Every finding on record at Avir at Childress

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for the month of April 2026 for 2 days reviewed for weekend RN coverage. The facility failed to ensure they had RN coverage of 8 hours a day, 7 days a week for the following days:04/05/2026 and 04/26/2026. This failure could place residents at risk for inconsistency in care and services. Findings included: Record review of the facility's undated employee roster revealed there were three RNs employed at the facility in April 2026. Record Review of time sheets provided by the ADM for the time from April 1, 2026 – June 28, 2026 revealed the following dates did not have RN coverage for at least 8 hours a day for the following days: 04/05/2026 04/26/2026 In an interview on 7/8/26 at 1:40 pm, the ADM stated the facility had missed a couple of days of RN coverage. When asked about the consequences of not having RN coverage in the building, she stated the LVN cannot do everything, and an RN is needed to ensure quality of care for the residents. She further stated there were things only an RN could do Record review of the facility policy titled Staffing, Sufficient and Competent Staff dated August 2022 revealed the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable and attractive for 3 of 3 food forms (Regular, Mechanical and Alternative) for 1 of 1 (Lunch) meal reviewed for palatability.The facility failed to provide food that was palatable for the lunch meal on 07/06/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.The findings included:During confidential individual interviews 6 of 17 residents voiced concerns related to food palatability, stating the food did not taste good and it was tasteless for most meals. During a confidential individual interview 1 of 17 residents voiced concerns related to food palatability, stating he had to buy snacks to keep in his room due to the food not tasting good. During a confidential group interview 3 of the 6 residents voiced concerns related to food palatability, stated the food did not taste good, it was tasteless.Observation on 07/06/2026 at 1:05 PM the regular diet test tray, mechanical soft tray and alternative test tray arrived at the conference room and was sampled by three surveyors at 1:07 PM with the following results:Regular Meal meatloaf -blandMashed Potatoes-bland, tastelessBroccoli-no issuesroll-no issueshummingbird cake-bland, not fully cooked Mechanical soft/AlternativeFish-no issuesMashed Potatoes-blandBroccoli-no issuesroll-no issueshummingbird cake-bland, not fully cooked.During an interview on 07/06/2026 at 1:07 PM, the DM was asked to try the test tray and apologized for the cake being bland and undercooked, she did not have any concerns related to the other items on the trays. During an interview on 07/06/2026 at 1:10 PM, the ADM was asked to try the test tray. She stated the hummingbird cake tasted like angel food cake without the texture but did not have any concerns related to the other items on the trays. During an interview on 07/08/26 at 9:45 AM, the DM stated the cooks were expected to taste food prior to serving it to residents; however, she was unsure whether this practice was consistently completed. The DM stated she had been the only dietary employee working in the kitchen on 07/06/2026 due to staff call ins. The DM stated the hummingbird cake lacked flavor because she forgot to put the pineapple in the cake. The DM stated the potatoes were instant potatoes and should have been seasoned, however, she couldn't remember if she had seasoned them due to being understaffed and trying to get the food out to the residents in a timely manner. The DM stated she was not aware of residents complaining about the food, she stated she recently got a grievance regarding the temperature but not about the taste. The DM stated she did not routinely conduct meal rounds. The DM stated a potential negative outcome for serving unpalatable food would be residents could lose weight. During an interview on 07/08/2026 at 10:02 AM, [NAME] F stated she had worked in the kitchen for five years and assisted with meal preparations. [NAME] F stated she was unsure whether seasoning had been added to the food because she did not personally add seasoning during food preparation. [NAME] F stated inadequate staffing in the dietary department could contribute to food being prepared in a hurry and could result in missed proper seasonings causing the food to be bland. During an interview on 07/08/2026 at 10:50 AM, the ADM stated the DM was responsible for food palatability. The ADM stated the dietary staff had been trained in food palatability and have completed test trays. The ADM stated the residents had not complained to her recently about the food. The ADM stated a potential negative outcome to the residents with the food not tasting good was they could not eat enough and have weight loss.During an interview on 07/08/2026 at 10:59 AM, the DON stated she had overheard residents complaining of food dissatisfaction, although those concerns had not been communicated directly to her. The DON stated she believed the food quality could be better. The DON said a potential negative outcome for not having tasteful food would be decreased meal consumption and potential loss of weight. Record review of the facility's policy and procedure titled The Dining Experience, not dated, reflected the following:Policy: the dining experience will enhance each individual's quality of life through person centered dining: providing nourishing, palatable and attractive meals that meet the individual's daily needs and preferences Procedure:The director of food and nutrition services will perform meal rounds routinely to determine if the meals are timely, attractive, nutritious and [NAME] the needs and preferences of each individual. The director of food and nutrition services will observe meals for preference, portion sizes, temperature, flavor and accuracy.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure pantry and freezer items were properly stored and closed to air.2. The facility failed to ensure proper hand hygiene and glove use was practiced. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the pantry on 7/6/26 at 10:15 am revealed a large plastic storage bin with loose dry rice in the bottom of the bin and a large plastic scoop in the rice in the bottom of the storage bin. On top of the loose rice and the scoop were 2 large opened to air 25-pound bags of rice in the bucket: The lid to the rice bin was left open to air. In an observation on 7/6/26 at 12:00 pm [NAME] E was observed with her gloved hands to touch various kitchen services, pick up food pans and dishes, get a Styrofoam cup for a resident, picked up the serving utensils, put the serving utensils down on the counter. [NAME] E began putting bowls on the counter, cut the cake into squares and picked up a fork. [NAME] E then began plating the cake using her hand to steady the cake pieces on the fork and place the cake into the bowls. [NAME] E then picked up another bowl, plated the cake, steadied the cake with her hand then touched the bowl. [NAME] E did not wash her hands or change her gloves. In an observation of the pantry on 7/7/26 at 9:15 am, revealed a large plastic storage bin with loose dry rice in the bottom of the bin and a large plastic scoop in the rice in the bottom of the storage bin. On top of the loose rice and the scoop were 2 large opened to air 25-pound bags of rice in the bucket: In an observation on 7/7/26 at 9:20 am, of the freezer revealed one box of taquitos open to air. In an interview on 7/8/26 at 10:45 am, [NAME] E stated she realized she had touched the cake while cutting the cake. She stated she should have washed her hands and changed her gloves between tasks and should not have used her hands to put the cake in the bowls. She stated consequences of this were cross contamination and food borne illness. She stated she was in a hurry. In an interview and a walk through the kitchen on 7/8/26 at 9:50 am, the DM stated she had seen [NAME] E touching the cake with her gloved hands while cutting and plating the cake. The DM stated [NAME] E should not have touched the cake with her hands. She stated the consequences of not washing hands and wearing gloves and touching the cake would be cross contamination for the residents. The DM stated of the bin of rice that the scoop should not have been in the bin and the rice bags should not have been stored on top of the loose rice. She stated the bin should have been closed to air. She stated the taquitos should have been closed to air. She stated if foods were not properly wrapped up or closed to air, this could cause food contamination and sickness to residents. The DM stated she trained the kitchen staff and she had been trained by the dietician in kitchen sanitation and hand hygiene. Record Review of the facility policy and procedure, dated 2023, titled Hand Washing documented employees will wash hands as frequently and as needed throughout the day using proper handwashing procedures. Staff will be educated on the importance of hand washing and retrained and reminded as necessary. Record Review of the facility policy and procedure, dated 2023, titled Bare Hand Contact with Food and Use of Gloves documented single use gloves will be worn when handling food directly. Gloved hands are considered a food contact surface that can become contaminated or soiled. gloves shall be used for only one taskand discarded when soiled or when interruptions occur in the operation. Hands are to be washed before putting on single use gloves Record Review of the facility policy and procedure, dated 2023, titled Dry Storage Areas documented dry storage areas will be maintained to keep food safe and free of infestation or contamination. employees will wash hands as frequently and as needed throughout the day using proper handwashing procedures. Staff will be educated on the importance of hand washing and retrained and reminded as necessary. Record Review of the facility policy and procedure, dated 2022, titled Food Preparation and Service documented cross contamination occurs when disease causing micro-organisms are transferred to food by hands (including gloved hands), food contact surfaces, .Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. employees will wash hands as frequently and as needed throughout the day using proper handwashing procedures. Staff will be educated on the importance of hand washing and retrained and reminded as necessary. Record Review of the facility policy and procedure, dated 2023, titled Food Safety and Sanitation documented all foods must be covered, labeled and dated.Food should be protected from contamination.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 1 of 1 facility observed. Hall 2 contained dried splashed residue on the wall located at the entrance with dusty handrails with cobwebs attached. Flies were present throughout the facility and interfered with residents during lunch time.An anonymous resident had a fly become entangled in her recently styled hair. A bathroom on Hall 3 contained residue at the base of the toilet, peeling paint above the sink and areas of exposed patch material that had not been painted. Fluorescent light fixtures located on Halls 3 and 5 and in the dining, area contained accumulations of dead insects with some insects appearing to still be alive. These failures could affect residents by placing them in an uncomfortable and unsanitary environment.Findings included: During an observation on 07/06/2026 at 10:30 AM dried splashed residue was observed on the wall near the handrail at the entrance of Hall 2. The handrail contained a layer of dust and cobweb extended from the handrail to the wall. During an observation on 07/06/2026 at 11:06 AM, A bathroom on Hall 3 contained residue at the base of the toilet, peeling paint above the sink and areas of exposed patch material that had not been painted. During an interview and observation on 07/06/2026 at 12:00 PM, numerous flies were observed in the dining room during lunch service. Flies repeatedly interfered with two anonymous residents while they attempted to eat, causing residents to swat at the insects. The fluorescent light fixtures in the dining room appeared to be dirty and contained dead insects. The two anonymous residents stated the flies were a problem. During an interview and observation on 07/07/2026 at 9:00 AM, An anonymous resident was observed with a fly repeatedly circling and becoming entangled in her hair. The resident reported she had recently had her hair styled and stated the flies had been bad this year. During an interview on 07/07/2026 at 9:30 AM, the MS stated he was the facility's only maintenance employee and had been absent due to illness. The MS stated multiple work orders remained outstanding, including painting and other maintenance repairs and stated he had been unable to complete all required work. During an observation on 07/07/2026 at 11:30 AM, dried splashed residue was observed on the wall near the handrail at the entrance of Hall 2. The handrail contained a layer of dust and cobweb extended from the handrail to the wall. During an observation on 07/07/2026 at 11:35 AM fluorescent light fixtures located on Halls 2 and 5 contained multiple dead insects, with several insects appearing to still be alive. During an interview on 07/07/2026 at 1:25 PM, the DON stated that all staff were responsible for maintaining a clean and homelike environment. The DON stated housekeeping was responsible for routine cleaning and maintenance was responsible for repairs. The DON stated the facility had only one maintenance employee and he had been sick; she stated a negative outcome of failing to maintain a clean and homelike environment would be a decreased quality of life for residents. During an observation and interview on 07/08/2026 at 10:13 AM, the HK Supervisor stated housekeeping staff were responsible for ensuring resident rooms and hallways remained clean and that maintenance staff were responsible for repairs and lighting maintenance. After observing the residue on Hall 2 and the insects in the light fixtures on Hall 5, he stated those conditions should have been addressed. During an interview on 07/08/2026 at 10:20 AM, HK G stated halls and resident room should be cleaned daily and stated the residue observed on Hall 2 should have been removed. HK G could not explain why the items had not been addressed but stated residents living in an unclean environment could become ill if the cleaning was not addressed. During an interview on 07/08/2026 at 10:50 AM, the ADM stated housekeeping staff were responsible for cleaning the building and maintenance staff were responsible for repairs. The ADM stated the MS had been ill but did not explain why the tasks had not been completed. The ADM stated she was ultimately responsible for ensuring staff fulfilled their duties and stated the potential negative outcomes included illness, allergies and more institutional rather than homelike environment. During an observation on 07/08/2026 at 11:30 AM, dried splashed residue was observed on the wall near the handrail at the entrance of Hall 2. The handrail contained a layer of dust and cobweb extended from the handrail to the wall. Record review of Homelike Environment policy dated February 2021 reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person-centered care that emphasized the resident's comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment and personalized furniture and room arrangements, clean bed and linens that are in good condition.

Based on observation, interview and record review the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for all residents reviewed for activities. A. The activity calendar was not followed. B. There were no daily activities occurring on a regular basis in the facility. C. The activities did not meet the needs of the residents.D. Room visits were not conducted and did not meet the needs of the residents. These failures could potentially place all residents at risk of decreased self-worth, boredom, poor quality of life, depression, behaviors and decreased cognitive function. Findings included: During record review of the activity calendar for July 2026 on 7/6/26 at 11:00 am activities listed for the day for all residents were: Monday 7/6/26 8:30 am Gentle July Stretch 10:00 AM Coloring Club 1:00 PM One to One with [NAME] 3:00 PM [NAME] and Share Tuesday 7/7/26 8:30 AM Rise and Shine Stretch 10:00 AM Puzzle Time 2:00 pm Glamour Shots 3:00 PM Faith and Fellowship Wednesday 7/8/26 8:30 AM Midweek Mobility 10:00 AM Games 4:00 PM UNO In an observation and confidential group interview on 7/6/26 at 10:00 am, seven residents in wheelchairs were sitting outside the front facility door and eight residents were lined up against the walls in the front lobby. There were no activities ongoing in the facility. One resident stated there had been no activities that day. He stated no exercise had been done that morning and there was no coloring activity going on at 10am. He stated There are no activities I love Skip-Bo and dominoes. They have the dominoes, but no one will get them out. He stated There was no puzzle time at 10 am. Another resident stated there had been no activities that day and there were usually no activities any day. Another resident stated there were never any activities and it was boring. In a confidential interview at an undisclosed date and time - one resident stated there were no activities. When asked where the AD was, he stated, He left a few minutes ago. He just drove off into the sunset He stated there were no stretching exercises this am. He stated he would like to have more activities He stated that any kind of activity would be good. He stated there were not even any puzzles out for the residents to do. In a confidential interview , one resident stated There aren't any activities. I'd like to go to the exercise room and do exercise. You have to have a staff in there with you. I can't go in there without the staff. He stated Monday exercise and the coloring had not occurred., He stated he would have liked to do the group exercise if it had occurred. When asked if the AD had ever taken a group of residents to the exercise room he said he had not. In a confidential interview one resident stated there were no exercise or coloring activities done on Monday am. She stated she would have liked to color but the activity did not occur. She further stated the exercise activity for 7/7/26 had not occurred either. In a confidential interview one resident stated there were no activities most days. He stated he and the other residents would sure love to do something. He stated any kind of game would be good. He stated there was nothing to do all day. He stated the AD did not follow the activity calendar. In a confidential interview one resident stated there were no activities done during the day. He stated he likes dominoes and chess. He stated the games were never offered and supplies were never left out for residents to use. In an observation and record review on 7/7/26 at 8:30 am through 8:50 am, the activity calendar listed Rise and Shine exercises. Observations of the facility dining room, lobby and outside area revealed no exercise activities were being done. Residents were observed sitting outside with no activities and in the lobby lined up against the wall. There were no games or coloring supplies, or other activity supplies out in the facility. In an interview on 7/7/26 at 8:55 am, the AD stated he had not done the Rise and Shine activity on this date, but he would when he woke up. He stated he did not do morning exercises or the coloring activity listed on the calendar for 7/6/26. He stated he did do 1-1 room visits on Monday for Residents #11 and #40. He stated he had not been aware of needing to document his room visits until recently, so he did not have all the room visit documentation. When asked what activities he provided on room visits, he stated he just talked to the residents. He stated sometimes he listened to music with them and let them watch videos on his phone. The AD stated he did not see the residents who were not able to get out of bed or speak to him. He stated he had never done a sensory stimulation activity such as lotion rubs with residents who were bedridden. He stated he did not see the bedridden residents who could not talk to him. He said Why would I see the residents who can't talk to me? When the AD was asked what the consequences of not having activities that meet the needs of the residents would do to them, he stated the residents would not get what they need and would be bored and get depressed. In an observation on 7/7/26 at 9:10 am, the AD was observed sitting outside with 2 residents for 10 minutes. There was no resident interaction by the AD. There were no game activity supplies out. Record Review of the In room paperwork dated 7/7/26 at 9:23 am revealed the AD made a one-to-one room visit with Resident #11 in her room and did a puzzle for 45 minutes. Review of in room paperwork for Resident #40 revealed he did a room visit with Resident #40 and had a coloring activity which occurred for 30 minutes. In a confidential interview one resident stated, We don't have much activities, there were no activities yesterday. Bingo is not an activity. She stated she would like to play dominoes, cards, and games. She stated of the stretching exercise listed on the calendar for 7/7/26, it did not occur. She stated there was nothing to do all day. She stated the staff do not leave any activity supplies out for the residents either. In a confidential group interview on 7/7/26 at 10:06 am, the residents' comments about the activity program included the following comments: As far as activities they get very few activities, They would like to more choices and more activities. They would like activities with exercise There was no activity this morning, the AD was not there all the time, he was more a van driver. In a confidential interview one resident stated she likes cards and singing. She stated the facility used to have activities like cards and singing but it had been a long, long time since she had seen anyone doing that in the facility. She stated she would like to get up more and go to the activities, but no one gets her up. She stated she liked bingo but she did not know it was going on yesterday. She stated it was not listed on the calendar. She stated she did not know who the AD was and had never met him. In a confidential interview the one-to-one room visit sheet was reviewed with the resident. The resident was sitting in the lobby and stated there were no activities during the day and the AD did not do any activities. She stated the AD had never been to her room for one to one room activities. She stated this am she did not have any in room activity in her room with the AD. The resident stated she had her own personal coloring book and she had colored so much she needed a new book. She stated all she does every day was go outside in the am until it gets too hot then comes in and watches tv or colors. She stated she needed another color book because all she had was that one book. She stated she would like some animals to color. She stated she would like to ride around, do table games, exercise and have some music and dancing. She stated those activities were never offered. In a confidential interview the one-to-one room visit sheet was reviewed with the resident. The resident stated he had not had a room visit at 9:39 am on 7/7/26 by the AD. Resident #40 stated the AD did not see him in his room today and did not do any in room activities. He stated he had not colored in his room for 30 minutes with the AD. He stated he would like to exercise, go to Bingo and do a lot of different activities. In a confidential interview on 7/8/26 at 10:40 am an employee stated the AD did not put any effort into doing activities. The employee stated the AD leaves the building and was gone for hours. The employee stated the AD does not do activities the residents want to do and he does not follow the activity calendar. In a confidential interview on 7/8/26 at 1:30 pm, one employee stated the AD never does activities for the residents except bingo. The employee stated the AD worked 8-5 Monday through Friday and was not in the building on the weekends. The employee stated there were never any activity supplies left out for the residents. The employee stated the AD would leave the facility during the day and not come back for hours. In an interview on 7/8/26 at 1:40 pm the ADM stated the issues with the activity program were not acceptable and she would make some changes. Record review of the facility policy titled Activity Programs dated 2018, documented: Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Activities offered are based on the preferences of the resident .The activity program includes facility organized group activities, independent and assisted individual activities.Activities are scheduled 7 days a week.Our activity programs consist of individual, small group and large group activities designed to meet the interests of the residents.All activities are documented in the resident record. Findings include:

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #33) reviewed for infection control. The facility failed to ensure CNA B performed hand hygiene between glove changes during incontinence care for Resident #33. This failure could place residents at risk for cross contamination and infection. The findings included: Record review of Resident #33's face sheet dated 07/08/26 revealed a [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with the following diagnosis: urinary tract infection (bacteria in the urinary system), cellulitis (bacterial infection in skin), and need for assistance with personal care. Record review of Resident #33's annual MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 13 which indicated his cognition was intact. The MDS further revealed Resident #33 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene and Resident #33 was always incontinent of bladder and bowel. Record review of Resident #33's care plan, undated, revealed a focus area: The resident bowel and/or bladder incontinence r/t impaired mobility, resident refuses to let staff get her up to bedside commode when is actually capable to do so with an intervention/task: .clean peri-area with each incontinence episode with an initiation date of 06/09/26. During an observation incontinence care on 07/07/26 at 2:13 PM, CNA B washed her hands with soap and water, put on clean gloves and wiped Resident #33's groin and buttocks. CNA B removed her gloves and washed her hands with soap and water. CNA B then put on clean gloves and grabbed the dirty brief under Resident #33 with her right hand. CNA B then stated, I should not have done that and removed her right-hand glove and replaced it with a clean glove with no hand hygiene between the glove change. CNA B then removed the dirty brief and CNA C helped put a clean brief under Resident #33. During an interview on 07/07/26 at 2:24 PM, CNA B and CNA C stated they were trained to perform hand hygiene between glove changes. CNA B and CNA C stated they had a skills check-off recently but could not remember the exact date. CNA B stated after she caught her mistake with how she wiped the left buttocks once, then it went downhill from there and she continued to mess up. CNA B and CNA C stated a risk to the residents was they could get a UTI and it was an infection control risk. During an interview on 07/08/26 at 10:03 AM, the Corporate Nurse D stated she called corporate and was told the facility did not have a specific Infection Prevention and Control Policy and the facility used the Infection Preventionist Policy for Infection Control and a facility document titled, Infection Control by Systems was provided. During an interview on 07/08/26 at 10:05 AM, the DON stated she expected the CNAs to perform hand hygiene between glove changes. The DON stated CNA B should have taken off both gloves, performed hand hygiene and continued with the care. The DON stated the CNAs recently had a skills check off and the date it was done would be on the check-off sheets. The DON stated she did not know why CNA B did not perform hand hygiene between all glove changes. The DON stated a potential risk for the residents was infection or poor hygiene. During an interview on 07/08/26 at 10:20 AM, the ADM stated she expected the CNAs to follow the policy and procedure for hand hygiene and not break infection control. The ADM stated CNA B could have been nervous with state in the building. The ADM stated she did not know when the staff was last trained for infection control. The ADM stated a potential risk to the residents was infection and skin breakdown from not being cleaned properly. Record review of the facility document titled, CNA Orientation/Competency Checklist for CNA B, dated 03/16/26 revealed initials for completing Handwashing Technique Record review of the facility document titled, In-Service Training report dated 04/16/26 reflected the following: Subject: Handwashing CNA B's name and signature was noted. Record review of the facility document titled, In-Service Training report dated 05/13/26 reflected the following: Subject: Handwashing CNA B's name and signature was noted. Record review of the facility's policy titled, Infection Preventionist with a revised date of 09/22, reflected the following: Policy Statement: The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program. Record review of the facility document titled, Infection Control System, dated 05/25 reflected the following: .Completion of hand hygiene.is to be completed. Record review of the facility policy titled, Handwashing/Hand Hygiene, undated reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and Implementation:.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to tother personnel, residents, and visitors.Indications for Hand Hygiene1. Hand hygiene is indicated:.g. immediately after glove removal.

