provide the required supervision and assistance to prevent (resident's) fall on [DATE]. Interview with the Administrator on February 20, 2013, at 2:00 p.m., in the conference room, confirmed had been made aware of the resident's fall at approximately 7:00 a.m., on [DATE], (approximately one-hour after the fall). "Through investigation initiated (after) the fall, the facility confirmed, the resident was provided incontinence care by one CNA (#1), instead of two CNA's, as required for the safety of the resident. (RN #1) was the 'house supervisor' on [DATE]. (RN #1) was responsible for the general oversight of the nursing department on (RN #1's) shift. (RN #1) did not report (to the Administrator) any CNA's being non-compliant with providing the resident the required assistance to ensure the safety of the resident..." Continued interview confirmed CNA #1 failed to provide the correct turning technique and failed to provide the correct amount of assistance required for (resident) and the resident fell from the bed (on [DATE]) and RN #1 failed to ensure the required supervision to ensure the safety of (resident). The Administrator confirmed the facility failed to ensure (resident #1) received the required supervision and assistance to prevent the fall on [DATE]. In summary, CNA #1, failed to obtain the required assistance when turning and attempting to provide incontinence care to the resident, resulting in a fall with injury from the bed on [DATE], at 6:00 a.m. RN #1 failed to ensure supervision and the required assistance for the resident's safety. The Immediate Jeopardy was effective from [DATE], through February 20, 2013, and was removed on February 20, 2013. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on February 21, 2013. The surveyor verified the corrective actions by: 1. Reviewing the facility's in-service records to ensure all nursing staff had been educated on neglect, assistance with ADL's, turning and positioning a resident, and non-compliance with assistance levels; 2. Reviewing the facility's in-service records to ensure all nursing staff knew where the residents' care plans are and how to use them; 3. Reviewing the facility's in-service records to ensure all CNA staff had been educated on the electronic care plan system; 4. Reviewing the facility's in-service records to ensure all licensed nursing staff had been educated on and the implementation of the facility's policy and procedure on "Special Handling and Movement Challenges related to Bariatrics;" 5. Reviewing the corrective actions implemented for the non-compliant staff, (RN #1, CNA's #1, #4, and #5) 6. Conducting interviews with eight of nineteen licensed nursing staff employed to determine the level of comprehension gained through in-service education conducted regarding facility policies on neglect, assistance with ADL's, turning and positioning a resident, care plans, non-compliance with, (a) the supervision of resident care, and (b) assistance levels; 7. Conducting interviews with nineteen of forty-four CNA staff employed to determine the level of comprehension gained through in-service education conducted regarding facility policies on assistance with neglect, ADL's, turning and positioning a resident, care plans, and non-compliance with required assistance levels; 8. Conducting interviews and observations of seven CNA's regarding the use of the electronic care plan system; 9. Observing the level of assistance CNA's provided to five residents requiring the assistance of two, in accordance with the resident's care plan and electronic care plan system; Non-compliance continues at a "D" level for monitoring corrective actions. Refer to F-282 (J). C/O #

Based on medical record review, review of facility investigation, review of facility in-service, review of facility policy, and interview, the facility failed to follow the resident's individualized care plan, and provide the required level of assistance to prevent a fall for one resident (#1) of eight residents reviewed. The facility's failure to ensure resident #1's care plan was followed and the required safe assistance was provided when turning the bedridden resident resulted in a fall from the bed with multiple bodily injuries and sudden death on [DATE]. The facility's failure placed resident #1 in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Administrator and Chief Nursing Officer were informed of the Immediate Jeopardy in the Conference Room on February 20, 2013, at 1:35 p.m. The findings included: Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Advanced Directive for Health Care, dated February 11, 2011, signed by the resident (as declared by two different witnesses), revealed, "...I, (resident), have made this document to set forth my treatment instructions...in case of my incapacity. As a student of the Holy Scriptures I direct that NO [MEDICAL CONDITION] of whole blood, red cells, white cells, platelets, or plasma be given me under any circumstances, even if the health care providers believe that such are necessary to preserve my life...I give no one...any authority to disregard or override my instructions