Based on observations, interviews, and record reviews, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 Resident's personal refrigerators reviewed for food safety (Resident #35) in that:The facility did not have a system in place to assist residents in cleaning and maintaining their personal refrigerators to ensure safe food handling and prevent consumption of spoiled and/or expired foods.The personal refrigerator in Resident #35's refrigerator contained unknown substances that were not labeled or dated and left uncovered. There was lunch meat that expired on 06/09/2026.These failures could put residents at risk of foodborne illness from consuming spoiled food.Findings included:Record review of Resident #35's electronic face sheet dated 07/06/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included but not limited to delirium due to known physiological condition (triggers affects thinking, memory, awareness and focus), Alcohol induced persisting dementia (cognitive impairment cause by long term heavy alcohol consumption), generalized anxiety disorder (excessive fear or worry), and acute gastric ulcer with hemorrhage (bleeding that occurs with a sudden sore develops in the stomach lining). Record review of Resident #35's Quarterly MDS dated [DATE], under Section C Cognitive Patterns, revealed a BIMS score of 11, indicating the resident was moderately cognitively impaired.Record review of Resident #35's Careplan dated 06/16/2026 revealed resident had potential for pressure ulcers with an intervention to have good nutrition. During an observation and interview on 07/06/2026 at 10:47 AM, Resident #35's room contained a personal refrigerator. Observation of the refrigerator revealed multiple perishable food items, including uncovered, unlabeled and undated red substances and purple substances. Further observation revealed a wrapped Taco Bell burrito had become hardened and dried as well as packed ham lunch meat with an expiration date of 06/09/2026. Resident #35 stated he did not know who was responsible for cleaning or monitoring his refrigerator and was unable to state how long the food items had remained in the refrigerator.During an interview on 07/08/2026 at 10:13 AM, HK Supervisor stated housekeepers were expected to inspect and clean residents' refrigerators every three days and discard spoiled food items when identified. The HK Supervisor stated housekeeping staff were not responsible for labeling or dating food items and was unable to identify which department or staff members were responsible for ensuring food items were properly labeled, dated and monitored for safety. The HK Supervisor further stated he was unaware of a facility policy or procedure in addressing personal refrigerators. The HK Supervisor stated the failure to clean resident refrigerators could result in residents consuming spoiled food potentially getting sick. During an interview on 07/08/2026 at 10:20 AM, HK G stated he was not aware that housekeeping was expected to clean out residents' refrigerators and did not know of any policy regarding personal refrigerators. He stated a negative outcome for residents to have spoiled food would be they could get sick by eating rotten food.During an interview on 07/08/2026 at 10:41 AM, LVN I stated she had been employed by the facility for several years and believed responsibility for monitoring and maintaining personal refrigerators located in residents' rooms was shared among facility staff. LVN I stated that, historically, the nursing department had monitored resident refrigerators for expired or spoiled food items, however, under current administration responsibility for monitoring personal refrigerators had not been assigned to any specific department or staff member. LVN I stated a possible negative outcome for not monitoring refrigerators could result in residents eating spoiled food, getting sick. Interview with ADM pm 07/08/2026 at 10:50 AM, the ADM stated no specific staff member, or department had been assigned responsibility for routinely inspecting, cleaning, or monitoring personal refrigerators located in residents' rooms. The ADM stated she was in the process of implementing rounding to residents' rooms to ensure the residents' environments remained safe and sanitary. The ADM stated that failure to monitor food stored in residents' refrigerators could result in residents consuming spoiled and expired food placing them at risk of getting sick. Record review of facility policy Food Brought by Family/Visitors dated March 2022 reflected the following:Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance residents' choice and a homelike environment with the nutritional and safety needs of the residents. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable.Perishable foods are stored in re-sealable containers with tightly fitted lids in a refrigerator. Containers are labeled.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Med Cart A) reviewed for medication storage. The facility failed to ensure Med Cart A was locked when unattended. This failure could place residents at risk of medication errors or drug diversion. The findings included: During an observation on 07/06/26 at 11:45 AM, Med Cart A was observed by the nursing station between the 500 and 600 Hallways unlocked and unattended. No staff members were observed within eyesight of the medication cart, and two female residents were sitting in the common area within eyesight of the medication cart. During an interview on 07/06/26 at 11:50 AM, MA A stated she had been trained to lock her medication cart when she walked away from it. MA A stated she had her hands full when she walked away and she forgot to lock the cart. MA A stated she thought she was last trained in March 2026 regarding medication cart security. MA A stated a potential risk to the residents was they could get into it [medication cart]. During an interview on 07/08/26 at 10:05 AM, the DON stated she expected the MA's or the nurses to lock their carts when they walked away from them. The DON stated MA A probably got nervous and that was why she forgot to lock her medication cart. The DON stated the pharmacy did a training with the MA's and the nurses regarding medication administration and medication storage. The DON stated the pharmacist was last at the facility in June 2026 and went over medication storage, but MA A was not working that day and missed the training. The DON stated a potential risk to the residents was they could get any of the medications. During an interview on 07/08/26 at 10:20 AM, the ADM stated she expected the medication carts to be locked when staff walked away from them. The ADM stated she did not know the last time staff was trained regarding medication storage. The ADM stated she did not know why MA A left her medication cart unlocked when she walked away from it. The ADM stated a potential risk to the residents was anybody could get in there and get anything they wanted and it could have a bad outcome. Record review of the facility policy titled, Medication Labeling and Storage with a revised date of 02/23 reflected the following: Policy heading: The facility stores all medications and biologicals in locked compartments.Only authorized personnel have access to keys.Policy Interpretation and Implementation:Medication Storage.4. Compartments (including, but not limited to.carts.) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 Residents (Resident #33) reviewed for incontinent care. The facility failed to ensure Resident #33 was wiped using the correct technique during incontinent care performed by CNA B. This failure places the residents at risk of urinary tract infections or skin breakdown.Findings included: Record review of Resident #33's face sheet dated 07/08/26 revealed a [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] with the following diagnosis: urinary tract infection (bacteria in the urinary system), cellulitis (bacterial infection in skin), and need for assistance with personal care. Record review of Resident #33's annual MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 13 which indicated his cognition was intact. The MDS further revealed Resident #33 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene and Resident #33 was always incontinent of bladder and bowel. Record review of Resident #33's care plan, undated, revealed a focus area: The resident bowel and/or bladder incontinence r/t impaired mobility, resident refuses to let staff get her up to bedside commode when is actually capable to do so with an intervention/task: .clean peri-area with each incontinence episode with an initiation date of 06/09/26. During an observation on 07/07/26 at 2:13 PM, CNA B provided incontinent care for Resident #33 with the help of CNA C. CNA B washed her hands with soap and water and cleansed Resident #33's groin with wipes. CNA B turned Resident #33 on her side and changed her gloves, using ABHR between the glove change. CNA B wiped Resident #33's left buttocks towards the vaginal area with one wipe. CNA B then wiped Resident #33's left buttock away from the vaginal area and wiped the right buttock away from the vaginal area. CNA B wiped the upper buttocks area in the middle away from the vaginal area but did not wipe the anus. During an interview on 07/07/26 at 2:24 PM, CNA B and CNA C stated they were trained to wipe the buttocks area from front to back [away from the vaginal area]. CNA B and CNA C stated they were trained regularly with in-services quarterly and stated they were due for one soon. CNA B stated she wiped towards the vaginal area once because she was at an odd angle and it threw her off. CNA B and CNA C stated a risk to the residents was they could get a UTI. During an interview on 07/08/26 at 10:03 AM, Corporate Nurse D stated the facility did not have a specific policy for urinary incontinence, but she would be able to provide a copy of the skill check off that was used for the CNAs. During an interview on 07/08/26 at 10:05 AM, the DON stated she expected the CNAs to wipe the resident's buttocks in the correct direction, away from the vaginal area. The DON stated the CNAs recently had a skills check off and the date it was done would be on the check-off sheets. The DON stated she did not know why CNA B wiped towards the vaginal area when wiping Resident #33's buttock. The DON stated a potential risk for the residents was infection or poor hygiene. During an interview on 07/08/26 at 10:20 AM, the ADM stated she expected the CNAs to follow the policy and procedure for incontinent care and wipe the residents from front to back and to wipe all areas of the buttocks. The ADM stated CNA B could have been nervous with state in the building. The ADM stated she did not know when the staff was last trained for incontinence care. The ADM stated a potential risk to the residents was infection and skin breakdown from not being cleaned properly. Record review of the facility document titled, Competency Assessment Perineal Care with a revised date of 02/18 reflected the following: A) Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.D) Steps in the Procedure:.For a female resident.e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Record review of the facility document titled, CNA Orientation/Competency Checklist for CNA B, dated 03/16/26 revealed initials for completing Toileting Assist.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 16 residents (Resident #35) reviewed for accidents and hazards.The facility allowed Resident #35 to possess smokeless tobacco in his room. This failure could affect the residents at the facility by placing them at risk of injury.Findings included:Record review of Resident #35's electronic face sheet dated 07/06/2026 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included but not limited to delirium due to known physiological condition( triggers affects thinking, memory, awareness and focus), Alcohol induced persisting dementia (cognitive impairment cause by long term heavy alcohol consumption), generalized anxiety disorder(excessive fear or worry) and acute gastric ulcer with hemorrhage(bleeding that occurs with a sudden sore develops in the stomach lining). Record review of Resident #35's Quarterly MDS dated [DATE], under Section C Cognitive Patterns, revealed a BIMS score of 11, indicating the resident was moderately cognitively impaired.Record review of Resident #35's Care plan dated 06/16/2026 revealed resident enjoys using smokeless tobacco with a goal to adhere to Tobacco policies of the facility and resident will not suffer injury from unsafe smoking practices. Record review of Resident #35's clinical file revealed that no smokeless tobacco assessment or evaluation was in the file. During an interview and observation on 07/06/2026 at 10:47 AM, Resident #35 was lying in his bed. On his bedside table there was a can of smokeless tobacco. Resident #35 stated he was allowed to have smokeless tobacco in his room.During an interview and observation on 07/06/2026 at 12:40 PM, Resident #35 was not in his room, the tobacco was located on his bedside table. During an interview on 07/08/2026 at 10:41 AM, LVN I stated she had seen Resident #35 with the tobacco in his room and reported it but was told the ADM was allowing Resident #35 to have smokeless tobacco in his room. LVN I stated she had worked at the facility for many years, and this was new because in the past residents were not allowed to have tobacco in their room.During an interview on 07/08/2026 at 10:59 AM, the ADM stated she allowed Resident #35 to have the tobacco in his room and stated she did not read her facility's policy and admitted she was wrong by allowing Resident #35 to have the smokeless tobacco. The ADM said she would be looking to change the policy. The ADM said not having an evaluation or following facility's policy could put residents at risk for injury. Resident #35 had smokeless tobacco and said didn't read her own policy but a resident that wanders in a room could possibly get hurt.During an interview and observation on 07/08/2026 at 11:30 AM, the DON stated she was aware of Resident #35 having tobacco in his room and felt it could be a resident right. She looked in Resident #35's clinical file and stated he did not have a smokeless assessment but said she had learned something new and would be implementing a smokeless tobacco assessment. Record review of facility's policy Smoking Policy-Residents dated October 2022 reflected the following: Policy statement: This facility shall establish and maintain safe resident smoking practices. The resident will be evaluated on admission to determine if she or he is a smoker or nonsmoker. If a smoker or smokeless tobacco user, the evaluation will include current level of Tobacco consumption, method of tobacco consumption. A resident's ability to smoke or chew tobacco safely will be re-evaluated quarterly, upon significant change and as determined by the staff. Residents may not have or keep any smoking articles including tobacco except when are under directs supervision.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety.The facility failed to ensure stored food was properly labeled and dated.The facility failed to ensure dry goods and frozen items were not open to air.The facility failed to ensure lidded tubs and other containers for dry goods were clean and sanitized.These failures could place residents at risk of food borne illness.Findings Included:An observation of the pantry on 02/12/26 at 06:51 AM revealed the following:A bag of macaroni noodles open to airA plastic storage container of cereal that had greyish marks on the outside that were grimy and sticky to touchA plastic, lidded, rectangular tub of a white flour-like substance with no label or date and a scoop lying on top of the flour-like substance.A plastic, lidded, rectangular tub of a rice-like substance with no label or dateA plastic, lidded, rectangular tub with no label or date that was grimy and sticky to touch and contained a zipped bag with no date which contained an open box of sugar cubesAn empty, plastic, lidded, rectangular tub labeled sugar that was grimy and sticky to touchA wheeled, plastic bin containing breadcrumbs half in and half out of a large bag with no label or dateA plastic container labeled freeze dried chives, open to air, 1/3 full of a white granular substance.A plastic container labeled paprika open to airA plastic container labeled garlic herb seasoning open to airA plastic container labeled rotisserie chicken seasoning open to airA plastic container labeled cloves open to airA plastic container labeled garlic bread sprinkle open to airA plastic container labeled celery seed open to airA plastic container labeled sage open to airA plastic container labeled basil open to airA plastic container labeled chili powder open to airTwo plastic containers labeled cinnamon open to airA cardboard container of seasoning open to airA plastic tub of peanut butter with brownish smears of what appeared to be peanut butter around the lid and sides of the tubAn observation of the freezer on 05/12/26 at 07:01 AM revealed two small, clear, plastic bowls containing what appeared to be vanilla ice cream open to air with no label or date.An observation of the refrigerator on 05/12/26 at 07:03 AM revealed a small, clear, plastic cup full of a red liquid and covered with plastic wrap with no label or date.During an interview on 05/12/26 at 09:18 AM [NAME] C stated all kitchen staff were responsible for keeping the containers in the pantry clean. He stated they had a daily, weekly, and monthly cleaning schedule posted on the wall in the kitchen.During an interview on 05/12/26 at 09:25 AM DA A stated all kitchen staff were responsible for labeling and dating food. She stated she thought cooks were responsible for cleaning the plastic storage containers in the pantry. She stated a possible negative outcome of not keeping the containers clean and not labeling and dating food was residents could get sick.During an interview on 05/12/26 at 09:48 AM DM stated all staff were responsible for labeling and dating food. She stated she usually had a daily, weekly, and monthly cleaning schedule hanging in the kitchen, but her bulletin board had fallen recently, and she had not rehung the cleaning schedules. She stated residents could get sick if food was not labeled and dated properly. DM stated she was the person responsible for ensuring the plastic storage containers in the pantry were clean. She stated when the storage containers were empty she ran them through the dishwasher.During an interview on 05/12/26 at 11:17 AM DA C stated all kitchen staff were responsible for labeling and dating food and keeping the plastic storage containers in the pantry clean. She stated residents could get sick if food was not labeled and dated properly and storage containers were not kept clean.During an interview on 05/12/26 at 11:26 PM [NAME] D stated cooks were responsible for cleaning the plastic storage containers in the pantry. She stated the containers were cleaned when they became empty. [NAME] D stated all kitchen staff were responsible for labeling and dating food. She stated residents could get food borne illnesses if food was not properly labeled and dated and if storage containers were not kept clean.Record review of facility policy titled Dry Storage Areas and dated 2023 revealed the following: . Dry storage areas will be maintained to keep food safe and free of infestation or contamination. 1. storage areas will be kept clean. 7. Staff will maintain the storeroom according to the following directions. b. Canned and dry foods should be labeled with date of receipt. d. The storeroom will be cleaned on a regular basis.Record review of facility policy titled Food Safety - Director of Food and Nutrition Services' Responsibilities revealed the following: . The director of food and nutrition services should assure all of the following: . 2. Regulatory requirements for food safety and sanitation will be met. 3. Sanitary conditions will be maintained in the food storage, preparation and serving areas. 4. All refrigerated and frozen foods will be stored and handled properly. All dry and staple food items will be stored properly. 10. Cleaning schedules will be posted and followed.Record review of a monthly cleaning schedule provided by DM and dated 2020 revealed the following item: Clean & Sanitize Ingredient BinsRecord review of facility policy titled Food Safety and dated 06/11/14 revealed the following: Food will be handled, stored, prepared and transported in a safe manner. 9. Open package food . is to be stored in clean air tight containers, labeled, and dated an stored appropriately.

Based on observation, interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 6 residents (Resident #1) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #1 for oral/dental status on his annual MDS assessment. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings include: Record review of Resident #1's admission record, dated 01/28/26, revealed a [AGE] year-old male resident who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Guillain-Barre syndrome (a rare, serious, but usually temporary condition where your immune system mistakenly attacks your own nerves, often after a viral or bacterial infection), lack of coordination and need for assistance with personal care. Record review of Resident #1's annual MDS assessment dated [DATE] revealed she had a BIMS of 12 indicating he was cognitively intact. Section L Oral/Dental Status revealed none of the above were present was checked off. Record review of Resident #1's comprehensive care plan, undated, revealed there was not a focus area for dental care. During an observation and interview on 01/28/26 at 2:45 PM Resident #1 was talking with the surveyor and the surveyor noted brown/discolored teeth. Resident #1 stated it had been a while since he had seen the dentist, and he probably needs to be put back on a list to see the dentist due to some pain in his mouth. During a phone interview on 01/28/26 at 4:10 PM, the MDS Nurse stated she had completed the annual MDS for Resident #1. The MDS Nurse stated Resident #1 had told her he did not have any pain in his mouth and did not need anything, but he would not let the MDS Nurse look in his mouth. The MDS Nurse stated she must have been in a hurry, but she should have checked off the box that stated, Unable to examine. The MDS nurse stated checking off unable to examine in Section L would have triggered a care plan decision to be made by other staff to do a care plan in Section V. The MDS nurse stated a potential negative outcome to the resident was he could have an infection [in his mouth]. During an interview on 01/28/26 at 4:53 PM, the Interim ADM stated he did not think the MDS nurse marked the MDS incorrectly for Resident #1's dental status. The Interim ADM stated he understands that she was not able to see any issues with Resident #1's dental status so she marked no issues. The Interim ADM stated he would look into it as he could see both sides and was not sure exactly how the MDS should have been marked. The Interim ADM stated a potential negative outcome was a care are not being added to a care plan. During an interview on 01/28/26 at 5:38 PM, the Interim ADM stated after discussion, he does think the MDS nurse marked the dental status for Resident #1 incorrectly. The Interim ADM stated the facility did not have a policy regarding the MDS assessment and stated the facility follows the RAI guidelines from CMS. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025 revealed the following: Section L: Oral/Dental StatusL0200:Dental:Item Rationale - Health-related Quality of Life-Poor oral health has a negative impact on:Quality of life, overall health, and nutritional status.-assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes.Steps for Assessment -.6. Oral examination of residents who are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues.Coding Instructions:.-Check.unable to examine: if the resident's mouth cannot be examined.

Based on interview and record review, the facility failed to ensure the right to receive written or verbal notice of a room change before the change was made for 1 of 6 residents (Resident #2) reviewed for resident rights. The facility failed to ensure Resident #2's Responsible Party (RP) received verbal or written notice prior to a room change. This failure could place residents at risk for being displaced without notice and/or reason in order to accommodate other individuals.Findings included: Record review of Resident #2's admission record, dated 01/28/26 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses: hemiplegia and hemiparesis following a cerebrovascular disease (paralysis), peripheral vascular disease (poor circulation) and major depressive disorder (mood disorder). Record review of Resident #2's annual MDS dated [DATE] reflected Resident #2 had a BIMS score of 04 indicating severe cognitive impairment. Record review of Resident #2's progress note, dated 12/11/25 written by LVN A stated, .resident moved to [a room] for contact isolation precautions. Resident aware. Awaiting new orders from physician. During a phone interview on 01/28/26 at 2:32 PM, LVN A stated she was the nurse who moved Resident #2 to an isolation room back in December 2025. LVN A stated she did not remember contacting the family regarding the room change. LVN A stated the DON had stated she would contact the family, but she did not. LVN A stated it was ultimately her responsibility to contact the family regarding the room change. LVN A stated a potential negative outcome to the residents with moving rooms and not notifying family was the resident was at a higher risk for falls. During a phone interview on 01/28/26 at 3:45 PM, Resident #2's RP stated she did not receive a call from the facility notifying her of a room change back in December 2025. The RP stated she was not aware of a room change for Resident #2 until the family went to visit Resident #2 and she was in a different room. During an interview on 01/28/26 at 4:42 PM, the DON stated she expected family or a resident who was cognitively intact to be notified of a room change right away if it was an unexpected room change. The DON stated the nurses were trained to notify the residents RP for room changes and stated the nurse who changed the resident's room should have contacted the family. The DON stated she did not know why the family was not notified regarding Resident #2's room change. The DON stated the family would think there were risks to the residents' changing rooms but did not give an exact answer. During an interview on 01/28/26 at 4:53 PM, the Interim ADM stated the nurses were trained to contact the residents' RP when changing rooms. The Interim ADM stated he did not know why Resident #2's family was not contacted prior to her moving rooms back in December 2025. The Interim ADM stated a potential negative outcome to the residents was that the residents gets used to another room and may get confused or the family may go to the facility and not be able to find their loved one. Record review of the facility's policy titled, Change in Resident's Condition or Status, with a revised date of April 2025, reflected the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (.resident rights.)Policy Interpretation and Implementation:.4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:.c. there is a need to change the resident's room assignment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents observed for infection control practices. CNA B performed Resident #1's catheter care without placing a gown for EBP. This deficient practice could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old male resident admitted to the facility originally on 3/03/2022 and readmitted on [DATE] with diagnoses to include urinary tract infection with onset date of 9/17/2025, benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of the prostate gland that causes urinary issues). Record review of Resident #1's clinical record revealed his last full MDS was a quarterly completed 9/01/25 listing him with a BIMS of 9 indicating he was moderately cognitively impaired, he had a functionality of requiring set-up/clean-up for most of his activities of daily living, and he did not require a catheter at that time. Record review of Resident #1's care plan with admission date of 9/17/25 revealed the following: Resident has a bladder disorder requiring foley catheter (a flexible tube inserted into the blader through the urethra to drain urine) and is at risk for UTI. During an observation on 11/25/2025 at 10:11 AM CNA B performed catheter care for Resident #1. CNA B was noted observing the sign posted on Resident #1's door for EBP while placing gloves before entering the resident's room. This surveyor noted a PPE station placed on top of the unoccupied roommate's dresser. CNA B proceeded to perform catheter care to include cleaning the urinary tube, the resident peri and rectal area, and placing a new brief before replacing Resident #1's shorts and covers and ensuring he was comfortable. She then performed her final hand hygiene, gathered the used supplies, and exited Resident #1's room. CNA B never placed a PPE gown to maintain EBP and prevent contamination. During an interview on 11/25/2025 at 10:25 AM CNA B reported that Resident #1 should be on EBP because he has a catheter and stated, That was my mistake. I am used to them having a PPE station outside their room and I just missed the sign on his door. CNA B reported she did not see the PPE station inside Resident #1's room. CNA B stated, I know better. CNA B reported that she had been trained on EBP by the ADON who was no longer the infection control officer and that she (CNA B) was not sure who the current infection control officer was because they have had several management changes recently. CNA B reported that if EBP was not followed then they could get urine on themselves and could spread infection. During an interview on 11/25/2025 at 10:58 AM the DON reported that the facility has a new ADON that was currently completing the infection control training, that the previous ADON was no longer available to do the training. The DON reported that she expects her staff to place the proper PPE like a mask and gown when EBP was needed such as with catheter care. The DON reported that if the proper PPE was not used with EBP, then cross contamination would occur, and staff could carry infection from one resident to another. During an interview on 11/25/2025 at 11:27 AM ADON A reported that she would be the infection control nurse and would train staff when she completes her training. ADON A reported that she would expect staff to wear gloves and gowns when performing care such as catheter care. ADON A reported if a staff member did not follow EBP, then they could carry an infection from one resident to another resulting in cross-contamination. Record review of the facility provided Enhance Barrier Precautions (EBP) educational posting placed in each resident's room that required Enhance Barrier Precautions (EBP) revealed the following information provided for visitors and staff: Enhanced Barrier Precautions.Providers and staff must also:Wear gloves and gowns for the following High Contact Resident Care Activities--Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Record review of the facility provided policy titled, Enhanced Barrier Precautions date 2001, revealed the following: Policy Statement:Enhanced barrier precautions (EBP) are utilized to reduce the transmission of multi-drug-resistant organisms (MDRO's) to residents. Policy Interpretation and Implementation:3. Examples of high-contact resident care activities requiring the use of gown, and gloves for EBP's include:g. device care or use, (central ling, urinary catheter.

Based on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to ensure RN coverage for 51 days of the last 6 months. This failure could place residents at risk of harm due to being left without supervisory coverage for coordination of events such as emergency care and disasters. Findings Included: Record review of the facility payroll-based journal for the first quarter of fiscal year 2025 revealed the facility did not have RN coverage on November 16, 17, and 30 and December 1, 14, 15, 28, and 29 of 2024. Record review of facility payroll revealed the facility did not have RN coverage for January 20; February 8, 9, 12, 13, 18, 20, 21, 22, 23, 24, 25, 26 ,27, and 28; March 3, 4, 5, 6, 7, 8, 9, 15, 16, 22, 23, 29, and 30; April 1, 2, 3, 4, 5, 6, 12, 13, 19, 26, and 27; May 3, 4, 10, and 11 of 2025. During an interview on 05/13/25 at 11:20 AM ADM provided the last quarter RN hours and stated he did not have any RN hours for the rest of the time beginning on April 1st. He stated his only RN was the DON and she started on April 7th and worked M-F. He stated he was planning to get this tag because he knew he was lacking RN hours. During an interview on 05/13/25 at 11:27 AM ADM stated he had been advertising for a weekend RN position and a regular RN position and had not had anyone apply. He stated the only weekend day DON had worked since starting was Easter Sunday, April 20, 2025. He stated not having RN coverage could negatively impact residents. ADM stated, Resident's health would be at risk if something happens, something could get missed as far as assessment or needing to go to the hospital. During an interview on 05/14/25 at 09:12 AM LVN C stated it was important to have an RN in the building each day. She stated, Because as an LVN we need that reference point. Their skill set is higher than ours they have a larger scope of practice. We do need the reference point if we have a question or are wondering about something. It is like asking your parent or your boss. During an interview on 05/14/25 at 09:30 AM ADON stated it was important to have an RN in the building every day. She stated, You need a reliable RN in case you second guess yourself. During an interview on 05/14/25 at 09:38 AM DON stated it was important to have an RN in the building each day. She stated, I just think you need that higher level of educated person to be available. She stated she and ADM shared the responsibility for ensuring RN coverage. She stated, We keep updating the ad (for RN positions available) and even saying PRN. We have tried everything. When asked if the facility could use agency RNs, DON stated, It is not in the budget, they can charge up to 100 dollars an hour for an agency RN. During an interview on 05/14/25 at 09:43 AM ADM stated he was responsible for ensuring RN coverage. Record review of facility policy titled Staffing and dated 9/28/23 revealed the following, . 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Record review of facility policy titled Director of Nursing Services and dated 2006 revealed the following: . 2. The Director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: . g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure general cleanliness was maintained. B. Ensure kitchen equipment was in good repair. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: In an observation on 5/12/25 at 10:32 am, of the kitchen revealed the plastic drawers holding utensils was grimy and sticky to the touch. There were food crumbs on the outside and inside of the drawers. The stainless-steel prep table shelves had crumbs and food debris on the lower shelves. The toaster had crumbs in the bottom of the toaster and was sticky to the touch. Observation of the door of the walk-in cooler revealed the door handle was black and sticky to the touch. The walk-in pantry had food crumbs and trash in the floor. In an observation on 5/12/25 at 10:35 am, the walk-in cooler thermometer read 45 degrees. The milk cartons and juice container were warm to the touch. In an interview and observation of the walk-in cooler on 5/12/25 at 11:00 am revealed the walk-in cooler thermometer read 44 degrees. The DM stated, The cooler had not been cooling right. We have thrown so much food out because it goes bad. Every time it quits working, I call the MD. The repairman came out and did something, but it still did not work right. We need a new one. The DM stated the consequences of not having a cooler that worked correctly was a lot of spoiled food. In an observation of the walk-in cooler on 5/12/25 at 12:40 pm revealed the walk-in cooler thermometer read 45 degrees. In an observation of the walk-in cooler on 5/12/25 at 2:40 pm revealed the walk-in cooler thermometer read 45 degrees. In an interview and observation of the walk-in cooler on 5/13/25 at 8:40 am revealed the walk-in cooler thermometer read 44 degrees. [NAME] F stated, The cooler keeps freezing up. It has not been cooling right. They keep bandaging it up. The milk goes bad real fast. We have had to throw out a lot of food because it does not cool right. We need a new cooler. In an observation on 5/13/25 at 9:45 am, of the kitchen revealed the plastic drawers holding utensils was grimy and sticky to the touch. There were food crumbs on the outside and inside of the drawers. The stainless-steel prep table shelves had crumbs and food debris on the lower shelves. The toaster had crumbs in the bottom of the toaster and was sticky to the touch. Observation of the door of the walk-in cooler revealed the door handle was black and sticky to the touch. In an observation of the walk-in cooler on 5/13/25 at 2:40 pm revealed the walk-in cooler thermometer read 44 degrees. In an interview on 5/13/25 at 3:30 pm the DM stated of the cleaning that she expected all staff to clean as needed. She stated the consequences of not cleaning were food borne illness and contaminated food. In an interview on 5/14/25 at 12:50 pm, the MD stated last night the cooler went out. He stated the repairman was called and was there currently. The MD stated he thought the facility had had trouble with the cooler for the past 2 weeks. The MD stated about 2 weeks ago the repairman came out and worked on the cooler. The next day the cooler did not work. The repairman took the defrost timer off and it worked for a couple of days. The MD stated the cooler is really old and it needed to be replaced. He stated the cooler was as old as the Mayflower. The MD stated he was not responsible for repairing the cooler. He stated any time the DM tells him it is not working he calls a repairman. In an interview on 5/14/25 at 1:20 pm the ADM stated he was not sure what they would do with the cooler. He stated the facility rented two refrigerators today. Record review of the Refrigerator and Freezer log for April 2025 revealed the cooler temperatures were above 41 degrees on 4/2/25,4/3/254/12/254/13/25, 4/28/25, 4/29/25 and 4/30/25. Record review of the Refrigerator and Freezer log for May 2025 revealed the cooler temperatures were above 41 degrees on 5/1/25,5/2/25, 5/6/25, 5/7/25. Record review of the repair invoice for the walk-in cooler dated 4/3/25 revealed the cooler was checked. There was no further information on the invoice. Record review of the repair invoices dated 5/2/25, 5/5/25 and 5/6/25 revealed onsite maintenance tasks on the cooler were done. Record review of the cleaning sheets for the kitchen had been signed as completed for all tasks. Record review of the policy titled Cabinets, Drawers and Shelving dated 2018, revealed the facility will maintain cabinets drawers and shelving free of food particles and dirt to minimize the risk of food hazards. Cabinets, drawers and shelving will be cleaned a minimum of every week or as needed. Record review of the policy titled Food Handling dated June 1, 2019, revealed the facility will maintain all cold prepared items at a temperature of 41 degrees or below. Check the temperature of all refrigerators to make sure the temperature stays below 41 degrees. When temperatures are outside the designated range, notify maintenance. Record review of the policy titled General Kitchen Sanitation dated 2018, revealed: Clean all food pre areas, food contact surfaces, and equipment. Keep food contact surfaces free of encrusted grease deposits and other accumulated soil. Clean nonfood surfaces as necessary.

Based on observation, interview and record review the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for all residents reviewed for activities. A. The activity calendar was not followed. B. There were no daily activities occurring on a regular basis in the facility. C. The activities did not meet the needs of the residents. D. Room visits were not conducted and did not meet the needs of the residents. The facility's failure to provide an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being could potentially place all residents at risk of decreased self-worth, boredom, poor quality of life, depression, behaviors and decreased cognitive function. Findings include: During entrance to the facility on [DATE] at 10:25 am, seven residents in wheelchairs were sitting in the lobby. There were no activities ongoing in the facility. In a confidential interview a facility employee stated the AD had taken a resident to a clinic physician appointment. During record review of the activity calendar for May 2025 on 5/12/25 activities listed for the day for all residents were: Monday 5/12/25 8:30 AM Outside Visit 9:30 AM Room visits 10:00 AM Kick-off Nursing Home Week 2:00 PM Residents Car Wash Tuesday 5/13/25 8:00 AM Morning Chat 8:30 AM Walk the Halls 9:30 AM Puzzle/Word Search 2:00 PM Minute 2Win It Wednesday 5/14/25 8:30 AM Humpday News 9:30 AM Room Visits 2:00 PM Pick A game 3:30 PM McCurley's Bible Talk In an observation and a confidential interview on 5/12/25 at 11:00 am a resident was in bed with no light or tv. He stated he was bored so he slept a lot because there was nothing to do. He stated he would attend activities if he were asked but he never knew when or where they would be. He stated no one ever asked him if he wanted to go to any activities. He stated he needed assistance to get out of bed. He stated he had not had any room activities from anyone. He stated he had no special activity requests and liked a variety of activities. In an observation of the facility on 5/12/25 at 2:10 PM, there were no activities being conducted in the building. There was no car wash activity outside. In an observation on 5/12/25 at 3:00 pm the AD was observed alone in her office. In an observation of the facility on 5/13/25 at 8:30 am the AD was observed walking the halls of the facility alone. The AD had a Hawaiian skirt on and was passing out flower necklaces. There were no additional activities observed to include or incorporate the residents into this activity. In a confidential interview on 5/13/25 at 9:40 am, one employee stated The residents are bored. You never know when the activities will occur or if the calendar will be followed. If you try to suggest an activity to the AD she does not listen. During a confidential group interview on 5/13/25 at 10:00 a.m., 8 residents confirmed the activity calendar is not followed. All resident's confirmed activities are not being held. All residents stated they are bored. All residents agreed the AD does not have activities that meet their needs. All residents agreed they had not been asked what they would like to do and if they did express a desire to play Bingo, they had been told they could not. All agreed they love Bingo but had not had Bingo in a long time. All residents agreed the AD does not like to do Bingo and that was why Bingo had not been offered in a long time. One resident stated she would like to play dominoes and had been told other residents would like to play dominoes as well, but it had never been scheduled. She stated she had her own dominoes and she and another resident play dominoes in her room. All residents stated they would like to exercise but it had never been offered. All residents agreed they did not have any activities on the weekends or go on outings. All residents agreed they would like to go on outings and have more activities on the weekends. All agreed the AD would rather sit outside and talk which is what she usually did. All residents stated the AD will give them coloring pages, but they did not want to color much. Residents stated activities were never announced nor did anyone come to tell them there was an activity about to start. All 6 residents said they would like more exercising activities. Residents also stated that they would like some field trips since Covid is over. All residents stated there had not been any outings in over a year. Residents also said that activities got canceled a lot. Residents stated there is no church on Sundays and they would like church offered to them. The Activity calendar was reviewed with the group. None of the residents knew what the activities called Making Rounds, Lets do Experiments or Walk the Halls were. The group stated they had not participated in those activities. the group stated table games in the lobby, room visits and morning chat had not occured. In an interview on 5/13/25 at 3:15 pm the AD was asked to review the activity schedule. The AD stated Outside Visit was where she and the residents sat on the porch of the facility. She stated Making Rounds was just her going up and down the halls saying hello and seeing if the residents needed anything. She stated of Trivia she would read a short paragraph and asked questions, and the residents guessed the answer. She stated 'Let's do Experiments' was setting up a microscope and the residents could look through the microscope at an Alka Seltzer and see it fizz. When asked if the activity listed on 5/12/25 of Outside Visit, Room visitsor Residents Car Washhad occurred, the AD stated there were no activities done that day. When asked what the Resident Car Wash was, she stated the residents were going to wash the staff cars. The AD stated Walk the Halls was an activity where she would walk around the halls and make faces at the residents. She stated the residents had not walked the halls with her. The AD stated 'Bingo had not been offered in a long time because the tv was out and calling Bingo was hard. The AD stated she did not offer any exercise classes and stated she did not have a reason for not offering exercises. The AD stated the bible studies offered on Wednesday and Thursday afternoons were provided by visitors. The AD stated the Walmart trips did not include residents. She stated she took the money and a list of what they wanted and got it for them. She stated she planned on starting some outings for the residents in the future. The AD stated of the activities listed on Saturday and Sunday were tv programs and there were no activities on the weekends. The AD stated she had not encouraged all residents to come to the activities and had not allowed time for them to get up. She stated she did activities with the residents who were already in the dining room or the front lobby. The AD stated she had not been documenting on the residents who participate in activities or who she did room visits with. She stated she just found out she was supposed to document the room visits. When the AD was asked what the consequences of not having activities that meet the needs of the residents would do to them, she stated the residents would not get what they needed and would be bored and get depressed. In an observation of the facility on 5/14/25 from 9:25 to at 9:55 am there were no activities being conducted in resident rooms for room visits. In a confidential interview on 5/14/25 at 10:00 am one resident, who was listed on the AD's list of room visits, stated he had never had any room visits from the AD. He stated if there were exercise classes he would get up and go. He stated he had never been asked to join any activities and stayed in bed most of the time. He stated he was thinking of getting arm weights so he could exercise in bed since there are no exercise classes. In a confidential interview on 5/14/25 at 10:20 am, one resident, who was listed on the AD's list of room visits, and a family member who was visitng, stated he had not been offered any room activities and had not had any activities in the room since his admission. The family member confirmed the resident had not had any room visits since admission. In confidential interviews on 5/14/25 from 10:10 am to 10:30 am, 4 residents from the list provided by the AD for room visits, were asked if they had ever had any room visits from the AD or had any activities in the room. None of the residents interviewed knew who the AD was or had been offered any room activities. Record review of the facility policy titled Activity Programs dated November 2021, documented: Activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are geared to meet individual needs. Activities consist of individual and small group activities that stimulate the cardiovascular system and assist with range of motion such as exercise, movement to music Intellectual activities, outings, at least one evening activity is offered per week, at least 2 group activities per day are offered on Saturday and Sunday, at least 4 group activities offered per day Monday through Friday, Activities are provided to residents who are bedbound or visually impaired . Individualized activities are provided that reflect the schedules and choices of residents.