set forth herein. Family members, relatives, or friends may disagree with me, but any such disagreement does not diminish the strength or substance of my refusal of blood or other instructions..." Medical record review of a hospital History and Physical dated [DATE], revealed the resident was transferred and admitted to the hospital and treated for [REDACTED]. Medical record review of a Physician's Progress Note dated [DATE], at 3:52 p.m., revealed the resident was discharged from the hospital back to the nursing home on [DATE]. Continued review of a Physician's Progress Note dated [DATE], revealed the resident stated to have "contemplated long and has come to a decision after discussion with friends, counselor, brother, social worker, and after (resident's) care plan meeting with (nursing home) staff. (Resident) wishes for...goals to be changed to 'DNR (Do Not Resuscitate)-Comfort Care.' (Resident) does not wish to be transferred to the hospital for life-threatening conditions...wants us (nursing home) to treat...pain and anxiety and have (a) goal of 'comfort' as foremost." Medical record review of Physician order [REDACTED]. "Other instructions" on the POST revealed, "DO NOT HOSPITALIZE." Medical record review of a Significant Change in Status Minimum Data Set (MDS), dated [DATE], revealed a cognition score of thirteen (thirteen-fifteen cognitively intact). Continued review revealed the resident was totally dependent and required the physical assistance of two or more staff for bed mobility and toilet use. The resident's weight measured 429 pounds. Medical record review of the Resident Kardex (Certified Nursing Assistant (CNA) care plan), dated [DATE], revealed, "...The following interventions are to be provided to the resident as a part of his/her individual plan of care...Toileting (Please Circle)..." Continued review revealed the required circled intervention for toileting (still current at the time of the fall) was "Assist of 2 (two staff)." Medical record review of the MDS's dated [DATE], and [DATE], revealed the resident's cognition had improved to a score of fifteen but; remained totally dependent and continued to require the physical assistance of two or more staff. The resident's body weight revealed 469 pounds and 476 pounds, respectively. Medical record review of the Physician's Recapitulation Orders, dated [DATE] through [DATE], revealed, "[MEDICATION NAME] (stimulates the production of red blood cells for [MEDICAL CONDITION]-associated [MEDICAL CONDITION]), inject...200 mcg (micrograms), sub-q (subcutaneous; under the skin), every week..." Continued review revealed the resident's hemoglobin (a lab test to determine the blood's ability to carry oxygen throughout the body) was to be obtained routinely, every week. If the hemoglobin was equal to, or greater than ten, the [MEDICATION NAME] was to be held. Medical record review of the hemoglobin tests obtained [DATE], through [DATE], revealed hemoglobin levels ranged from 7.8 to 9.1 (normal range 12XXX,[DATE].0). Review of a facility investigation dated [DATE], revealed, at approximately 6:00 a.m., the resident "fell off the bed during am (a.m.) care." The "Type of Injury" section with check boxes had the following injuries checked, "...abrasion (scraped)...bruise...laceration (cut)...pain...other." The documentation after "other" included "neurochecks." The resident's reported pain was ten, on a scale of one-to-ten, with ten being the worse. Continued review revealed, "...res (resident) lost grip of side rails and continued momentum over the side of the bed..." Review of a Root Cause Analysis (no date) revealed, "...What steps...contributed to...the event? Associate usually performed this duty alone...What human factors were relevant to the outcome? One CNA assisting the resident during rounds. Resident stated that '(CNA #1) moves me kind of fast'...Are there any other factors that have directly influenced this outcome? Resident's wt (weight) was 430# (pounds)..." Review of a written witness statement dated [DATE], by (CNA #1), revealed, "...I went to change (resident) for morning rounds before I would leave. Told (resident) to lift (resident's) hip to turn (resident). I took and push (pushed) (resident) to (resident's) side. Then before I knew it (resident) was going over. I try (tried) to stop (resident) but (resident) kept on going over and it was to (too) late..." Review of a written witness statement dated [DATE], by Registered Nurse (RN) #1, revealed, "...'As told by res after the fall'...