Based on interview and record review, the facility failed to provide an activities program directed by a qualified professional for 1 of 1 Activity Director reviewed for staff qualifications . The facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. Findings Include: During an interview on 5/13/25 at 3:15 pm, the AD stated she had not become a certified AD and had not started the classes to become certified. The AD stated she started the job as the AD on 9/12/24. The AD stated she had never been an AD before and had not had any experience in activities. The AD stated the facility would not pay for the classes up front and would reimburse her once she completed the classes. She stated she had not had the money to start the classes. She stated she hoped to start the classes in September. When asked if anyone was supervising her as the AD, she stated the ADM was her direct supervisor. She stated no one had told her there was a time limit on beginning the class. The AD stated a few people had tried to help her plan activites and stated if she has any questions, she could ask the DM who a previous AD. was The AD stated she usually did not ask her any questions. The AD stated the consequenses of not having a certified AD would be residents not having the activities they need. In an interview on 5/14/25 at 8:20 am, the DM stated when the AD started the job, she had tried to assist the AD by telling her how she set up activities, but the AD did not want to hear it. The DM stated the AD wanted to do it her way. The DM stated the last time she had done any activities with the residents was a week before the AD started her job as the AD in September of 2024. The DM stated the corporate office had told her to stay in the kitchen and did not want her doing activities. The DM stated she did not supervise the AD. In an interview on 5/14/25 at 8:40 am, the ADM stated the DM is a certified DM and she supervises the AD and helps her as needed. He stated the facility was working off the DM activity license. He stated the AD had not had any AD classes. Record Review of the Activity Director's personnel file indicated this employee was hired at the facility as the AD on 9/3/24 and started working on 9/12/24. Record review of the facility document titled Job Description Activity Director, dated 5/20/21, revealed: Under the supervision of the ADM, the AD develops, coordinates, and implements activity programs for the personal enjoyment and benefit of the residents in accordance with current federal, state and local standards to ensure the spiritual, emotional, recreational and social needs of residents are met on an individual basis. Must be able to obtain the qualifications outlined in the federal. state regulations. Record review of the facility document titled Activity Programs- Staffing, dated August 2006, revealed: Our activity programs are staffed with personnel who have the appropriate training and experience to meet the needs and interests of each resident. our activity programs are under the supervision of a qualified professional who is licensed or eligible. and has completed a training course approved by the state.

Based on observations, interview, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #33) of 12 residents reviewed for pharmacy services and 1 of 1 treatment cart and 1 of 1 medication room. 1. The facility failed to ensure LVN B did not leave medications unattended with Resident #33. 2. The facility failed to ensure the medication room did not contain expired medications and expired IV tubing and the treatment cart did not contain expired medications. These failures could place residents at risk of harm due to not receiving needed medication, receiving expired medication; receiving medication at the wrong time or in the wrong dose; or receiving another resident's medication. Findings Included: 1. Record review of Resident #33's face sheet dated 05/13/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinsonism (conditions that affect the ability to move and live independently), need for assistance with personal care, and unspecified dementia (breakdown of thought process). Record review of Resident #33's quarterly MDS completed on 02/25/25 revealed the following: Section C Cognitive Patterns: Resident #33 had a BIMS score of 12 which indicated moderately impaired cognition. Section N Medications: Resident #33 was receiving antidepressant, antianxiety, diuretic, opioid, and antiplatelet medications. Record review of Resident #33's care plan dated 04/01/25 revealed he exhibited behaviors not directed at others. The goal for this was Resident will not harm self and/or others. Resident #33 was noted to be receiving anticoagulant (blood thinner) medication and staff were to administer medication as ordered. He was noted to be receiving psychotropic medication for generalized anxiety disorder. Resident #33 was noted to have cognitive loss and staff were to explain their actions as they provided care. Record review of Resident #33's active orders as of 05/13/25 revealed he was to receive the following medications in the morning and throughout the day as indicated: -allopurinol tablet 100 mg by mouth once a day in the morning -aspirin 81 tablet mg by mouth once a day in the morning -buspirone tablet 5 mg by mouth twice a day in the morning and the evening -apixaban tablet 5 mg by mouth once a day in the morning -furosemide tablet 20 mg by mouth once a day in the morning -magnesium oxide tablet 400 mg by mouth twice a day in the morning and the evening -meclizine 12.5 mg by mouth twice a day at lunch and dinner -meclizine 25 mg tablet by mouth twice a day in the morning and the evening -omeprazole capsule delayed release 20 mg by mouth once a day in the morning -potassium chloride packet 20 mEq once a day in the morning -carbidopa-levodopa tablet 25-100 mg by mouth twice a day in the morning and the evening Record review of Resident #33's MAR for the morning of 05/13/25 revealed he received the following medications from LVN B: allopurinol tablet 100 mg, aspirin 81 tablet mg, buspirone tablet 5 mg, apixaban tablet 5 mg, furosemide tablet 20 mg, magnesium oxide tablet 400 mg, meclizine 25 mg tablet, omeprazole capsule delayed release 20 mg, potassium chloride packet 20 mEq, and carbidopa-levodopa tablet 25-100 mg. During an observation on 05/13/25 at 08:28 AM Resident #33's room door was closed and LVN B was standing at the medication cart outside his door. During an observation on 05/13/25 at 08:31 AM Resident #33's closed door was knocked on and opened by this surveyor. Resident #33 was seated in his w/c next to his tray table. On the tray table was an opaque plastic up 3/4 full of orange liquid and a small opaque plastic medication cup containing 3-4 small pills. During an observation on 05/13/25 at 08:32 AM LVN B entered Resident #33's room, glanced at his tray table, and walked back out of his room. During an interview on 05/13/25 at 09:39 AM LVN B stated she was the nurse who gave Resident #33 his medications this morning. She stated, I stand at his door, and he came and shut it behind me, but I stand there until he takes them (the medications). He likes to take them one at a time. I generally try to stand there 'til he is done. She stated there was a possible negative outcome to leaving medications behind closed doors with residents. She stated, But when he closed the door that is when you went in, and I went in behind you. We don't leave medications with residents and move on. During an interview on 05/13/25 at 09:10 AM DON stated it was never okay for a nurse to leave medications with a resident. She stated nurses were to stay with residents until the medication was consumed. DON stated she did a training on this subject on 04/15/25. During an observation and interview on 05/13/25 Resident #33 was in the therapy room doing bicep curls. When asked if the nurse leaves his medication with him instead of watching him take it, he stated, Yes. She trusts me. During an interview on 05/13/25 at 09:50 AM ADON stated it was never okay to leave residents unsupervised with medications. She stated, They can forget to take it, it can sit there and somebody else might take it, they can be double dosed or take it at the wrong time of the day. During an interview on 05/13/25 at 10:02 AM DON stated if residents are left behind closed doors alone with their medication They might not get their medication and that can cause ill effects to the resident and another resident might get the medication which could cause ill effects to that resident. During an interview on 05/14/25 at 09:12 AM LVN C stated it was never okay to leave medications with residents unsupervised. She stated, They might choke on it, they might not take it, could put it in their pocket and what if at night they get their meds and find that one from morning in their pocket? They could take a double dose. And what if it is blood pressure medicine. No, girl, that is bad. We gotta watch them take the medicine. Record review of facility policy titled Administration Procedures for all Medications and dated 6/1/2022 did not directly address nurses remaining with residents until medications are swallowed but it revealed the following: . To administer medications in a safe and effective manner. Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide. J. After administration, return to cart . Record review of staff in-service dated 04/15/25 revealed the following: Topic: Medication administration: Remain with resident until all medications have been taken. Do not leave unattended Instructor(s): [name of DON] RN DON The signatures section of the in-service revealed LVN B signed the in-service on 04/15/25. 2. On 05/13/25 at 09:30 AM, an observation of the medication room was conducted with ADON. 64 - 5ml normal saline syringe was found with expiration date 02/28/25 and 03/31/25. Two IV tubing one with expiration date 12/15/22 and one with expiration date 11/18/21. During an interview on 05/13/25 at 09:35 AM with ADON, she stated there should be no expired medications in the medication room. She stated anything that was expired should be thrown away. She stated the expired normal saline syringes and the IV tubing was just missed. She stated the medication room was checked a few days ago. She stated all staff had been trained and it was the nurse's responsibility to monitor medications in the medication room. On 05/13/25 at 10:00 AM, an observation of the treatment cart was conducted with LVN B. Two 5ml normal saline syringes with expiration date 03/31/25 and one with expiration date 02/28/25. During an interview on 05/13/25 at 10:05 AM with LVN B, she stated there should be no expired medications on the treatment cart. She stated any expired item needs to be thrown away or replaced. She stated she has had training on checking the treatment cart for expired medications. During an interview on 05/14/25 at 08:40 AM with the DON, she stated med room and carts were checked monthly by the pharmacist and weekly by the night nursing staff. She stated staff have been trained. She stated expired meds need to be thrown away to prevent giving expired meds to residents. She stated there was no reason why expired meds should be left in medication room. She stated the potential negative outcome could be ill effects to a resident. During an interview on 05/14/25 at 08:54 AM with the ADM, he stated expired meds should be thrown away. He stated expired normal saline could grow bacteria and be harmful to the resident. He stated all staff have been trained. He stated nursing was responsible for checking medication and treatment carts and medication room. He stated it was scheduled for the night shift nurse once a week. He stated any nurse can check the medication room and medication and treatment carts. He stated the potential negative outcome could be normal saline could cause infection especially going into the circulatory system. Record review of the facility-provided policy titled, Storage of Medications, revised November 2020, revealed: Policy - The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 2 carts (medication cart, treatment cart) reviewed for medication storage. The medication cart had undated insulin pen. The treatment cart had undated wound care supplies. These failures could place residents at risk of receiving expired medications. The findings included: On 05/13/25 at 09:15 AM, an observation of the medication cart was conducted with LVN C. One insulin pen was found in top drawer opened with no date. During an interview on 05/13/25 at 09:20 AM with LVN C, she stated all opened multiuse insulin pens should have the date they were opened. She stated she did not know why the pen was not dated. She stated she had been trained to dated insulin pens at the time they were opened. She stated the potential negative outcome was you do not know how long it's been in medication cart and could give expired insulin to resident. 05/13/25 at 10:00 AM, an observation of the treatment cart was conducted with LVN B. Two open bottles of wound cleanser were found with no open date. One bottle of povidone-iodine 10% solution was found opened with no open date. During an interview on 05/13/25 at 10:05 AM with LVN B, she stated all items opened should have an open dated at the time they were opened. She stated she was not aware the wound cleaner or povidone-iodine 10% solution did not have an open dated. She stated she does not know when they were open. She stated she has been trained to date items at the time it was opened. During an interview on 05/14/25 at 08:40 AM with the DON, she stated insulin pens should be dated when opened, any multiuse supplies (wound cleanser or povidone-iodine) should be dated when open. She stated med room and carts were checked monthly by the pharmacist and weekly by the night nursing staff. She stated staff have been trained. She stated there was no reason why supplies in medication cart were not dated. She stated the potential negative outcome could be ill effects to a resident. During an interview on 05/14/25 at 08:54 AM with the ADM, he stated all items opened should have an open date written on it. He stated all staff have been trained. He stated nursing was responsible for checking medication and treatment carts and medication room. He stated it was scheduled for the night shift nurse once a week. He stated any nurse can check the medication room and medication and treatment carts. He stated the potential negative outcome could be not knowing how long it's been the cart and medications may not work how it's supposed to especially insulin. Normal saline could cause infection especially going into the circulatory system. Record review of the facility-provided policy titled, Storage of Medications, revised November 2020, revealed: Policy - The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices for each resident to prohibit accidents for 1 of 22 residents (Resident #22) reviewed for accident supervision and assistance devices. The facility failed to inform the physician of a resident with new onset of altered mental status that continued throughout the day. Resident #22 who was classified as a High Risk for Falls was confused and repeatedly trying to get out of his bed or chair during the day. The failure of the facility's system to notify the physician of the resident's mental status, the DON of this change, and lack of supervision and intervention by the facility staff members, ultimately resulted in the resident having a second fall within 24 hours at 7:25p.m.on [DATE]. The resident sustained [REDACTED]. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This lack of supervision of residents with significant changes places all of the 37 residents identified at risk for falls in imminent danger of significant injuries that could lead to death. Findings include: Record review of the Resident #22's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Review of the 14 day MDS assessment dated [DATE] documented that Resident #22 had some short and long term memory problems. It documented a score of 4 in the section relating to mood indicating little interest in doing things, and feelings of depression. There were no notations of behaviors. The assessment indicated the resident required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, toileting and bathing. It documented that resident used a wheelchair for mobility. It documented that there was not a need for a pain assessment to be conducted. There was no notation of any falls in this assessment. Reviews of the nurse's notes for Resident #22 indicate that on the date of [DATE] the resident was alert and assisted up to the wheelchair for evening meal by staff members. Resident #22 denied any discomfort at that time. On [DATE] at 4:50 a.m., the resident's bed alarm was going off and the resident was found sitting on the floor mat with the call light in reach. When the resident was asked what happened, his reply was the resident was trying to get to his pickup truck, that he was having car trouble. The resident further stated. "I haven't been drinking tonight." LVN 3 attempted to orient resident to time and place. An 8 cm long by 2 cm wide abrasion was noted to left side of back. No other injuries were noted. The resident was assisted from the floor to the bed. Two of the resident's doctors were notified at this time. The next entry is at 10:00 a.m. on [DATE] "....resident continuing attempting to get out of bed this AM without assistance, this nurse(LVN 4)re-directed resident multiple times without improvement ... ...abrasion with blue bruising noted to left back, small bruises x 2 noted to left abdomen side and small amount of dried blood noted to left elbow area ... " The following entry in the resident record was at 7:25 p.m. on [DATE], and stated that CNA 6 called LVN 5 and LVN 1 to the resident room. The resident was noted lying supine on the floor beside the chest of drawers. There was blood noted in a pool around the resident's head. The right leg was noted with external rotation. The resident was alert and answering questions appropriately. The resident indicated pain to the right leg. The hematoma to the back of the head was noted - unable to determine where the blood was coming from, an ambulance was called at 7:28 p.m. The indwelling urinary bag was attached to the bed and the inflated balloon of the indwelling urinary was lying in the floor. There was blood noted on the tip of the penis and the report was written on the transfer sheet to the hospital ER. Review of the facility's incident report on [DATE] shows that Resident #22 was found on the floor of his room at 7:25 p.m. CNA 6 immediately notified LVN 5. The resident was found in his room in the supine position with his head near the dresser, the fall mat in place, the indwelling urinary catheter bag remained attached to the bed and the indwelling urinary catheter was pulled out of the resident and lying on the floor with the balloon inflated. The resident was noted to have blood to back of his head with a hematoma. The nurse noted external rotation of the right lower extremity, and the resident was complaining of pain to the right lower extremity. The ambulance was called to transfer the resident to the hospital emergency room at this time. Summary of the facility investigation report says the witness statements show that the bed alarm was on, but did not alarm. It was tested three times after the fall and did sound. Fall mat was in place and the side rails were up. At 6:00 p.m. the resident was in the dining room for the evening meal, he was upset with his wife and told her to leave. He was fed by staff and put to bed. Review of the Care Plans for Resident #22 shows care plans for the following problems/needs: -I am not as mobile as I used to be but still want to remain as independent as I can, My skin is fragile I take aspirin and Plavix. It indicated that the resident has problems with skin tears and bruising. -I need ? side rails to assist with turning and repositioning and to establish my boundaries. -I have multiple problems that all affect my ability to walk. I have a history of and/or the potential to fall. - I require assistance with all my activities of daily living related to my weakness from cholecystectomy and volume depletion. Review of the Treatment Flow sheets for Resident #22 indicated that the bed alarm is checked every shift as well as the fall mat beside the bed. All shifts have been initialed including the 10:00 p.m. to 6:00 a.m. on [DATE]; the day after the resident had been transferred out of the facility. Review of the Fall/Risk Assessment for Resident #22 shows that on [DATE] the score was 16 and again on [DATE] the score was also a 16. Any score on this assessment that rates higher that a 10 indicates a High Risk for Falls. During an observation on [DATE] at 6:00 p.m., Resident #22 was observed in the dining room for the evening meal, seated in the wheelchair and being encouraged with the meal by the staff members. Observation of Resident #22's bedroom on [DATE] at 4:27 p.m. revealed an adjustable hospital bed that was in the low position, ? side rails were in the elevated position, and there was a floor mat beside the bed. A bed alarm was hanging on the side rail and a call light attached to the curtain several feet away. During an interview with CNA 6 on [DATE] at 4:35 p.m., CNA 6 reported that he was providing care for another resident who was a neighbor to Resident #22 when he heard Resident #22 yelling. CNA 6 entered the room and found the resident lying on the floor with blood pooled around his head. CNA 6 then called for the nurse. The resident was found in front of the dresser. He was not moved and first aid was initiated. The resident was responding appropriately. CNA 6 said the bed alarm was on, but not working, "The nurse had to hit it hard to make it work." This was the only alarm on the resident. In another interview at 5:59 p.m. on [DATE], CNA 6 stated he brought Resident #22 out of the dining room sometime after 6:00 p.m., and put the resident in bed. The next time CNA 6 saw Resident #22 was around 7:15 p.m. when he was yelling. During an interview with LVN 3 on [DATE] at 2:15 p.m., LVN 3 stated that she was working the 10:00 p.m. to 6:00 a.m. shift and caring for Resident #22 on [DATE]. LVN 3 said that Resident #22 fell at approximately 4:30 a.m. The bed alarm was going off and she was called to the room by a CNA. Another LVN (LVN 10) was with her, and they found the resident sitting on the floor on a fall mat. When asked about any changes in his orientation, the LVN said it was unusual that the resident was talking about a pick-up. LVN 3 continued to say that this resident is usually asleep while she is at work and is able to answer all of her questions appropriately. LVN 3 talked to the nurse in the emergency room about Resident #22's confusion and to the on-call physician about his fall. She also sent a fax to another physician informing of the fall and that the resident was looking for his pick-up, but did not actually address the new onset of change in mental status. LVN 3 told LVN 4 of the fall and asked LVN 4 to call the resident's spouse during shift change at 6:00 a.m. LVN 3 was asked about the disorientation that Resident #22 was experiencing and LVN 3 said she had told the Registered Nurse in the emergency room about this when she called the on-call doctor. LVN 3 continued to say that this is usually reported to the on-coming nurse and put in the 24 hour report. She stated, "I probably should have told them." During an interview with LVN 4 on [DATE] at 2:30 p.m., LVN 4 said that she had provided care for Resident #22 on the 6:00 a.m. to 2:00 p.m. shift on [DATE]. LVN 3 had told her that Resident #22 was confused and slid out of bed. The resident had an abrasion to his left back, and she sent a communication to the physician. LVN 3 told her that the resident was saying that he needed to get his pickup fixed. While caring for Resident #22 he was trying to get up out of bed multiple times. When LVN 4 was asked if she notified the physician about the resident's confusion and trying to get out of bed, she stated, "I probably should have, but I didn't." During an interview with LVN 5 on [DATE] at 4:35 p.m., LVN 5 said that Resident #22 had an unwitnessed fall at approximately 7:30 p.m. on [DATE]. LVN 5 was talking with LVN 1 in the hallway of the facility. CNA 6 shouted out for them to come down to where he was. They went into Resident #22's room and found him lying on his back in the floor in a big pool of blood around his head with his right leg externally rotated. When LVN 5 asked the resident what happened he told her that he could not move his right leg. She reported that the resident was able to move his arms and left leg. She also noticed that the indwelling urinary bag was still attached to the bed and the indwelling urinary catheter with inflated balloon was pulled out of the resident and was lying on the floor. LVN 5 filled out transfer papers for the resident and stayed with him until the ambulance came. The fall mat was noted to be on the floor and alarm on the bed by LVN 5. During a follow-up interview on [DATE] at 5:55 p.m., LVN 5 said that at 2:30 p.m. on [DATE] Resident #22 was trying to climb out of bed, he was trying to find his pick-up. Normally the resident is "with it "according to LVN 5. When asked if she thought she should have contacted the doctor about the change in mental status she said, "I probably should have called the doctor, but I didn't." An additional telephone interview was completed on [DATE] at 5:00 p.m. with LVN 5. During this interview LVN 5 was asked about the mental status of Resident #22 during her shift; she said the resident was telling her he was going to get his pick-up. At 2:30 p.m. Resident 22's bed alarm was going off, and she was able to get him laid down with the help of an aide. It happened again later, so they got the resident up. LVN 5 said that she was told about Resident #22's falls and abrasions when she came on shift. In an interview with LVN 1 completed on [DATE] at 4:30 p.m., LVN 1 revealed that CNA 6 came and got herself and LVN 5. They found Resident #22 on the floor with his feet towards the bed, and the indwelling urinary catheter bag still attached to the bed. The indwelling urinary catheter with balloon still inflated, was lying on the floor. The resident was alert, conscious and talking. There was blood on the floor by his head and he had blood in his hair on the right side. A hematoma was noted on the right side with a laceration. They placed an ice bag on his head. In an interview with the CRN(Corporate RN) she said that Resident #22 had fallen on Monday, [DATE], at 7:30 p.m. Resident #22 was transported to the hospital and had a hip fracture. He had surgery on [DATE] in the morning and never came out of the anesthesia. He was a DNR. She said the nurse on the floor said the alarms were going off and when they went to the room he had gotten up out of bed and fallen. He had a hematoma to one side of his head, but no open wound. Blood was noted on the floor. When the resident got up he pulled out his indwelling urinary catheter. He was awake and alert - his level of consciousness was the same as before the fall. They got him an ice pack and called the ambulance. His wife was called. When a staff member was delivering a lab specimen to the hospital on Tuesday afternoon, they found out that he did not wake up from anesthesia. The DON looked in the resident room today and there was a fall mat in the room. The bed alarm worked for the DON. The CRN reported that Resident #22 had both a bed and personal alarm on at the time of the fall. In an interview with the DON on [DATE] at 4:05 p.m.,the DON revealed that Resident #22 had been in the facility since March. On Monday evening ([DATE] around 7:30 p.m.) the resident ate dinner in the dining room. After dinner he was put to bed by CNA 6. CNA 6 found the resident on the floor at 7:25 p.m. and had LVN's 1 and 5 come to the room. The resident was found with his feet toward the bed, head towards the dresser. His indwelling urinary bag was still hooked to the bed and the indwelling urinary catheter with the balloon inflated was lying on the floor having been pulled out of the resident. A hematoma was noted to the right side of the head and a pool of blood was on the floor. They noticed external rotation of his right lower extremity. 911 was called and he was transported to the local hospital. He was admitted with a hip fracture and had surgery the following day. He passed away after surgery. She further stated that Resident #22 had a bed alarm and fall mat in place. She stated the bed alarm was not working. In an interview with the DON on [DATE] at 4:00 p.m., she said that she did not receive any incident report about Resident #22's fall during the night shift. The night nurse had given it to the 6:00 a.m. to 2:00 p.m. nurse to call the family and complete. There was no documentation on the 24 hour report of his fall or confusion. She was not made aware of his change in mentation until after his fall on the evening of [DATE]. Review of the 24 Hour Report/ Change of Condition Report for [DATE] had no mention of any changes with resident #22 until the evening shift. It stated, "Resident fall sent to ER." Review of hospital records for Resident #22 received on [DATE] showed that the resident was alert and confused at 8:15 p.m. on [DATE] according to the nurse's notes. Another entry at 9:45 p.m. on [DATE] states that the resident is alert, oriented to self and wife only, confused. Physician notes from [DATE] at 8:04 a.m. indicated the resident has had recent bouts with frequent urinary tract infections and required some hospitalization . The resident has been in the nursing home but was actually getting close to discharge. He got up yesterday without any assistance and fell which resulted in a displaced right femoral neck fracture of the right hip. Physician notes from [DATE] state the doctor was called to see Resident #22 who had surgery that day for a right hip fracture. He had not done well since the surgery. Blood pressure had been low. Urine output had also been minimal. He was a DNR. Resident #22 expired at 8:32 p.m. the note stated, "The family had been made aware of this possible complication in an elderly patient and understood that this might happen and seemed to very understanding." Review of the facility policy titled - Reporting/Investigation Resident Accidents/Incidents dated [DATE] states the following: All accidents/incidents involving residents must be reported to the administrator or his/her designee. Review of the facility policy titled - Change in a Resident's Condition or Status dated [DATE] states the following: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: c. A reaction to medication d. A significant change in the resident's physical/emotional/mental condition e. A need to alter the resident's medical treatment significantly i. Instructions to notify the physician of any changes in the resident's condition The facility administrator was notified on [DATE] at 6:30 p.m. that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 8:05 p.m. The Plan of Removal was accepted on [DATE] at 5:55 p.m. The facility took the following actions to remove the IJ: 1. Nursing staff will check that all interventions that are care planned are in place and properly functioning. 2. Fall risk assessments on all residents will be updated 3. All quarterly risk assessments will be updated the week the MDS is due 4. The RAC nurse will notify the DON/ADON if the assessments are not being done 5. In-service staff on appropriately filling out Fall Assessments - anti-slip socks, fall mat, personal alarm, bed alarm, physical therapy evaluation, cradle mattress 6. Shift to shift report will be given away from the nurse's station and family interruptions either in the family room or medication room 7. 24 hour report monitored daily by DON/ADON/RAC or combination of all 3 depending upon who is present in the building 8. All pertinent information happening on 8 hour shift will be responsible for being put on the 24 hour report - significant labs, changes in LOC, changes in resident's physical condition, any new medication changes 9. The DON/ADON/RAC will pick up the 24 hour report on Saturday and Sunday and check the documentation on the weekends. 10. The 24 hour report is filed in the DON office 11. Contact physician with current vital signs, any changes in LOC, adverse effects of medications, lab abnormalities if available and neuros if appropriate. 12. Any falls resulting in an obvious significant injury will be transferred immediately. 13. In-service on change of condition, notifying physician, proper use of 24 hour report, proper use of alarms and functioning starting with the ,[DATE] shift followed by ,[DATE] shift. 14. In-service training on change of condition on resident to include the following: changes in LOC, changes in v/s, abnormal labs, adverse effects of medications, etc. 15. In-service all non-nursing personnel on who to alert in the event they find a resident has fallen 16. The charge nurse for that resident will be held responsible for notifying the physician of any and all incidents in regards to that resident. Per policy except in emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status 17. Nurses will initial each shift for proper alarm functioning. 18. In-service to check for batteries, placement, lights flashing, and sound functioning of bed alarms. 19. Any changes of condition/risk for falls will be placed on the 24 hour report and passed on to all nurses coming on. The nurse will be expected to make the necessary interventions at this time. The DON/ADON/RAC will review the 24 hour report and follow up to ensure interventions were done. If further issues arise the Regional Nurse will be contacted. 20. The 24 hour report is used to communicate changes to nurses in regards to residents medical or mental condition, new admission, changes in medication regiment, lab values beyond the norm, changes in behavior, any significant illness or change in v/s or LOC, fall with or without injury, etc. 21. All medical emergencies requiring transport to the hospital the ADM/DON will be notified. 22. All other issues will be discussed in the morning stand up meeting when the DON goes over the 24 hour report 23. In-service staff on properly reporting any falls, injuries, that they witness or se on a resident to the nursing department while insuring the safety of the resident 24. In-service all staff on change of condition and who they are to contact each time 25. In-service all staff on reporting immediately any changes to MD and responsible party 26. In-service staff on correct way to fill out incident and accident form 27. Compliance rounds to be made by DON/ADON daily comparing list of alarms to the list on Matrix 28. Supervision of staff to insure that they are monitoring the alarms and checking for proper functioning 29. All interventions for falls are kept on the nurses treatment record to be checked every shift 30. Out of cycle Quality Assurance and Assessment on falls 31. DON/ADON/RAC will review all clinical records for a resident with a fall 32. Compliance rounds will be checked to make sure that batteries are in the personal alarms, alarms sound, turned on, switched on 33. All falls will be followed up in QAA for 6 months Record review of the in-service for the dates of [DATE] and ,[DATE] indicate that seven staff members have been in-serviced on change in condition and neglect. A checklist of all residents showing that fall assessments had been updated and all prescribed fall prevention equipment was in place and functioning, was provided by the DON on [DATE] at 11:10 a.m. for review. Record reviews of the additional 10 residents added to the resident sample were completed on [DATE]. The proper incident reports had been filled out for these residents who had falls in the last 30 days. There were care plans in place for fall risk on all of these residents and updated fall risk assessments. Each of these 10 resident rooms were checked to ensure that all equipment to prevent falls was in place and in working order. In an interview with LVN 1 on [DATE] at 5:40 p.m. she said that she had been in-serviced on the promptness of responding to alarms, use of fall mats, documentation and notification of physicians. She also stated that LVN 5 was also present for this in-service. On [DATE] at 6:00 p.m. the facility Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at severity level of actual harm, and a scope of pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that have been put into place. Review of a document provided by the facility on [DATE] showed there were 37 residents in the facility evaluated at risk of falls. The CMS Form 672 dated [DATE] indicated a census of 46.

Based on interview and record review, the facility failed to consult the physician and/or responsible/interested party of changes in condition for 1 of 22 residents (resident #22) as evidenced by: The facility failed to inform the physician of a resident with new onset of altered mental status that continued throughout the day. Resident #22 was confused and repeatedly trying to get out of his bed or chair during the day. The failure of the facility's system to notify the DON of this change, and lack of supervision and intervention by the facility staff members, ultimately resulted in the resident having a second fall within 24 hours. The resident sustained [REDACTED]. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. The failure of the facility to promptly notify the physician of changes in resident condition negatively affected one resident, and placed all 46 residents at risk for not having appropriate intervention. This lack of intervention may result in significant injuries that can lead to death. Findings include: Record review of the Resident #22's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Review of the facility's incident report on [DATE] shows that at 6:00 p.m. the resident was in the dining room for the evening meal, he was upset with his wife and told her to leave. He was fed by staff and put to bed. Resident #22 was later found on the floor of the room at 7:25 p.m. CNA 6 immediately notified LVN 5. The resident was found in his room in the supine position with his head near the dresser, the fall mat in place, the indwelling urinary catheter bag remained attached to the bed and the indwelling urinary catheter was pulled out of the resident and lying in the floor with the balloon inflated. The resident was noted to have blood to the back of his head with a hematoma. The nurse noted external rotation of the right lower extremity, and the resident was complaining of pain to the right lower extremity. The ambulance was called to transfer the resident to the hospital emergency room at this time. Summary of the facility investigation report says the witness statements show that the bed alarm was on, but did not alarm. It was tested three times after the fall and did sound. Fall mat was in place and the side rails were up. Reviews of the nurse's notes for Resident #22 indicate that on the date of [DATE] the resident was alert and assisted up to the wheelchair for evening meal by staff members. Resident #22 denied any discomfort at that time. On [DATE] at 4:50 a.m., the resident's bed alarm was going off and the resident was found in his room sitting on the floor mat with the call light in reach. When the resident was asked what happened, his reply was the resident was trying to get to his pickup truck, that he was having car trouble. The resident further stated. "I haven't been drinking tonight." LVN 3 attempted to orient resident to time and place. An 8 cm long by 2 cm wide abrasion was noted to left side of the resident's back. No other injuries were noted. The resident was assisted from the floor to the bed. Two of the resident's doctors were notified at this time. The next entry is at 10:00 a.m. on [DATE] " ....resident continuing attempting to get out of bed this AM without assistance, this nurse (LVN 4) re-directed resident multiple times without improvement ... ...abrasion with blue bruising noted to left back, small bruises x 2 noted to left abdomen side and small amount of dried blood noted to left elbow area ..." The following entry in the resident record is at 7:25 p.m. on [DATE], and states that CNA 6 called LVN 5 and LVN 1 to the resident room. The resident was noted lying supine on the floor in his room beside the chest of drawers. There was blood noted in a pool around the resident's head. The resident's right leg was noted with external rotation. The resident was alert and answering questions appropriately. The resident indicated pain to the right leg. The hematoma to the back of the resident's head was noted - unable to determine where the blood was coming from. An ambulance was called at 7:28 p.m. The resident's indwelling urinary bag was attached to the bed and the inflated balloon of the indwelling urinary catheter was lying in the floor. There was blood noted on the tip of the resident's penis and the report was written on the transfer sheet to the hospital ER. Review of the Fall/Risk Assessment for Resident #22 shows that on [DATE] the score was 16 and again on [DATE] the score was also a 16. Any score on this assessment that rates higher that a 10 indicates High Risk for Falls. Review of the Care Plans for Resident #22 shows care plans for the following problems/needs: -I am not as mobile as I used to be but still want to remain as independent as I can, My skin is fragile I take aspirin and [MEDICATION NAME]. It indicated that the resident has problems with skin tears and bruising. -I need ? side rails to assist with turning and repositioning and to establish my boundaries. -I have multiple problems that all affect my ability to walk. I have a history of and/or the potential to fall. - I require assistance with all my activities of daily living related to my weakness from cholecystectomy and volume depletion. Review of the Treatment Flow sheets for Resident #22 indicated that the bed alarm is checked every shift as well as the fall mat beside the bed. All shifts initialed the alarm check was performed including the 10:00 p.m. to 6:00 a.m. shift on [DATE]; the day after the resident had been transferred out of the facility. Review of the 14 day MDS assessment dated [DATE] documented that Resident #22 had some short and long term memory problems. It documented a score of 4 in the section relating to mood indicating little interest in doing things, and feelings of depression. There were no notations of behaviors. The assessment indicated the resident required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, toileting and bathing. It documented that resident used a wheelchair for mobility. It documented that there was not a need for a pain assessment to be conducted. There was no notation of any falls in this assessment. During an observation on [DATE] Resident #22 was observed in the dining room for the evening meal, seated in the wheelchair and being encouraged with the meal by the staff members. Observation of Resident #22's bedroom on [DATE] at 4:27 p.m. after the survey team had been notified of the situation revealed an adjustable hospital bed that was in the low position, ? side rails were in the elevated position, and there was a floor mat beside the bed. A bed alarm was hanging on the side rail and a call light attached to the curtain several feet away. During an interview with CNA 6 on [DATE] at 4:35 p.m., the CNA reported that he was providing care for another resident who was a neighbor to Resident #22 when he heard Resident #22 yelling. The CNA entered the room and found the resident lying on the floor with blood pooled around his head. The CNA then called for the nurse. The resident was found in his room front of the dresser. He was not moved and first aid was initiated. The resident was responding appropriately. CNA 6 said the bed alarm was on, but not working, "the nurse had to hit it hard to make it work." This was the only alarm on the resident. In an additional interview at 5:59 p.m. on [DATE] CNA 6 said he brought Resident #22 out of the dining room sometime after 6:00 p.m., and put the resident in bed. The next time that CNA 6 saw this resident was around 7:15 p.m. when he was yelling. During an interview with LVN 3 on [DATE] at 2:15 p.m., LVN 3 stated that she was working the 10:00 p.m. to 6:00 a.m. shift and caring for Resident #22 on [DATE]. LVN 3 said that Resident #22 fell at approximately 4:30 a.m. The bed alarm was going off and she was called to the room by a CNA. Another LVN (LVN 10) was with her, and they found the resident sitting in his room on the floor on a fall mat. When asked about any changes in his orientation, LVN 3 said it was unusual that the resident was talking about a pick-up. LVN 3 continued to say that this resident is usually asleep while she is at work and was able to answer all of her questions appropriately. LVN 3 talked to the nurse in the emergency room about Resident #22's confusion and to the on-call physician about his fall. She also sent a fax to another physician informing of the fall and that the resident was looking for his pick-up, but did not actually address the new onset of change in mental status. LVN 3 told LVN 4 of the fall and asked LVN 4 to call the resident's spouse during shift change at 6:00 a.m. LVN 3 was asked about the disorientation that Resident #22 was experiencing and LVN 3 said she had told the Registered Nurse in the emergency room about this when she called the on-call doctor. LVN 3 continued to say that this is usually reported to the on-coming nurse and put in the 24 hour report. She stated, "I probably should have told them." During an interview with LVN 4 on [DATE] at 2:30 p.m., LVN 4 said that she had provided care for Resident #22 on the 6:00 a.m. to 2:00 p.m. shift on [DATE]. LVN 3 had told her that Resident #22 was confused and slid out of bed. The resident had an abrasion to his left back, and she sent a communication to the physician. LVN 3 told her that the resident was saying that the needed to get his pickup fixed. While caring for Resident #22 he was trying to get up out of bed multiple times. When LVN 4 was asked if she notified the physician about the resident's confusion and trying to get out of bed, she stated, "I probably should have, but I didn't." During an interview with LVN 5 on [DATE] at 4:35 p.m., LVN 5 said that Resident #22 had an unwitnessed fall at approximately 7:30 p.m. on [DATE]. LVN 5 was talking with LVN 1 in the hallway of the facility. CNA 6 shouted out for them to come down to where he was. They went into Resident #22's room and found him lying on his back in the floor in a big pool of blood around his head with his right leg externally rotated. When the LVN asked the resident what happened he told her that he could not move his right leg. She reported that the resident was able to move his arms and left leg. She also noticed that the indwelling urinary bag was still attached to the bed and the indwelling urinary catheter with an inflated balloon was pulled out of the resident and lying on the floor. The LVN filled out transfer papers for the resident and stayed with him until the ambulance came. The fall mat was noted to be on the floor and alarm on the bed by LVN 5. LVN 5 stated that she was sorry this happened. During a follow-up interview on [DATE] at 5:55 p.m., LVN 5 said that at 2:30 p.m. on [DATE] Resident #22 was trying to climb out of bed, saying he was trying to find his pick-up. Normally the resident is " with it " according to LVN 5. When asked if she thought she should have contacted the doctor about the change in mental status she said, "I probably should have called the doctor, but I didn't." An additional telephone interview was completed on [DATE] at 5:00 p.m. with LVN 5. During this interview LVN 5 was asked about the mental status of Resident #22 during her shift; LVN 5 said the resident was telling her he was going to get his pick-up. At 2:30 p.m. Resident 22's bed alarm was going off, and she was able to get him laid down with the help of an aide. It happened again later, so they got the resident up. LVN 5 said that she was told about Resident #22's falls and abrasions when she came on shift. An interview with LVN 1 completed on [DATE] at 4:30 p.m. revealed that CNA 6 came and got herself and LVN 5. They found Resident #22 on the floor of his room with his feet towards the bed, and the indwelling urinary catheter bag still attached to the bed. The indwelling urinary catheter with balloon still inflated, was lying on the floor. The resident was alert, conscious and talking. There was blood on the floor by his head and he had blood in his hair on the right side. A hematoma was noted on the right side with a laceration. They placed an ice bag on his head. In an interview with the CRN (Corporate RN) she said that Resident #22 had fallen on Monday, [DATE], at 7:30 p.m. Resident #22 was transported to the hospital and had a [MEDICAL CONDITION]. He had surgery on [DATE] in the morning and never came out of the anesthesia. He was a DNR. She said the nurse on the floor said the alarms were going off and when they went to the room he had gotten up out of bed and fallen. He had a hematoma to one side of his head, but no open wound. Blood was noted on the floor. When the resident got up he pulled out his indwelling urinary catheter. He was awake and alert - his level of consciousness was the same as before the fall. They got him an ice pack and called the ambulance. His wife was called. When a staff member was delivering a lab specimen to the hospital on Tuesday afternoon, they found out that he did not wake up from anesthesia. The DON looked in the resident room today and there was a fall mat in the room. The bed alarm worked for the DON. The CRN reported that Resident #22 had both a bed and personal alarm on at the time of the fall. In an interview with the ADON on [DATE] at 4:14 p.m., she reported that Resident #22's son had come to the facility today and told them that after his father's surgery his blood pressure remained low. They had done multiple fluid boluses and medications and couldn't do more ...he passed away. In an interview with the DON on [DATE] at 4:05 p.m., the DON revealed that Resident #22 had been in the facility since March. On Monday evening ([DATE] around 7:30 p.m.) the resident ate dinner in the dining room. After dinner he was put to bed by CNA 6. CNA 6 found the resident in the floor at 7:25 p.m. and had LVN's 1 and 5 come to the room. The resident was found with his feet toward the bed, head towards the dresser. His indwelling urinary bag was still hooked to the bed and the catheter with the balloon inflated was lying on the floor having been pulled out of the resident. A hematoma was noted to the right side of the head and a pool of blood was on the floor. They noticed external rotation of his right lower extremity. 