(CNA #1) was drying me. (CNA #1) moves and turns me kinda (kind of) fast. As (CNA #1) was turning me and I was holding onto the rail (side rail). My hand slipped off the rail. Because I was already moving I fell off the bed. I hit my head. I know my leg hit something because I had a lot (a lot) of pain to my leg, the right one (right leg)..." Medical record review of a Nursing Progress Note dated [DATE] (2012), by RN #1 revealed the following: 610 (6:10 a.m.), "I was alerted to a 'big problem on 6th (sixth) floor.' I arrived to the 6th floor to observe (resident) laying on the floor of (resident's) room. Floor was wet with liquid cl (clear)/yellow and some red. Res (resident's) L (left) thigh was lying on top of (roommate's) bedside table. Table was removed for resident's comfort. Res is alert x (times) 3 (three) but very anxious...called (Local) Fire Depart (department) to assist with moving (resident) up off the floor. I called (physician)...to let (physician) know of ,[DATE] (three-to-four) inch laceration to R (right) lateral calf and res refusal to go to hospital. Res neurological intact during assmt (assessment). While waiting for (fire department) lac (laceration) to RLE (right lower extremity) cleaned & (and) dressed." 630 (6:30 a.m.), "1st (first) EMS (Emergency Medical Services) crew arrived-they called a 2nd (second) crew in to help with lifting the res up." 715p (7:15 a.m.), "Res rolled onto tarp and lifted to bed c (with) assist (assistance) of 10 (ten). Res positioned in bed. Tarp removed." 740 (7:40 a.m.), "Bath given to res. Large bruise noted to R thigh, abrasion & bruise noted to R elbow & RFA (right forearm). Abrasion noted to ABD (abdomen). Absion (abrasion) & bruis (bruise) to R hip/buttock (hip and buttock) area-Abrasion noted to L lateral torso (the part of the body to which the head, arms, and legs are attached)...to axilla..XXX,[DATE] (three-to-four) laceration to RLE laterally. Lac cleaned & covered c exerform (xeroform; gauze), ABD pad & wrapped c Kerlix (gauze roll)..." 815 (8:15 a.m.), "Spoke with (Physician office)...bringing a suture kit...(physician) will be here about 9A (9:00 a.m.)." Medical record review of a lab report dated [DATE], revealed the routine weekly hemoglobin was collected at 8:40 a.m. Medical record review of a Physician's Progress Note dated [DATE], revealed the resident had a fall in the early morning. Injuries included bruises to the right thigh; a three and one-half to four inch laceration on the right lateral lower extremity; numerous abrasions on the shoulder (right or left not identified), axillary region (right or left not identified), abdomen, and right hip. The resident was complaining of pain in the thigh (right or left not identified), and revealed, "I cannot move my leg." The resident complained of nausea and retching (unproductive effort to vomit); and was anxious due to the fall and laceration. The laceration was cleaned, locally (edges of the laceration) anaesthetized (numbed), and eight sutures were placed. Medical record review of the Physician's Telephone Orders dated [DATE], revealed the following orders: 1. X-ray of the right thigh, leg, and foot; 2. Clean incision (laceration) on right leg daily with normal saline; apply kerlix and xeroform dressing daily and PRN (as needed); 3. [MEDICATION NAME] (antibiotic), 500 milligrams, by mouth, three times daily for five days. Medical record review of the Medication Administration Record, [REDACTED] 1. The laceration was cleaned and dressed as ordered, for wound care; 2. [MEDICATION NAME], 0.5 milligrams, was administered by mouth, at 6:45 a.m., for anxiety; 3. [MEDICATION NAME] was started (at 8:00 a.m.), for prevention of infection; 4. [MEDICATION NAME]/[MEDICATION NAME], 5 milligrams-325 milligrams, was administered by mouth, at 8:00 a.m., for pain. Medical record review of the X-ray reports dated [DATE], at 1:00 p.m., revealed two radiologic reviews (x-rays) of the right femur, right tibia and fibula, and the right foot, with the following impressions: 1. Femur, "...no gross (visible) acute displaced fractures..." 2. Tibia and fibula, "...no acute displaced fractures..." 3. Foot, "...no gross acute fractures of the foot...Prominent soft tissue swelling..." Medical record review of a routine weekly hemoglobin lab report dated [DATE], collected at 8:40 a.m., revealed a result of 6.4, which was a 2.3 drop from the previous hemoglobin of 8.7 obtained on [DATE]. Medical record review of a Physician's Telephone Order dated [DATE], at 4:00 p.m., revealed orders for a Stat (immediately) repeat of the hemoglobin and to call the Physician with the results. Medical record review of a Nursing Progress Note dated [DATE], at 11:15 p.m., revealed, "...Rcvd (received) call from (hospital) lab...critical value...(hemoglobin)...4.6...Observed res at that time non responsive, resp (respiration) was observable. Called family...to notify...this occurred at 8:10 p.m. Difficult to obtain vs (vital signs), b/p (blood pressure) ,[DATE], pulse 51. LM (left message) with answering service for MD (Medical Doctor). Re: (regarding)...hemoglobin. CNA called for the nurse 8:20 p.m., to observe 0 (no) resp. Supervisor called to room. Family arrived in facility approx (approximately) 9:50 p.m. & was made aware of res passing..." Medical record review of a lab report dated [DATE], revealed the repeat hemoglobin result was 4.6, which was a further drop of 1.8 from the previous hemoglobin of 6.4 obtained earlier at 8:40 a.m. Medical record review of the Record of Death revealed the [AGE] year old resident's date and time of death were on [DATE], at 8:25 p.m. The immediate cause of death revealed, "Sudden death due to questionable internal bleeding secondary to fall." Review of facility in-service, ADL (Activities of Daily Living) Assistance and Kardex, dated [DATE] through [DATE], revealed, "...Explained the ADL coding...what each care level meant in the terms of type of assistance provided and the amount of staff needed for the assistance...Explained the new kardex system. Instead of looking in the care plan book a Kardex notebook will be located at each nurse's station for each hall...The Kardex book will contain an information sheet on each resident to provide the level of assistance needed in ADL's...check this book prior to assisting any resident. This will begin [DATE], (2011)..." Review of facility policy, "Comprehensive Care Plan," dated [DATE], revealed, "Purpose: Each resident's ...care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems...e. Identify...services that are responsible for each element of care; f. Aid in preventing or reducing (resident) declines...Policy: An individualized...care plan...to meet the resident's medical, nursing, mental and psychological needs...for each resident..." Interview with CNA #1 on February 12, 2013, at 5:30 p.m., in the conference room, confirmed, "...I went into the resident's (#1) room to change (provide incontinence care)...(resident) just before the end of the shift. (Resident) was a big woman and I had to take both of my hands and push (resident) hard, with a lot of force, because resident was so big." As CNA #1 described "pushing" the resident, CNA #1 held both hands up, and with the palms of both hands facing forward, demonstrated a pushing gesture using both hands. "I didn't ask anybody to help me...I did it by myself (turned the resident)...When I pushed (resident) over, I couldn't see the opposite side of (resident) because (resident) was so big...when (resident) was turned, (resident) went over so hard and fast, I couldn't stop (resident)...As (resident) went over, (resident) hit (resident's) head on the night stand...there was a huge knot on her forehead (CNA #1 reached up and touched the right side of CNA #1's forehead)...I think the right side of (resident's) forehead...(resident) landed on the bottom (metal base of the table) of the over-the-bed table...there was blood on the floor from a gash on (resident's) right lower leg, and it was (resident's) bad leg...the one that hurt (resident) all the time. I should have had someone helping me. Before I went out to get help, I made sure (resident) was breathing. (CNA #5) was in a nearby room...I hollered (called out loud) '(CNA #5)!'...because I knew (CNA #5) wasn't far from me...(CNA #5) came in and I stayed with (resident) while (CNA #5) went to get the nurse...(RN #1), Licensed Practical Nurse (LPN #3), (CNA #5), and myself were looking at (resident) trying to figure out how we were going to get (resident) off of the over-the-bed table...(RN #1), (CNA #5), and me pulled (resident) over as (LPN #3) pulled the over-the-bed table from under (resident)...We were talking to (resident)...(resident) was in pain...(LPN #3) got (resident) some [MEDICATION NAME] to help (resident) calm down...(resident) said (resident) couldn't breathe...I guess it was an anxiety attack...(resident) calmed down with the [MEDICATION NAME](Physician) told me it was an accident that ended bad...I was responsible...I pushed (resident) over...I couldn't see that (resident) had lost (resident's) hand grip...I couldn't see (resident's) hand...(resident) was so big..." Continued interview revealed CNA #1 denied knowing the resident required the assistance of two for toileting and "Nobody in-serviced (educated) me or gave me any disciplinary action." Interview with Resident Assessment Information Coordinator (RAIC) #1 on February 13, 2013, at 10:30 a.m., in the conference room, confirmed the resident was a total assist with turning, toileting, and transferring, and required the assistance of two or more staff. "The information was on the care plan and the kardex (a reference for resident-specific information related to nursing care); and the kardex is a CNA-based care plan. All CNA's were trained and required to use the kardex for resident specific information." RAIC #1 confirmed, "The resident's care plan identified the resident required total assistance with two staff for toileting. On [DATE], at 6:00 a.m., one CNA (#1) was assisting the resident with toileting, and the resident fell from the bed." RAIC #1 confirmed the facility failed to ensure the resident's individualized care plan was followed, and provide the required and safe assistance of two staff. Interview with RAIC #2 on February 13, 2013, at 12:15 p.m., in the conference room, confirmed, "...I completed (resident's) Significant Change in Status MDS, on [DATE], and MDS assessment on [DATE]...