911 was called and he was transported to the local hospital. He was admitted with a [MEDICAL CONDITION] and had surgery the following day. He passed away after surgery. She further stated that Resident #22 had a bed alarm and fall mat in place. She stated the bed alarm was not working. In an interview with the DON on [DATE] at 4:00 p.m., she said that she did not receive any incident report about Resident #22's fall during the night shift. The night nurse had given it to the 6:00 a.m. to 2:00 p.m. nurse to call the family and complete. There was no documentation on the 24 hour report of his fall or confusion. She was not made aware of his change in mentation until after his fall on the evening of [DATE]. Review of the 24 Hour Report/Change of Condition Report for [DATE] had no mention of any changes with resident #22 until the evening shift. It stated, "Resident fall sent to ER. " Review of hospital records for Resident #22 received on [DATE] showed that the resident was alert and confused at 8:15 p.m. on [DATE] according to the nurse's notes. Another entry at 9:45 p.m. on [DATE] states that the resident is alert, oriented to self and wife only, confused. Physician notes from [DATE] at 8:04 a.m. indicated the resident has had recent bouts with frequent urinary tract infections and required some hospitalization . The resident has been in the nursing home but was actually getting close to discharge. He got up yesterday without any assistance and fell which resulted in a displaced right femoral neck [MEDICAL CONDITION] hip. Physician notes from [DATE] state the doctor was called to see Resident #22 who had surgery that day for a right [MEDICAL CONDITION]. He had not done well since the surgery. Blood pressure had been low. Urine output had also been minimal. He was a DNR. Resident #22 expired at 8:32 p.m. the note stated, "The family had been made aware of this possible complication in an elderly patient and understood that this might happen and seemed to very understanding. " Review of the facility policy titled - Change in a Resident's Condition or Status dated [DATE] states the following: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor)of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: c. A reaction to medication d. A significant change in the resident's physical/emotional/mental condition e. A need to alter the resident's medical treatment significantly i. Instructions to notify the physician of any changes in the resident's condition Review of the facility policy titled - Abuse Prevention Program dated [DATE] states the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Review of the facility policy titled - Reporting/Investigation Resident Accidents/Incidents dated [DATE] states the following: All accidents/incidents involving residents must be reported to the administrator or his/her designee. The facility administrator was notified on [DATE] at 6:30 p.m. that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 8:05 p.m. The Plan of Removal was accepted on [DATE] at 5:55 p.m. The facility took the following actions to remove the IJ: 1. Nursing staff will check that all interventions that are care planned are in place and properly functioning. 2. Fall risk assessments on all residents will be updated 3. All quarterly risk assessments will be updated the week the MDS is due 4. The RAC nurse will notify the DON/ADON if the assessments are not being done 5. In-service staff on appropriately filling out Fall Assessments - anti-slip socks, fall mat, personal alarm, bed alarm, physical therapy evaluation, cradle mattress 6. Shift to shift report will be given away from the nurse's station and family interruptions either in the family room or medication room 7. 24 hour report monitored daily by DON/ADON/RAC or combination of all 3 depending upon who is present in the building 8. All pertinent information happening on 8 hour shift will be responsible for being put on the 24 hour report - significant labs, changes in LOC, changes in resident ' physical condition, any new medication changes 9. The DON/ADON/RCA will pick up the 24 hour report on Saturday and Sunday and check the documentation on the weekends. 10. The 24 hour report is filed in the DON office 11. Contact physician with current vital signs, any changes in LOC, adverse effects of medications, lab abnormalities if available and neuros if appropriate. 12. Any falls resulting in an obvious significant injury will be transferred immediately. 13. In-service on change of condition, notifying physician, proper use of 24 hour report, proper use of alarms and functioning starting with the ,[DATE] shift followed by ,[DATE] shift. 14. In-service training on change of condition on resident to include the following: changes in LOC, changes in v/s, abnormal labs, adverse effects of medications, etc. 15. In-service all non-nursing personnel on who to alert in the event they find a resident has fallen 16. The charge nurse for that resident will be held responsible for notifying the physician of any and all incidents in regards to that resident. Per policy except in emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status 17. Nurses will initial each shift for proper alarm functioning. 18. In-service to check for batteries, placement, lights flashing, and sound functioning of bed alarms. 19. Any changes of condition/risk for falls will be placed on the 24 hour report and passed on to all nurses coming on. The nurse will be expected to make the necessary interventions at this time. The DON/ADON/RAC will review the 24 hour report and follow up to ensure interventions were done. If further issues arise the Regional Nurse will be contacted. 20. The 24 hour report is used to communicate changes to nurses in regards to residents medical or mental condition, new admission, changes in medication regiment, lab values beyond the norm, changes in behavior, any significant illness or change in v/s or LOC, fall with or without injury, etc. 21. All medical emergencies requiring transport to the hospital the ADM/DON will be notified. 22. All other issues will be discussed in the morning stand up meeting when the DON goes over the 24 hour report 23. In-service staff on properly reporting any falls, injuries, that they witness or se on a resident to the nursing department while insuring the safety of the resident 24. In-service all staff on change of condition and who they are to contact each time 25. In-service all staff on reporting immediately any changes to MD and responsible party 26. In-service staff on correct way to fill out incident and accident form 27. Compliance rounds to be made by DON/ADON daily comparing list of alarms to the list on Matrix 28. Supervision of staff to insure that they are monitoring the alarms and checking for proper functioning 29. All interventions for falls are kept on the nurses treatment record to be checked every shift 30. Out of cycle Quality Assurance and Assessment on falls 31. DON/ADON/RAC will review all clinical records fir a resident with a fall 32. Compliance rounds will be checked to make sure that batteries are in the personal alarms, alarms sound, turned on, switched on 33. All falls will be followed up in QAA for 6 months Record review of the in-service for the dates of [DATE] and ,[DATE] indicate that seven staff members have been in-serviced on change in condition and neglect. A checklist of all residents showing that fall assessments had been updated and all prescribed fall prevention equipment was in place and functioning, was provided by the DON on [DATE] at 11:10 a.m. for review. Record reviews of the additional 10 residents added to the resident sample were completed on [DATE]. The proper incident reports had been filled out for these residents who had falls in the last 30 days. There were care plans in place for fall risk on all of these residents and updated fall risk assessments. Each of these 10 resident rooms were checked to ensure that all equipment to prevent falls was in place and in working order. In an interview with LVN 1 on [DATE] at 5:40 p.m., LVN 1 said that she had been in-serviced on the promptness of responding to alarms, use of fall mats, documentation and notification of physicians. She also stated that LVN 5 was also present for this in-service. On [DATE] at 6:00 p.m. the facility Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at severity level of actual harm, and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems that have been put into place. The CMS Form 672 dated [DATE] showed a census of 46 residents.

Based on observation, interview and record review, the facility failed to develop and implement policies and procedures to prohibit each resident from neglect for 1 of 22 residents, (Resident #22)reviewed for abuse, neglect and exploitation. The facility failed to inform the physician of a resident with new onset of altered mental status that continued throughout the day. Resident #22 who was classified as a High Risk for Falls was confused and repeatedly trying to get out of his bed or chair during the day. The failure of the facility's system to notify the physician of the resident's mental status, the DON of this change, and lack of supervision and intervention by the facility staff members, ultimately resulted in the resident having a second fall within 24 hours at 7:25p.m.on [DATE]. The resident sustained [REDACTED]. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This lack of supervision of residents with significant changes and failure to report these changes places all of the 37 residents identified at risk for falls in imminent danger of significant injuries that could lead to death. Findings include: Record review of the Resident #22's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Review of the facility's incident report on [DATE] shows that Resident #22 was found on the floor of his room at 7:25 p.m. CNA 6 immediately notified LVN 5. Resident #22 was found in the supine position with his head near the dresser, the fall mat in place, the indwelling urinary catheter bag remained attached to the bed and the indwelling urinary catheter was pulled out of the resident and lying on the floor with the balloon inflated. The resident was noted to have blood to back of his head with a hematoma. The nurse noted external rotation of the right lower extremity, and the resident was complaining of pain to the right lower extremity. The ambulance was called to transfer the resident to the hospital emergency room at this time. Summary of the facility investigation report says the witness statements show that the bed alarm was on, but did not alarm. It was tested three times after the fall and did sound. Fall mat was in place and the side rails were up. At 6:00 p.m. Resident #22 was in the dining room for the evening meal, he was upset with his wife and told her to leave. He was fed by staff and put to bed. Reviews of the nurse's notes for Resident #22 indicate that on the date of [DATE] Resident #22 was alert and assisted up to the wheelchair for the evening meal by staff members. Resident #22 denied any discomfort at that time. On [DATE] at 4:50 a.m., Resident #22's bed alarm was going off and the resident was found sitting on the floor mat with the call light in reach. When the resident was asked what happened, his reply was he was trying to get to his pickup truck, that he was having car trouble. Resident #22 further stated. "I haven't been drinking tonight." LVN 3 attempted to orient resident to time and place. An 8 cm long by 2 cm wide abrasion was noted to left side of back. No other injuries were noted. Resident #22 was assisted from the floor to the bed. Two of the resident's doctors were notified at this time. The next entry is at 10:00 a.m. on [DATE] " ....resident continuing attempting to get out of bed this AM without assistance, this nurse(LVN 4)re-directed resident multiple times without improvement ... ...abrasion with blue bruising noted to left back, small bruises x 2 noted to left abdomen side and small amount of dried blood noted to left elbow area ..." The following entry in the resident record is at 7:25 p.m. on [DATE], and states that CNA 6 called LVN 5 and LVN 1 to the resident room. Resident #22 was noted lying supine on the floor beside the chest of drawers. There was blood noted in a pool around the resident's head. The right leg was noted with external rotation. The resident was alert and answering questions appropriately. The resident indicated pain to the right leg. The hematoma to the back of the head was noted - unable to determine where the blood was coming from, an ambulance was called at 7:28 p.m. The indwelling urinary bag was attached to the bed and the inflated balloon of the indwelling urinary catheter was lying on the floor. There was blood noted on the tip of the resident's penis, and the report was written on the transfer sheet to the hospital ER. Review of the Fall/Risk Assessment for Resident #22 shows that on [DATE] the score was 16 and again on [DATE] the score was also a 16. Any score on this assessment that rates higher than a 10 indicates a High Risk for Falls. Review of the Care Plans for Resident #22 shows care plans for the following problems/needs: -I am not as mobile as I used to be but still want to remain as independent as I can, My skin is fragile I take aspirin and [MEDICATION NAME]. It indicated that the resident has problems with skin tears and bruising. -I need ? side rails to assist with turning and repositioning and to establish my boundaries. -I have multiple problems that all affect my ability to walk. I have a history of and/or the potential to fall. - I require assistance with all my activities of daily living related to my weakness from cholecystectomy and volume depletion. Review of the Treatment Flow sheets for Resident #22 indicated that the bed alarm is checked every shift as well as the fall mat beside the bed. All shifts initialed the alarm check was performed including the 10:00 p.m. to 6:00 a.m. on [DATE], the day after the resident had been transferred out of the facility. Review of the 14 day MDS assessment dated [DATE] documented that Resident #22 had some short and long term memory problems. It documented a score of 4 in the section relating to mood indicating little interest in doing things, and feelings of depression. There were no notations of behaviors. The assessment indicated the resident required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, toileting and bathing. It documented that resident used a wheelchair for mobility. It documented that there was not a need for a pain assessment to be conducted. There was no notation of any falls in this assessment. During an observation on [DATE] at 6:00 p.m., Resident #22 was observed in the dining room for the evening meal, seated in the wheelchair and being encouraged with the meal by the staff members. Observation of Resident #22's bedroom on [DATE] at 4:27 p.m. after the survey team had been notified of the situation revealed an adjustable hospital bed that was in the low position, ? side rails were in the elevated position, and there was a floor mat beside the bed. A bed alarm was hanging on the side rail and a call light attached to the curtain several feet away. During an interview with CNA 6 on [DATE] at 4:35 p.m., CNA 6 reported that he was providing care for another resident who was a neighbor to Resident #22 when he heard Resident #22 yelling. CNA 6 entered Resident #22's room and found the resident lying on the floor with blood pooled around his head. CNA 6 then called for the nurse. Resident #22 was found in front of the dresser. He was not moved and first aid was initiated. The resident was responding appropriately. CNA 6 said the bed alarm was on, but not working, The nurse had to hit it hard to make it work." This was the only alarm on the resident. In an additional interview at 5:59 p.m. that day CNA 6 said he brought Resident #22 out of the dining room sometime after 6:00 p.m., and put the resident in bed. The next time that CNA 6 saw this resident was around 7:15 p.m. when he was yelling. During an interview with LVN 3 on [DATE] at 2:15 p.m., LVN 3 stated that she was working the 10:00 p.m. to 6:00 a.m. shift and caring for Resident #22 on [DATE]. LVN 3 said that Resident #22 fell at approximately 4:30 a.m. The bed alarm was going off and she was called to the room by a CNA. Another LVN (LVN 10)was with her, and they found the resident sitting in his room on the floor on a fall mat. When asked about any changes in his orientation, LVN 3 said it was unusual that the resident was talking about a pick-up. LVN 3 continued to say that this resident is usually asleep while she is at work and is able to answer all of her questions appropriately. LVN 3 talked to the nurse in the emergency room about Resident #22's confusion and to the on-call physician about his fall. She also sent a fax to another physician informing of the fall and that the resident was looking for his pick-up, but did not actually address the new onset of change in mental status. LVN 3 told LVN 4 of the fall and asked LVN 4 to call the resident's spouse during shift change at 6:00 a.m. LVN 3 was asked about the disorientation that Resident #22 was experiencing and LVN 3 said she had told the Registered Nurse in the emergency room about this when she called the on-call doctor. LVN 3 continued to say that this is usually reported to the on-coming nurse and put in the 24 hour report. She stated, "I probably should have told them." During an interview with LVN 4 on [DATE] at 2:30 p.m., LVN 4 said that she had provided care for Resident #22 on the 6:00 a.m. to 2:00 p.m. shift on [DATE]. LVN 3 had told her that Resident #22 was confused and slid out of bed. The resident had an abrasion to his left back, and she sent a communication to the physician. LVN 3 told her that the resident was saying that he needed to get his pickup fixed. While caring for Resident #22 he was trying to get up out of bed multiple times. When LVN 4 was asked if she notified the physician about the resident's confusion and trying to get out of bed, she stated, "I probably should have, but I didn't." During an interview with LVN 5 on [DATE] at 4:35 p.m., LVN 5 said that Resident #22 had an unwitnessed fall at approximately 7:30 p.m. on [DATE]. LVN 5 was talking with LVN 1 in the hallway of the facility. CNA 6 shouted out for them to come down to where he was. They went into Resident #22's room and found him lying on his back in the floor in a big pool of blood around his head with his right leg externally rotated. When the LVN asked the resident what happened he told her that he could not move his right leg. She reported that the resident was able to move his arms and left leg. She also noticed that the indwelling urinary bag was still attached to the bed and the indwelling urinary catheter with an inflated balloon was pulled out of the resident ann was lying on the floor. LVN 5 filled out transfer papers for the resident and stayed with him until the ambulance came. The fall mat was noted to be on the floor and alarm on the bed by LVN 5. During a follow-up interview on [DATE] at 5:55 p.m., LVN 5 said that at 2:30 p.m. on [DATE] Resident #22 was trying to climb out of bed, he was trying to find his pick-up. Normally the resident is " with it " according to LVN 5. When asked if she thought she should have contacted the doctor about the change in mental status she said, "I probably should have called the doctor, but I didn't." An additional telephone interview was completed on [DATE] at 5:00 p.m. with LVN 5. During this interview LVN 5 was asked about the mental status of Resident #22 during her shift; she said the resident was telling her he was going to get his pick-up. At 2:30 p.m. Resident 22's bed alarm was going off, and she was able to get him laid down with the help of an aide. It happened again later, so they got the resident up. LVN 5 said that she was told about Resident #22's falls and abrasions when she came on shift. An interview with LVN 1 completed on [DATE] at 4:30 p.m. revealed that CNA 6 came and got herself and LVN 5. They found Resident #22 on the floor with his feet towards the bed, and the indwelling urinary catheter bag still attached to the bed. The indwelling urinary catheter with balloon still inflated, was lying on the floor. The resident was alert, conscious and talking. There was blood on the floor by his head and he had blood in his hair on the right side. A hematoma was noted on the right side with a laceration. They placed an ice bag on his head. In an interview with the CRN (Corporate RN)she said that Resident #22 had fallen on Monday, [DATE], at 7:30 p.m. Resident #22 was transported to the hospital and had a [MEDICAL CONDITION]. He had surgery on [DATE] in the morning and never came out of the anesthesia. He was a DNR. She said the nurse on the floor said the alarms were going off and when they went to the room he had gotten up out of bed and fallen. He had a hematoma to one side of his head, but no open wound. Blood was noted on the floor. When the resident got up he pulled out his indwelling urinary catheter. He was awake and alert - his level of consciousness was the same as before the fall. They got him an ice pack and called the ambulance. His wife was called. When a staff member was delivering a lab specimen to the hospital on Tuesday afternoon, they found out that he did not wake up from anesthesia. The DON looked in the resident room today and there was a fall mat in the room. The bed alarm worked for the DON. The CRN reported that Resident #22 had both a bed and personal alarm on at the time of the fall. In an interview with the ADON on [DATE] at 4:14 p.m., she reported that Resident #22's son had come to the facility today and told them that after his father's surgery his blood pressure remained low. They had done multiple fluid boluses and medications and couldn't do more ...he passed away. In an interview with the DON on [DATE] at 4:05 p.m., the DON revealed that Resident #22 had been in the facility since March. On Monday evening ([DATE] around 7:30 p.m.) the resident ate dinner in the dining room. After dinner he was put to bed by CNA 6. This CNA found the resident in the floor at 7:25 p.m. and had LVN's 1 and 5 come to the room. The resident was found with his feet toward the bed, head towards the dresser. His indwelling urinary bag was still hooked to the bed and the indwelling urinary catheter with the balloon inflated was lying on the floor having been pulled out of the resident. A hematoma was noted to the right side of the head and a pool of blood was on the floor. They noticed external rotation of his right lower extremity. 911 was called and he was transported to the local hospital. He was admitted with a [MEDICAL CONDITION] and had surgery the following day. He passed away after surgery. She further stated that Resident #22 had a bed alarm and fall mat in place. She stated the bed alarm was not working. In an interview with the DON on [DATE] at 4:00 p.m., she said that she did not receive any incident report about Resident #22's fall during the night shift. The night nurse had given it to the 6:00 a.m. to 2:00 p.m. nurse to call the family and complete. There was no documentation on the 24 hour report of his fall or confusion. She was not made aware of his change in mentation until after his fall on the evening of [DATE]. Review of the 24 Hour Report/ Change of Condition Report for [DATE] had no mention of any changes with resident #22 until the evening shift. It stated, "Resident fall sent to ER. " Review of hospital records for Resident #22 received on [DATE] showed that the resident was alert and confused at 8:15 p.m. on [DATE] according to the nurse's notes. Another entry at 9:45 p.m. on [DATE] states that the resident is alert, oriented to self and wife only, confused. Physician notes from [DATE] at 8:04 a.m. indicated the resident has had recent bouts with frequent urinary tract infections and required some hospitalization . The resident has been in the nursing home but was actually getting close to discharge. He got up yesterday without any assistance and fell which resulted in a displaced right femoral neck [MEDICAL CONDITION] hip. Physician notes from [DATE] state the doctor was called to see Resident #22 who had surgery that day for a right [MEDICAL CONDITION]. He had not done well since the surgery. Blood pressure had been low. Urine output had also been minimal. He was a DNR. Resident #22 expired at 8:32 p.m. the note stated, "The family had been made aware of this possible complication in an elderly patient and understood that this might happen and seemed to very understanding. " Review of the facility policy titled - Change in a Resident's Condition or Status dated [DATE] states the following: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor)of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: c. A reaction to medication d. A significant change in the resident's physical/emotional/mental condition e. A need to alter the resident's medical treatment significantly i. Instructions to notify the physician of any changes in the resident's condition Review of the facility policy titled - Abuse Prevention Program dated [DATE] states the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Review of the facility policy titled - Reporting/Investigation Resident Accidents/Incidents dated [DATE] states the following: All accidents/incidents involving residents must be reported to the administrator or his/her designee. The facility administrator was notified on [DATE] at 6:30 p.m. that an I situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 8:05 p.m. The Plan of Removal was accepted on [DATE] at 5:55 p.m. The facility took the following actions to remove the I: 1. Nursing staff will check that all interventions that are care planned are in place and properly functioning. 2. Fall risk assessments on all residents will be updated 3. All quarterly risk assessments will be updated the week the MDS is due 4. The RCA nurse will notify the DON/ADON if the assessments are not being done 5. In-service staff on appropriately filling out Fall Assessments - anti-slip socks, fall mat, personal alarm, bed alarm, physical therapy evaluation, cradle mattress 6. Shift to shift report will be given away from the nurse's station and family interruptions either in the family room or medication room 7. 24 hour report monitored daily by DON/ADON/RCA or combination of all 3 depending upon who is present in the building 8. All pertinent information happening on 8 hour shift will be responsible for being put on the 24 hour report - significant labs, changes in LOC, changes in resident ' physical condition, any new medication changes 9. The DON/ADON/RCA will pick up the 24 hour report on Saturday and Sunday and check the documentation on the weekends. 10. The 24 hour report is filed in the DON office 11. Contact physician with current vital signs, any changes in LOC, adverse effects of medications, lab abnormalities if available and neurons if appropriate. 12. Any falls resulting in an obvious significant injury will be transferred immediately. 13. In-service on change of condition, notifying physician, proper use of 24 hour report, proper use of alarms and functioning starting with the ,[DATE] shift followed by ,[DATE] shift. 