(resident) was totally dependent. I updated the care plan and kardex on [DATE], to include interventions for toileting with the assist of two. All care plans are developed, and updated according to each resident's assessment and any change in condition. The resident's information is, and was during this resident's stay, maintained in the care plan binders at each nurse's station...the kardex was also being used at that time, and was located at each nurse's station. In just looking at the resident's size, common sense would tell you it would take two, at least, to change, clean, and turn (resident). It was not safe for (resident) to be assisted by one CNA...We have switched to an electronic system with a kiosk (free-standing computer station and display screen) located on each hallway for the CNA's to reference for each resident's specific care and assistance." Continued interview confirmed, "When (CNA #1) assisted the resident by (CNA #1's) self, with toileting (on [DATE], at 6:00 a.m.), the care plan was not followed and (resident) fell from the bed." RAIC #2 confirmed the facility failed to follow the resident's care plan. Interview with RN #1 on February 13, 2013, at 11:15 a.m., in the conference room, confirmed, "On the morning of [DATE], I was called (RN #1 was on seventh floor; resident was on sixth floor), and told that (resident) was on the floor, and had fell from the bed. I assessed (resident's) neurological status...was alert, and oriented x3 (to person, place, time)...no neurological distress or changes. There was bloody fluid in the floor...was a cut on the (resident's) leg that was bleeding...right lateral calf (side area between knee and ankle)...The fire department was notified for assistance." RN #1 reviewed the Nursing Progress Notes and witness statement, written by RN #1, and confirmed the following injuries were observed by RN #1 from the resident's fall: 1. Left lateral torso-abrasion going into the axilla (armpit); 2. Abdomen-(belly)-abrasion; 3. Right hip and buttock area-abrasion and bruising; 4. Right lateral lower extremity (leg)-three-to-four lacerations; 5. Right thigh (upper leg), anterior (front)-large bruise; 6. Right elbow and forearm (part of arm between elbow and hand)-large bruise; 7. Right lateral calf-three-to-four inch laceration Continued interview with RN #1 confirmed RN #1 was aware the resident was a total assist and defined "total assist" as "required the assist of two or more staff." RN #1 confirmed to have observed only one CNA providing assistance to the resident, prior to the resident's fall. "I have seen one CNA assisting the resident...The CNA's knew not to provide ADL's with one CNA...but some did...It was not safe for the resident to be assisted by only one CNA..." Continued interview with RN #1 confirmed, "I did not report the CNA's non-compliance with the resident's required assistance to the Chief Nursing Officer (CNO), or Administrator...I didn't report it to anyone...I didn't do any disciplinary action or in-servicing was provided in response to the CNA's who were non-compliant with the resident's required assistance of two..." RN #1 confirmed the facility failed to ensure the resident received supervision and assistance to prevent the fall on [DATE]. Interview with the Physician on February 13, 2013, at 2:30 p.m., in the conference room, confirmed the Physician had completed a fell owship in Geriatric Medicine, and had provided Physician services to the resident for over one and one-half years. "The resident was chronically anemic secondary to [MEDICAL CONDITION], and was being treated with [MEDICATION NAME], which required routine weekly monitoring of the resident's hemoglobin. The resident's hemoglobin historically ranged between 8XXX,[DATE].0; with one occasion of a false-low. On ([DATE]), the day of the fall, (resident) had a routine hemoglobin, which came back critically low, with a result of 6.4. Due to the previous false-low, I ordered a Stat repeat (of the hemoglobin). The repeat (blood specimen) was difficult for the nurses to obtain from the resident, but once successfully obtained, the result remained critically low...even lower at 4.6. I discussed (resident's) Advanced Directives with (resident). (Resident) refused to go to the hospital after the fall, and continued to refuse to go with the critically low hemoglobin results...This drop in the hemoglobin indicated internal bleeding...There is normally not a 'two-point drop' in an approximate ten-hour period; there would have to be a significant bleed for that much of a drop (in the hemoglobin)...With the resident's size, the bleed was not obvious..." Continued interview with the Physician confirmed, "...Due to the resident's obese and debilitated condition, it was not safe to turn or clean (resident) with one CNA; at least two were needed. While the resident was comorbidly obese...this accident (fall) was separate from (resident's) disease processes. The immediate cause of (resident's) death was due to the accident, not (resident's) diagnoses." Interview with CNA #4 on February 13, 2013, at 3:50 p.m., in the conference room, confirmed, "I routinely cared for (resident) and periodically, I reviewed the (resident's) care plan and kardex...I knew the resident was a total assist with two people, to turn and clean; but there were days I did it by myself, and there were days I got other CNA's to help with (resident)..." Interview with CNA #5 on February 13, 2013, at 3:50 p.m., in the conference room, confirmed, "...I knew (resident was a two-person assist...I knew it was not safe to do (resident) by myself but, I did. If (resident's) bed needed changing, I always got another person to help because you would not be able to reach across the bed; it was too big and you would run yourself to death going from side-to-side. It was quicker if two did it (changed the bed). We had the kardex and care plan...I knew it took two people but I just thought I could get it done by myself and move on. Continued interview with CNA #5 confirmed, "On the morning of the fall ([DATE]), I was in a room beside of (resident's) room...I heard the loudest noise and I thought, 'God, I hope nobody fell out of bed.' About that time, (CNA #1) came rushing through the door (where CNA #5 was)...screaming, '(CNA #5)! (Resident) fell out of bed!' (Resident) was on the floor; (CNA #1) stayed with (resident) while I got help...I called upstairs and said, 'We need somebody down here now! We've got a resident in an incident and need somebody NOW!' (Resident) looked pitiful lying there. (RN #1) came down. EMS and the fire department responded to the call for help. The fire department had to help us get (resident) up...we got (resident) onto a bed pad and little-by-little, we were able to get (resident) onto a floor mat. Once on the mat, at least ten firemen, maybe more, lifted the resident to the bed. (Resident's) leg was messed up...cut...there was blood...we just had to get (resident) up...it was awful...it was pitiful." Interview with RN #2 on February 13, 2013, at 8:00 p.m., in the conference room, confirmed RN #2 routinely provided the care and services, and supervision of (resident). "(Resident) went 'down-hill' in 2011...had declined and required the assistance of two people. I was quite surprised...shocked...when I found out (resident) had fallen (on [DATE]), when only one CNA had attempted to assist (resident) with care. I didn't realize or even think it could be done, and obviously, it shouldn't have. Continued interview with RN #1 confirmed, "It was not safe for one to assist (resident) in turning, incontinence care...the potential for harm was so much greater." Interview by telephone with RN #3 on February 14, 2013, at 12:52 p.m., confirmed, "I was the previous CNO, at the time of (resident's) fall (on [DATE]). (Resident) was a two-person assist with turning and incontinence care and (resident's) assist level was on the kardex...'assist of two.' I recall this because it was a very serious event...we investigated it thoroughly..." Continued interview with RN #3 confirmed no one, to include (RN #1), had reported observing any CNA's who were non-compliant regarding using the required assistance with (resident). "The facility neglected to provide the care the resident needed." Interview by telephone with LPN #3 on February 14, 2013, at 6:42 p.m., confirmed LPN #3 provided assistance to the resident and nursing staff, after the resident's fall from the bed on [DATE]. (Resident's) leg was bleeding badly...(resident) was in a lot of pain and was anxious. (Resident) refused to go to the hospital...I gave (resident) anxiety and pain medication, and it helped...(resident) calmed down and slept. As the day went on, (resident) declined...it was a steady decline from the point of the fall until (resident) died . (Resident) was a two-person assist. This was all because the CNA (#1) failed to obtain the assistance of another person; and used the inappropriate turning technique, by turning (resident) in the opposite direction of the CNA (#1) (instead of toward CNA #1)..." A second interview with CNA #1 on February 15, 2013, at 12:15 p.m., in the conference room, confirmed, "I was 'blurry' in my recall of the incident with assisting (resident) with incontinence care on [DATE]. I've had time to think about it, and my memory is now clear. I was trained in orientation to use the kardex to find the care and assist needs the residents' needed, including (resident). I was trained to always turn the resident toward me, never to turn away from me. I knew (resident) was needed the assist of two people...I just felt like I could do (resident) by myself. There was staff here to help me, and they would have if I had asked them; but I just didn't ask them. When I was changing (resident) (on [DATE]), (resident) was too big for me to pull (resident) to me. I had to push (resident) to get (resident) over and to be on the side where (resident's) bottom was to clean it. When I pushed (resident) over, I took my hands off of (resident) to get the brief ready; then I proceeded to clean (resident). It was at this point I noticed (resident) was going over (falling out of the bed). (Resident) was in an over-sized bed and it was impossible for me to get around the bed to break (resident's) fall. (Resident) was too big for me to see over (resident's) body and see that (resident's) hand was not on the side rail. Continued interview with CNA #1 confirmed, "I was never meaning to lie to you about this. It has been seven months and I had to re-think it. I was caught off-guard when I talked to you Tuesday night (February 12, 