14. In-service training on change of condition on resident to include the following: changes in LOC, changes in v/S, abnormal labs, adverse effects of medications, etc. 15. In-service all non-nursing personnel on who to alert in the event they find a resident has fallen 16. The charge nurse for that resident will be held responsible for notifying the physician of any and all incidents in regards to that resident. Per policy except in emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status 17. Nurses will initial each shift for proper alarm functioning. 18. In-service to check for batteries, placement, lights flashing, and sound functioning of bed alarms. 19. Any changes of condition/risk for falls will be placed on the 24 hour report and passed on to all nurses coming on. The nurse will be expected to make the necessary interventions at this time. The DON/ADON/RCA will review the 24 hour report and follow up to ensure interventions were done. If further issues arise the Regional Nurse will be contacted. 20. The 24 hour report is used to communicate changes to nurses in regards to residents medical or mental condition, new admission, changes in medication regiment, lab values beyond the norm, changes in behavior, any significant illness or change in v/S or LOC, fall with or without injury, etc. 21. All medical emergencies requiring transport to the hospital the ADN/DON will be notified. 22. All other issues will be discussed in the morning stand up meeting when the DON goes over the 24 hour report 23. In-service staff on properly reporting any falls, injuries, that they witness or se on a resident to the nursing department while insuring the safety of the resident 24. In-service all staff on change of condition and who they are to contact each time 25. In-service all staff on reporting immediately any changes to MD and responsible party 26. In-service staff on correct way to fill out incident and accident form 27. Compliance rounds to be made by DON/ADON daily comparing list of alarms to the list on Matrix 28. Supervision of staff to insure that they are monitoring the alarms and checking for proper functioning 29. All interventions for falls are kept on the nurses treatment record to be checked every shift 30. Out of cycle Quality Assurance and Assessment on falls 31. DON/ADON/RCA will review all clinical records fir a resident with a fall 32. Compliance rounds will be checked to make sure that batteries are in the personal alarms, alarms sound, turned on, switched on 33. All falls will be followed up in AA for 6 months Record review of the in-service for the dates of [DATE] and ,[DATE] indicate that seven staff members have been in-serviced on change in condition and neglect. A checklist of all residents showing that fall assessments had been updated and all prescribed fall prevention equipment was in place and functioning, was provided by the DON on [DATE] at 11:10 a.m. for review. Record reviews of the additional 10 residents added to the resident sample were completed on [DATE]. The proper incident reports had been filled out for these residents who had falls in the last 30 days. There were care plans in place for fall risk on all of these residents and updated fall risk assessments. Each of these 10 resident rooms were checked to ensure that all equipment to prevent falls was in place and in working order. In an interview with LVN 1 on [DATE] at 5:40 p.m. she said that she had been in-serviced on the promptness of responding to alarms, use of fall mats, documentation and notification of physicians. She also stated that LVN 5 was also present for this in-service. On [DATE] at 6:00 p.m. the facility Administrator and DON were notified that the immediacy of the I was removed. However, the facility remained out of compliance at severity level of actual harm, and a scope of pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that have been put into place. Review of a document provided by the facility on [DATE] showed there were 37 residents in the facility evaluated at risk of falls. The CMS Form 672 dated [DATE] showed a census of 46 residents.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures to prohibit each resident from neglect for 1 of 22 resident(Resident #22)reviewed for neglect . The facility failed to inform the physician of a resident with new onset of altered mental status that continued throughout the day. Resident #22 was confused and repeatedly trying to get out of his bed or chair during the day. The failure of the facility's system to notify the DON of this change, and lack of supervision and intervention by the facility staff members, ultimately resulted in the resident having a second fall within 24 hours. The resident sustained [REDACTED]. These failures resulted in identification of an IJ(Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This failure to implement facility policy to prevent neglect including the lack of supervision of residents with significant changes and failure to report these changes places all of the 37 residents identified at risk for falls in imminent danger of significant injuries that could lead to death. Findings include: Policies- Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor)of changes in the resident's medical/mental condition and/or status(e.g. changes in level of care, billing/payments, resident rights, etc.) 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: c. A reaction to medication d. A significant change in the resident's physical/emotional/mental condition e. A need to alter the resident's medical treatment significantly i. Instructions to notify the physician of any changes in the resident's condition Record review of the Resident #22's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Review of the facility's incident report on [DATE] shows that Resident #22 was found on the floor of his room at 7:25 p.m. CNA 6 immediately notified LVN 5. Resident #22 was found in his room in the supine position with his head near the dresser, the fall mat in place, the indwelling urinary catheter bag remained attached to the bed and the indwelling urinary catheter with inflated balloon was pulled out of the resident and lying on the floor. The resident was noted to have blood to back of his head with a hematoma. The nurse noted external rotation of the right lower extremity, and the resident was complaining of pain to the right lower extremity. The ambulance was called to transfer the resident to the hospital emergency room at this time. Summary of the facility investigation report says the witness statements show that the bed alarm was on, but did not alarm. It was tested three times after the fall and did sound. Fall mat was in place and the side rails were up. At 6:00 p.m. the resident was in the dining room for the evening meal, he was upset with his wife and told her to leave. He was fed by staff and put to bed. Reviews of the nurse's notes for Resident #22 indicate that on the date of [DATE] the resident was alert and assisted up to the wheelchair for evening meal by staff members. Resident #22 denied any discomfort at that time. On [DATE] at 4:50 a.m., Resident #22's bed alarm was going off and the resident was found sitting on the floor mat with the call light in reach. When the resident was asked what happened, his reply was he was trying to get to his pickup truck, that he was having car trouble. The resident further stated. "I haven't been drinking tonight." LVN 3 attempted to orient resident to time and place. An 8 cm long by 2 cm wide abrasion was noted to left side of th resident's back. No other injuries were noted. Resident #22 was assisted from the floor to the bed. Two of the resident's doctors were notified at this time. The next entry is at 10:00 a.m. on [DATE] "....resident continuing attempting to get out of bed this AM without assistance, this nurse(LVN 4)re-directed resident multiple times without improvement ... ...abrasion with blue bruising noted to left back, small bruises x 2 noted to left abdomen side and small amount of dried blood noted to left elbow area ... " The following entry in the resident record is at 7:25 p.m. on [DATE], and states that CNA 6 called LVN 5 and LVN 1 to the resident room. The resident was noted lying supine on the floor beside the chest of drawers. There was blood noted in a pool around the resident's head. The right leg was noted with external rotation. The resident was alert and answering questions appropriately. The resident indicated pain to the right leg. The hematoma to the back of the head was noted - unable to determine where the blood was coming from, an ambulance was called at 7:28 p.m. The indwelling urinary bag was attached to the bed and the inflated balloon of the indwelling urinary catheter was lying on the floor. There was blood noted on the tip of the resident's penis and the report was written on the transfer sheet to the hospital ER. Review of the Fall/Risk Assessment for Resident #22 shows that on [DATE] the score was 16 and again on [DATE] the score was also a 16. Any score on this assessment that rates higher that a 10 indicates a High Risk for Falls. Review of the Care Plans for Resident #22 shows care plans for the following problems/needs: -I am not as mobile as I used to be but still want to remain as independent as I can, My skin is fragile I take aspirin and [MEDICATION NAME]. It indicated that the resident has problems with skin tears and bruising. -I need ? side rails to assist with turning and repositioning and to establish my boundaries. -I have multiple problems that all affect my ability to walk. I have a history of and/or the potential to fall. - I require assistance with all my activities of daily living related to my weakness from cholecystectomy and volume depletion. Review of the Treatment Flow sheets for Resident #22 indicated that the bed alarm is checked every shift as well as the fall mat beside the bed. All shifts initialed the alarm was checked, including the 10:00 p.m. to 6:00 a.m. on [DATE]; the day after the resident had been transferred out of the facility. Review of the 14 day MDS assessment dated [DATE] documented that Resident #22 had some short and long term memory problems. It documented a score of 4 in the section relating to mood indicating little interest in doing things, and feelings of depression. There were no notations of behaviors. The assessment indicated the resident required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, toileting and bathing. It documented that resident used a wheelchair for mobility. It documented that there was not a need for a pain assessment to be conducted. There was no notation of any falls in this assessment. During an observation on [DATE] Resident #22 was observed in the dining room for the evening meal, seated in the wheelchair and being encouraged with the meal by the staff members. Observation of Resident #22's bedroom on [DATE] at 4:27 p.m. after the survey team was notified of the situation, revealed an adjustable hospital bed that was in the low position, ? side rails were in the elevated position, and there was a floor mat beside the bed. A bed alarm was hanging on the side rail and a call light attached to the curtain several feet away. During an interview with CNA 6 on [DATE] at 4:35 p.m., CNA 6 reported that he was providing care for another resident who was a neighbor to Resident #22 when he heard Resident #22 yelling. CNA 6 entered the room and found the resident lying on the floor with blood pooled around his head. CNA 6 then called for the nurse. The resident was found in front of the dresser. He was not moved and first aid was initiated. The resident was responding appropriately. CNA 6 said the bed alarm was on, but not working, "The nurse had to hit it hard to make it work." This was the only alarm on the resident. In an additional interview at 5:59 p.m. that day, CNA 6 said he brought Resident #22 out of the dining room sometime after 6:00pm., and put the resident in bed. The next time that CNA 6 saw this resident was around 7:15 p.m. when he was yelling. During an interview with LVN 3 on [DATE] at 2:15 p.m., LVN 3 stated that she was working the 10:00 p.m. to 6:00 a.m. shift and caring for Resident #22 on [DATE]. LVN 3 said that Resident #22 fell at approximately 4:30 a.m. The bed alarm was going off and she was called to the room by a CNA. Another LVN (LVN 10)was with her, and they found the resident sitting on the floor on a fall mat. When asked about any changes in his orientation, LVN 3 said it was unusual that the resident was talking about a pick-up. LVN 3 continued to say that this resident is usually asleep while she is at work and is able to answer all of her questions appropriately. LVN 3 talked to the nurse in the emergency room about Resident #22's confusion and to the on-call physician about his fall. She also sent a fax to another physician informing of the fall and that the resident was looking for his pick-up, but did not actually address the new onset of change in mental status. LVN 3 told LVN 4 of the fall and asked LVN 4 to call the resident's spouse during shift change at 6:00 a.m. LVN 3 was asked about the disorientation that Resident #22 was experiencing and LVN 3 said she had told the Registered Nurse in the emergency room about this when she called the on-call doctor. LVN 3 continued to say that this is usually reported to the on-coming nurse and put in the 24 hour report. She stated, "I probably should have told them." During an interview with LVN 4 on [DATE] at 2:30 p.m., LVN 4 said that she had provided care for Resident #22 on the 6:00 a.m. to 2:00 p.m. shift on [DATE]. LVN 3 had told her that Resident #22 was confused and slid out of bed. The resident had an abrasion to his left back, and she sent a communication to the physician. LVN 3 told her that the resident was saying that he needed to get his pickup fixed. While caring for Resident #22 he was trying to get up out of bed multiple times. When LVN 4 was asked if she notified the physician about the resident's confusion and trying to get out of bed, she stated, "I probably should have, but I didn't." During an interview with LVN 5 on [DATE] at 4:35 p.m., LVN 5 said that Resident #22 had an unwitnessed fall at approximately 7:30 p.m. on [DATE]. The LVN was talking with LVN 1 in the hallway of the facility. CNA 6 shouted out for them to come down to where he was. They went into Resident #22's room and found him lying on his back in the floor in a big pool of blood around his head with his right leg externally rotated. When the LVN asked the resident what happened he told her that he could not move his right leg. She reported that the resident was able to move his arms and left leg. She also noticed that the indwelling urinary bag was still attached to the bed and the indwelling urinary catheter was pulled out of the resident with an inflated balloon was lying on the floor. The LVN filled out transfer papers for the resident and stayed with him until the ambulance came. The fall mat was noted to be on the floor and alarm on the bed by the LVN. During a follow-up interview on [DATE] at 5:55 p.m., LVN 5 said that at 2:30 p.m. on [DATE] Resident #22 was trying to climb out of bed, he was trying to find his pick-up. Normally the resident is "with it "according to LVN 5. When asked if she thought she should have contacted the doctor about the change in mental status she said, "I probably should have called the doctor, but I didn't." An additional telephone interview was completed on [DATE] at 5:00 p.m. with LVN 5. During this interview LVN 5 was asked about the mental status of Resident #22 during her shift; she said the resident was telling her he was going to get his pick-up. At 2:30 p.m. Resident 22's bed alarm was going off, and she was able to get him laid down with the help of an aide. It happened again later, so they got the resident up. LVN 5 said that she was told about Resident #22's falls and abrasions when she came on shift. An interview with LVN 1 completed on [DATE] at 4:30 p.m. revealed that CNA 6 came and got herself and LVN 5. They found Resident #22 on the floor of his room with his feet towards the bed, and the indwelling urinary catheter bag still attached to the bed. The indwelling urinary catheter with balloon still inflated, was lying on the floor. The resident was alert, conscious and talking. There was blood on the floor by his head and he had blood in his hair on the right side. A hematoma was noted on the right side with a laceration. They placed an ice bag on his head. In an interview with the CRN(Corporate RN) she said that Resident #22 had fallen on Monday, [DATE], at 7:30 p.m. Resident #22 was transported to the hospital and had a [MEDICAL CONDITION]. He had surgery on [DATE] in the morning and never came out of the anesthesia. He was a DNR. She said the nurse on the floor said the alarms were going off and when they went to the room he had gotten up out of bed and fallen. He had a hematoma to one side of his head, but no open wound. Blood was noted on the floor. When the resident got up he pulled out his indwelling urinary catheter. He was awake and alert - his level of consciousness was the same as before the fall. They got him an ice pack and called the ambulance. His wife was called. When a staff member was delivering a lab specimen to the hospital on Tuesday afternoon, they found out that he did not wake up from anesthesia. The DON looked in the resident room today and there was a fall mat in the room. The bed alarm worked for the DON. The CRN reported that Resident #22 had both a bed and personal alarm on at the time of the fall. In an interview with the ADON on [DATE] at 4:14 p.m., the ADON reported that Resident #22's son had come to the facility today and told them that after his father's surgery his blood pressure remained low. They had done multiple fluid boluses and medications and couldn't do more ...he passed away. In an interview with the DON on [DATE] at 4:05 p.m., the DON revealed that Resident #22 had been in the facility since March. On Monday evening ([DATE] around 7:30 p.m.)the resident ate dinner in the dining room. After dinner he was put to bed by CNA 6. CNA 6 found the resident on the floor at 7:25 p.m. and had LVN's 1 and 5 come to the room. The resident was found with his feet toward the bed, head towards the dresser. His indwelling urinary bag was still hooked to the bed and the indwelling urinary catheter with the balloon inflated was lying on the floor having been pulled out of the resident. A hematoma was noted to the right side of the head and a pool of blood was on the floor. They noticed external rotation of his right lower extremity. 911 was called and he was transported to the local hospital. He was admitted with a [MEDICAL CONDITION] and had surgery the following day. He passed away after surgery. She further stated that Resident #22 had a bed alarm and fall mat in place. She stated the bed alarm was not working. In an interview with the DON on [DATE] at 4:00 p.m., she said that she did not receive any incident report about Resident #22's fall during the night shift. The night nurse had given it to the 6:00 a.m. to 2:00 p.m. nurse to call the family and complete. There was no documentation on the 24 hour report of his fall or confusion. She was not made aware of his change in mentation until after his fall on the evening of [DATE]. Review of the 24 Hour Report/ Change of Condition Report for [DATE] had no mention of any changes with resident #22 until the evening shift. It stated, "Resident fall sent to ER." Review of hospital records for Resident #22 received on [DATE] showed that the resident was alert and confused at 8:15 p.m. on [DATE] according to the nurse's notes. Another entry at 9:45 p.m. on [DATE] states that the resident is alert, oriented to self and wife only, confused. Physician notes from [DATE] at 8:04 a.m. indicated the resident has had recent bouts with frequent urinary tract infections and required some hospitalization . The resident has been in the nursing home but was actually getting close to discharge. He got up yesterday without any assistance and fell which resulted in a displaced right femoral neck [MEDICAL CONDITION] hip. Physician notes from [DATE] state the doctor was called to see Resident #22 who had surgery that day for a right [MEDICAL CONDITION]. He had not done well since the surgery. Blood pressure had been low. Urine output had also been minimal. He was a DNR. Resident #22 expired at 8:32 p.m. the note stated, "The family had been made aware of this possible complication in an elderly patient and understood that this might happen and seemed to very understanding." The facility administrator was notified on [DATE] at 6:30 p.m. that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 8:05 p.m. The Plan of Removal was accepted on [DATE] at 5:55 p.m. The facility took the following actions to remove the IJ: 1. Nursing staff will check that all interventions that are care planned are in place and properly functioning. 2. Fall risk assessments on all residents will be updated 3. All quarterly risk assessments will be updated the week the MDS is due 4. The RAC nurse will notify the DON/ADON if the assessments are not being done 5. In-service staff on appropriately filling out Fall Assessments - anti-slip socks, fall mat, personal alarm, bed alarm, physical therapy evaluation, cradle mattress 6. Shift to shift report will be given away from the nurse's station and family interruptions either in the family room or medication room 7. 24 hour report monitored daily by DON/ADON/RAC or combination of all 3 depending upon who is present in the building 8. All pertinent information happening on 8 hour shift will be responsible for being put on the 24 hour report - significant labs, changes in LOC, changes in resident's physical condition, any new medication changes 9. The DON/ADON/RAC will pick up the 24 hour report on Saturday and Sunday and check the documentation on the weekends. 10. The 24 hour report is filed in the DON office 11. Contact physician with current vital signs, any changes in LOC, adverse effects of medications, lab abnormalities if available and neuros if appropriate. 12. Any falls resulting in an obvious significant injury will be transferred immediately. 13. In-service on change of condition, notifying physician, proper use of 24 hour report, proper use of alarms and functioning starting with the ,[DATE] shift followed by ,[DATE] shift. 14. In-service training on change of condition on resident to include the following: changes in LOC, changes in v/s, abnormal labs, adverse effects of medications, etc. 15. In-service all non-nursing personnel on who to alert in the event they find a resident has fallen 16. The charge nurse for that resident will be held responsible for notifying the physician of any and all incidents in regards to that resident. Per policy except in emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status 17. Nurses will initial each shift for proper alarm functioning. 18. In-service to check for batteries, placement, lights flashing, and sound functioning of bed alarms. 19. Any changes of condition/risk for falls will be placed on the 24 hour report and passed on to all nurses coming on. The nurse will be expected to make the necessary interventions at this time. The DON/ADON/RAC will review the 24 hour report and follow up to ensure interventions were done. If further issues arise the Regional Nurse will be contacted. 20. The 24 hour report is used to communicate changes to nurses in regards to residents medical or mental condition, new admission, changes in medication regiment, lab values beyond the norm, changes in behavior, any significant illness or change in v/s or LOC, fall with or without injury, etc. 21. All medical emergencies requiring transport to the hospital the ADM/DON will be notified. 22. All other issues will be discussed in the morning stand up meeting when the DON goes over the 24 hour report 23. In-service staff on properly reporting any falls, injuries, that they witness or se on a resident to the nursing department while insuring the safety of the resident 24. In-service all staff on change of condition and who they are to contact each time 25. In-service all staff on reporting immediately any changes to MD and responsible party 26. In-service staff on correct way to fill out incident and accident form 27. Compliance rounds to be made by DON/ADON daily comparing list of alarms to the list on Matrix 28. Supervision of staff to insure that they are monitoring the alarms and checking for proper functioning 29. All interventions for falls are kept on the nurses treatment record to be checked every shift 30. Out of cycle Quality Assurance and Assessment on falls 31. DON/ADON/RAC will review all clinical records for a resident with a fall 32. Compliance rounds will be checked to make sure that batteries are in the personal alarms, alarms sound, turned on, switched on 33. All falls will be followed up in QAA for 6 months Record review of the in-service for the dates of [DATE] and ,[DATE] indicate that seven staff members have been in-serviced on change in condition and neglect. A checklist of all residents showing that fall assessments had been updated and all prescribed fall prevention equipment was in place and functioning, was provided by the DON on [DATE] at 11:10 a.m. for review. Record reviews of the additional 10 residents added to the resident sample were completed on [DATE]. The proper incident reports had been filled out for these residents who had falls in the last 30 days. There were care plans in place for fall risk on all of these residents and updated fall risk assessments. Each of these 10 resident rooms were checked to ensure that all equipment to prevent falls was in place and in working order. In an interview with LVN 1 on [DATE] at 5:40 p.m. she said that she had been in-serviced on the promptness of responding to alarms, use of fall mats, documentation and notification of physicians. She also stated that LVN 5 was also present for this in-service. On [DATE] at 6:00 p.m. the facility Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at severity level of actual harm, and a scope of pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that have been put into place. Review of a document provided by the facility on [DATE] showed there were 37 residents in the facility evaluated at risk of falls. The CMS Form 672 dated [DATE] showed a census of 46 residents.