2013). I've had time to think about it and I wanted to clear this up." Interview with the CNO on February 15, 2013, at 2:00 p.m., in the conference room, confirmed the CNO began working for the facility in 1998, and has since held various positions, to include: MDS Coordinator, Quality Assurance Coordinator, Quality Assurance Director; and most current, CNO. "I personally trained (CNA #1) on using the kardex in November of 2011." Continued interview with the CNO confirmed, "I was the Quality Assurance Director at the time of the resident's fall (on [DATE]). I was aware of the fall and completed a root-cause analysis, which identified (CNA #1) failed to ensure the assist of two people when turning and providing incontinence care to the resident. (RN #1) was required to ensure any nursing staff who failed to provide the assistance required for (resident) was disciplined; and was required to ensure reporting of the non-compliance to administration (CNO especially), to ensure education and follow-up...this did not happen..." The CNO confirmed the facility failed to provide the required supervision and assistance to prevent (resident's) fall on [DATE]. Interview with the Administrator on February 20, 2013, at 2:00 p.m., in the conference room, confirmed (Administrator) had been made aware of the resident's fall at approximately 7:00 a.m., on [DATE], (approximately one-hour after the fall). "Through investigation initiated upon the fall, the facility confirmed, the resident was provided incontinence care by one CNA (#1), instead of two CNA's, as required for the safety of the resident. (RN #1) was the 'house supervisor' on [DATE]. (RN #1) was responsible for the general oversight of the nursing department on (RN #1's) shift. (RN #1) did not report (to the Administrator) any CNA's being non-compliant with providing the resident the required assistance to ensure the safety of the resident..." Continued interview confirmed, "(CNA #1) failed to provide the correct turning technique and failed to provide the correct amount of assistance required for (resident) and the resident fell from the bed (on [DATE]). (RN #1) failed to ensure the required supervision to ensure the safety of (resident). The Administrator confirmed the facility failed to ensure (resident #1) received the required supervision and assistance to prevent the fall on [DATE]. In summary, CNA #1, failed to follow the resident's care plan and obtain the required assistance when turning and attempting to provide incontinence care to the resident, resulting in a fall with injury from the bed on [DATE], at 6:00 a.m. The Immediate Jeopardy was effective from [DATE], through February 20, 2013, and was removed on February 20, 2013. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on February 21, 2013. The surveyor verified the corrective actions by: 1. Reviewing the facility's in-service records to ensure all nursing staff had been educated on neglect, assistance with ADL's, turning and positioning a resident, and non-compliance with assistance levels; 2. Reviewing the facility's in-service records to ensure all nursing staff knew where the residents' care plans are and how to use them; 3. Reviewing the facility's in-service records to ensure all CNA staff had been educated on the electronic care plan system; 4. Reviewing the facility's in-service records to ensure all licensed nursing staff had been educated on and the

Based on medical record review, review of facility investigations, review of facility policy, and interview, the facility failed to ensure the Quality Assurance (QA) Committee implemented a plan to train and educate on the required supervision and safe assistance to prevent a fall for one resident (#1) of eight residents reviewed. The facility's failure to ensure resident #1 was provided the required supervision and safe assistance when turning the bedridden resident resulted in a fall from the bed with multiple bodily injuries and sudden death on [DATE]. The facility's failure placed resident #1 in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death). The Administrator and Chief Nursing Officer were informed of the Immediate Jeopardy in the Conference Room on February 20, 2013, at 1:35 p.m. Substandard Quality of Care was cited under tag F-323 at a scope and severity level of a "J." The findings included: Review of a Root Cause Analysis (no date) revealed, "...What steps...contributed to...the event? Associate usually performed this duty alone...What human factors were relevant to the outcome? One CNA (Certified Nursing Assistant) assisting the resident during rounds. Resident stated that '(CNA #1) moves me kind of fast'...Are there any other factors that have directly influenced this outcome? Resident's wt (weight) was 430# (pounds)..." Continued review revealed a plan for in-services to be completed for Resident assistance requirements for turning and incontinence care and "...educated in the correct lifting/turning procedures..." Review of facility in-service documentation and personnel records revealed the facility failed to provide the planned education and in-service training for using two CNA's to provide repositioning and incontinence care and lifiting/turning procedures. Interview with the CNO on February 15, 2013, at 2:00 p.m., in the conference room, confirmed the CNO began working for the facility in 1998, and has since held various positions, to include: MDS Coordinator, Quality Assurance Director; and most current, CNO. "I personally trained (CNA #1) on using the kardex in November of 2011." Continued interview with the CNO confirmed, "I was the Quality Assurance Director at the time of the resident's fall (on [DATE]). I was aware of the fall and completed a root-cause analysis, which identified (CNA #1) failed to ensure the assist of two people when turning and providing incontinence care to the resident. (RN #1) was required to ensure any nursing staff who failed to provide the assistance required for (resident) was disciplined; and was required to ensure reporting of the non-compliance to administration (CNO especially), to ensure education and follow-up...this did not happen..." The CNO confirmed the facility failed to provide the required supervision and assistance to prevent (resident's) fall on [DATE], and failed to provide the inservices as developed and planned after completion of the Root Cause Analysis. Refer to F-282 (J); and F-323 (J) Substandard Quality if Care. C/O #

Based on medical record review, observation, and interview, the facility failed to provide treatment for [REDACTED].#8. The findings included: Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated August 16, 2011 revealed the resident was at moderate risk for development of pressure sores. Medical record review of the Admission Skin assessment dated [DATE], revealed left heel red and "no areas of apparent skin impairment". Medical record review of a physician's orders [REDACTED]. Apply skin prep let dry. Place bilat feet in (pressure relief boot) while in bed..." Medical record review of the PAR (patient at risk) Notes dated August 23, 2011, revealed, "...wt (weight)...111.2 (pounds)..." Medical record review of the Weekly Wound Observation Report dated August 26, 2011, revealed, "...Pressure Ulcer...Stage II...L (length) 3.6 (centimeters) W (width) 4.2 (centimeters) clear fluid filled blister...Exudate Amount (drainage) none...Comments: Res (resident) admitted (with) bilateral red boggy heels. Post op left hip repair..." Medical record review of a physician's orders [REDACTED]. Pat dry. Apply skin prep. Cover (with) dry gauze. Wrap (with) kerlix. Change daily..." Medical record review of the Treatment Record dated (August, 2011) revealed, "...Clean clear fluid filled blister (with) wound cleaner. Pat dry. Apply skin (prep). Cover (with) dry gauze. Wrap (with) kerlix. Change daily..." Continued review of the treatment record revealed the treatment was initialed by LPN #2 as completed on August 27 and 28, 2011. Medical record review of a facsimile transmittal sheet to the physician dated August 30, 2011, revealed, "...(resident #8) noted to have decline in wound to left heel. Wound has progressed to unstageable Has dark red/purple area to center of wound. Area only opened at top of blister..." Medical record review of the Weekly Wound Observation Report (undated) revealed, "...wound measured on 8/30/11. 4.5 (centimeters) x 6.2 (centimeters) open area at top of blister measures 2.3 (centimeters) in length. Has deep purple area in center of wound that measures 3 (centimeters) x 3 (centimeters). Wound noted to have small to moderate amount of (serosanguineous) drainage. Contacted MD (physician)...cont (continue) current tx (treatment) at this time..." Observation and interview on August 29, 2011, at 10:20 a.m., with Licensed Practical Nurse (LPN) #5, revealed the resident seated in a wheelchair, in the resident's room, with a dressing on the left foot dated August 26, and signed with LPN #3's first initial and last name. Observation on August 30, 2011, at 9:40 a.m., revealed LPN #3 (wound care nurse) providing wound care to the resident's left heel. Continued observation revealed LPN #3 removed the dressing from the left heel and described the wound as follows: an unstageable pressure ulcer, measuring 4.5 cm (centimeters) x 6.2 cm, with a blister open at the top of the wound measuring 2.3 cm in length, with a small to moderate amount of serosanguineous drainage. Continued observation and interview with LPN #3 revealed "that's much worse", (after removing the dressing from the left heel pressure ulcer). Observation and interview on August 30, 2011, at 9:40 a.m., with LPN #3, revealed the resident lying on the bed with a pressure mattress on the bed. Continued observation and interview revealed the pressure mattress setting at 200-250 pounds. (resident's weight documented on August 23, 2011, was 111.2) Interview on August 30, 2011, at 10:40 a.m., with LPN #2, in the Quality of Life Office, with the Director of Nursing present, confirmed the treatment record was signed on August 27 and 28, 2011 indicating the treatment was completed. Continued interview confirmed LPN #2 did not change the dressing on the left foot on August 27 and 28, 2011.