Based on observation, interview and record review, the administrator failed to administrate the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility administrator failed to implement the facility policies for Neglect, Physician Reporting of Significant Changes, and Prevention of Accidents in order to protect each resident from neglect and accidents for 1 of 22 residents (Resident #22) reviewed for neglect, physician reporting of changes, and accident prevention. The facility failed to inform the physician of a resident with new onset of altered mental status that continued throughout the day. Resident #22 was confused and repeatedly trying to get out of his bed or chair during the day. The failure of the facility's system to notify the DON of this change, and lack of supervision and intervention by the facility staff members, ultimately resulted in the resident having a second fall within 24 hours. The resident sustained [REDACTED]. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern, that is not immediate jeopardy; due to the facility's need to evaluate the effectiveness of the corrective systems which were put into place. This lack of supervision of residents with significant changes and failure to report these changes places all of the 37 residents identified at risk for falls in imminent danger of significant injuries that could lead to death. Findings include: Record review of the Resident #22's clinical record documented that he was admitted to the facility on [DATE] and was [AGE] years of age with the following Diagnoses: [REDACTED]. Review of the facility's incident report on [DATE] shows that Resident #22 was found on the floor of his room at 7:25 p.m. CNA 6 immediately notified LVN 5. The resident was found in the supine position with his head near the dresser, the fall mat in place, the indwelling urinary catheter bag remained attached to the bed and the indwelling urinary catheter was pulled out of the resident and lying on the floor with the balloon inflated. The resident was noted to have blood to back of his head with a hematoma. The nurse noted external rotation of the right lower extremity, and the resident was complaining of pain to the right lower extremity. The ambulance was called to transfer the resident to the hospital emergency room at this time. Summary of the facility investigation report says the witness statements show that the bed alarm was on, but did not alarm. It was tested three times after the fall and did sound. Fall mat was in place and the side rails were up. At 6:00 p.m. the resident was in the dining room for the evening meal, he was upset with his wife and told her to leave. He was fed by staff and put to bed. Reviews of the nurse's notes for Resident #22 indicate that on the date of [DATE] the resident was alert and assisted up to the wheelchair for evening meal by staff members. Resident #22 denied any discomfort at that time. On [DATE] at 4:50 a.m., the resident's bed alarm was going off and the resident was found in his room sitting on the floor mat with the call light in reach. When the resident was asked what happened, his reply was that he was trying to get to his pickup truck, that he was having car trouble. The resident further stated, "I haven't been drinking tonight." LVN 3 attempted to orient resident to time and place. An 8 cm long by 2 cm wide abrasion was noted to left side of the resident's back. No other injuries were noted. The resident was assisted from the floor to the bed. Two of the resident's doctors were notified at this time. The next entry is at 10:00 a.m. on [DATE] " ....resident continuing attempting to get out of bed this AM without assistance, this nurse (LVN 4) re-directed resident multiple times without improvement ... ...abrasion with blue bruising noted to left back, small bruises x 2 noted to left abdomen side and small amount of dried blood noted to left elbow area ..." The following entry in the resident record is at 7:25 p.m. on [DATE], and states that CNA 6 called LVN 5 and LVN 1 to the resident's room. The resident was noted lying supine on the floor beside the chest of drawers. There was blood noted in a pool around the resident's head. The right leg was noted with external rotation. The resident was alert and answering questions appropriately. The resident indicated pain to the right leg. The hematoma to the back of the head was noted - unable to determine where the blood was coming from, an ambulance was called at 7:28 p.m. The indwelling urinary bag was attached to the bed and the inflated balloon of the indwelling urinary catheter that had been pulled out of the resident was lying on the floor. There was blood noted on the tip of the resident's penis and the report was written on the transfer sheet to the hospital ER. Review of the Fall/Risk Assessment for Resident #22 shows that on [DATE] the score was 16 and again on [DATE] the score was also a 16. Any score on this assessment that rates higher that a 10 indicates a High Risk for Falls. Review of the Care Plans for Resident #22 shows care plans for the following problems/needs: -I am not as mobile as I used to be but still want to remain as independent as I can, My skin is fragile I take aspirin and [MEDICATION NAME]. It indicated that the resident has problems with skin tears and bruising. -I need ? side rails to assist with turning and repositioning and to establish my boundaries. -I have multiple problems that all affect my ability to walk. I have a history of and/or the potential to fall. - I require assistance with all my activities of daily living related to my weakness from cholecystectomy and volume depletion. Review of the Treatment Flow sheets for Resident #22 indicated that the bed alarm is checked every shift as well as the fall mat beside the bed. All shifts have been initialed including the 10:00 p.m. to 6:00 a.m. on [DATE]; the day after the resident had been transferred out of the facility. Review of the 14 day MDS assessment dated [DATE] documented that Resident #22 had some short and long term memory problems. It documented a score of 4 in the section relating to mood indicating little interest in doing things, and feelings of depression. There were no notations of behaviors. The assessment indicated the resident required extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, toileting and bathing. It documented that resident used a wheelchair for mobility. It documented that there was not a need for a pain assessment to be conducted. There was no notation of any falls in this assessment. During an observation on [DATE] at 6:00 p.m., Resident #22 was in the dining room for the evening meal, seated in the wheelchair, and being encouraged with the meal by the staff members. Observation of Resident #22's bedroom on [DATE] at 4:27 p.m. after the survey team was notified of the situtaion revealed an adjustable hospital bed that was in the low position, ? side rails were in the elevated position, and there was a floor mat beside the bed. A bed alarm was hanging on the side rail and a call light attached to the curtain several feet away. During an interview with CNA 6 on [DATE] at 4:35 p.m., CNA 6 reported that he was providing care for another resident who was a neighbor to Resident #22 when he heard Resident #22 yelling. CNA 6 entered the room and found the resident lying on the floor with blood pooled around his head. CNA 6 then called for the nurse. The resident was found in front of the dresser. He was not moved and first aid was initiated. The resident was responding appropriately. CNA 6 said the bed alarm was on, but not working saying, "The nurse had to hit it hard to make it work." This was the only alarm on the resident. In an additional interview at 5:59 p.m. that day CNA 6 said he brought Resident #22 out of the dining room sometime after 6:00 p.m., and put the resident in bed. The next time that CNA 6 saw this resident was around 7:15 p.m. when he was yelling. During an interview with LVN 3 on [DATE] at 2:15 p.m., LVN 3 stated that she was working the 10:00 p.m. to 6:00 a.m. shift and caring for Resident #22 on [DATE]. LVN 3 said that Resident #22 fell at approximately 4:30 a.m. The bed alarm was going off and she was called to the room by a CNA. Another LVN (LVN 10) was with her, and they found the resident sitting on the floor on a fall mat. When asked about any changes in his orientation, LVN 3 said it was unusual that the resident was talking about a pick-up. LVN 3 continued to say that this resident is usually asleep while she is at work and is able to answer all of her questions appropriately. LVN 3 talked to the nurse in the emergency room about Resident #22's confusion, and to the on-call physician about his fall. She also sent a fax to another physician informing of the fall and that the resident was looking for his pick-up, but did not actually address the new onset of change in mental status. LVN 3 told LVN 4 of the fall and asked LVN 4 to call the resident's spouse during shift changer eport at 6:00 a.m. LVN 3 was asked about the disorientation that Resident #22 was experiencing, and LVN 3 said she had told the Registered Nurse in the emergency room about this when she called the on-call doctor. LVN 3 continued to say that this is usually reported to the on-coming nurse and put in the 24 hour report. She stated, "I probably should have told them." During an interview with LVN 4 on [DATE] at 2:30 p.m., LVN 4 said that she had provided care for Resident #22 on the 6:00 a.m. to 2:00 p.m. shift on [DATE]. LVN 3 had told her that Resident #22 was confused and slid out of bed. The resident had an abrasion to his left back, and she sent a communication fax to the physician. LVN 3 told her that the resident was saying that the needed to get his pickup fixed. While LVN 4 was caring for Resident #22 during the day he was trying to get up out of bed multiple times. When LVN 4 was asked if she notified the physician about the resident's confusion and trying to get out of bed, she stated, "I probably should have, but I didn't." During an interview with LVN 5 on [DATE] at 4:35 p.m., LVN 5 said that Resident #22 had an unwitnessed fall at approximately 7:30 p.m. on [DATE]. LVN 5 was talking with LVN 1 in the hallway of the facility. CNA 6 shouted out for them to come down to where he was. They went into Resident #22's room and found him lying on his back in the floor in a big pool of blood around his head with his right leg externally rotated. When LVN 5 asked the resident what happened, he told her that he could not move his right leg. She reported that the resident was able to move his arms and left leg. She also noticed that the indwelling urinary bag was still attached to the bed and the indwelling urinary catheter with an inflated balloon was pulled out of the resident and was lying on the floor. LVN 5 filled out transfer papers for the resident and stayed with him until the ambulance came. The fall mat was noted to be on the floor and alarm on the bed by the LVN. During a follow-up interview on [DATE] at 5:55 p.m., LVN 5 said that at 2:30 p.m. on [DATE] Resident #22 was trying to climb out of bed, he was trying to find his pick-up. Normally the resident is "with it" according to LVN 5. When asked if she thought she should have contacted the doctor about the change in mental status she said, "I probably should have called the doctor, but I didn't." An additional telephone interview was completed on [DATE] at 5:00 p.m. with LVN 5. During this interview LVN 5 was asked about the mental status of Resident #22 during her shift; she said the resident was telling her he was going to get his pick-up. At 2:30 p.m. Resident 22's bed alarm was going off, and she was able to get him laid down with the help of an aide. It happened again later, so they got the resident up. LVN 5 said that she was told about Resident #22's falls and abrasions when she came on shift. An interview with LVN 1 completed on [DATE] at 4:30 p.m. revealed that CNA 6 came and got herself and LVN 5. They found Resident #22 on the floor with his feet towards the bed, and the indwelling urinary catheter bag still attached to the bed. The indwelling urinary catheter with balloon still inflated, was lying on the floor. The resident was alert, conscious and talking. There was blood on the floor by his head and he had blood in his hair on the right side. A hematoma was noted on the right side with a laceration. They placed an ice bag on his head. In an interview with the CRN (Corporate RN) she said that Resident #22 had fallen on Monday, [DATE], at 7:30 p.m. Resident #22 was transported to the hospital and had a [MEDICAL CONDITION]. He had surgery on [DATE] in the morning and never came out of the anesthesia. He was a DNR. She said the nurse on the floor said the alarms were going off and when they went to the room he had gotten up out of bed and fallen. He had a hematoma to one side of his head, but no open wound. Blood was noted on the floor. When the resident got up he pulled out his indwelling urinary catheter. He was awake and alert - his level of consciousness was the same as before the fall. They got him an ice pack and called the ambulance. His wife was called. When a staff member was delivering a lab specimen to the hospital on Tuesday afternoon, they found out that he did not wake up from anesthesia. The DON looked in the resident room today and there was a fall mat in the room. The bed alarm worked for the DON. The CRN reported that Resident #22 had both a bed and personal alarm on at the time of the fall. In an interview with the DON on [DATE] at 4:05 p.m., the DON revealed that Resident #22 had been in the facility since March. On Monday evening ([DATE] around 7:30 p.m.) the resident ate dinner in the dining room. After dinner he was put to bed by CNA 6. This CNA found the resident in the floor at 7:25 p.m. and had LVN's 1 and 5 come to the room. The resident was found with his feet toward the bed, head towards the dresser. His indwelling urinary bag was still hooked to the bed and the catheter with the balloon inflated was lying on the floor having been pulled out of the resident. A hematoma was noted to the right side of the head and a pool of blood was on the floor. They noticed external rotation of his right lower extremity. 911 was called and he was transported to the local hospital. He was admitted with a [MEDICAL CONDITION] and had surgery the following day. He passed away after surgery. She further stated that Resident #22 had a bed alarm and fall mat in place. She stated the bed alarm was not working. In an interview with the DON on [DATE] at 4:00 p.m., she said that she did not receive any incident report about Resident #22's fall during the night shift. The night nurse had given it to the 6:00 a.m. to 2:00 p.m. nurse to call the family and complete. There was no documentation on the 24 hour report of his fall or confusion. She was not made aware of his change in mentation until after his fall on the evening of [DATE]. She said that she felt that Resident #22's confusion was a factor in his fall. He was also mad, she had seen him at dinner and someone was helping him to eat. When the staff found him and the alarm was not alarming, he had to have stood up from the bed because of where he was found on the floor in his room. She had no explanation of why the alarm was not alarming or why the staff had not taken more interventions with the changes that Resident #22 was experiencing that day. During an interview on [DATE] at 3:45 p.m., the administrator was asked what he felt did not occur concerning this fall that should have. He replied that the floor nurse or CNA should have at least mentioned to the administration that something was not quite right with Resident #22. When asked how this usually is reported, the administrator mentioned the 24 hour report, but was unable to say what the report said about Resident #22 on the day of the fall. When asked if he was aware that this resident had a change in mental status, the ADM said that he lets nursing deal with nursing issues and he deals with the social things. He stated that he likes to stick to asking about social things as opposed to specific nursing things like mentation, "That's not good to ask." He deals with the residents,"Like man to man, because they respond better - of course the women are different." When the administrator was asked if he had reviewed the resident record and what had happened on the day of the fall, he replied that he had not; "...since we had had the record since it happened." Review of the 24 Hour Report/ Change of Condition Report for [DATE] had no mention of any changes with resident #22 until the evening shift. It stated, "Resident fall sent to ER." Review of hospital records for Resident #22 received on [DATE] showed that the resident was alert and confused at 8:15 p.m. on [DATE] according to the nurse's notes. Another entry at 9:45 p.m. on [DATE] states that the resident is alert, oriented to self and wife only, confused. Physician notes from [DATE] at 8:04 a.m. indicated the resident has had recent bouts with frequent urinary tract infections and required some hospitalization . The resident has been in the nursing home but was actually getting close to discharge. He got up yesterday without any assistance and fell which resulted in a displaced right femoral neck [MEDICAL CONDITION] hip. Physician notes from [DATE] state the doctor was called to see Resident #22 who had surgery that day for a right [MEDICAL CONDITION]. He had not done well since the surgery. Blood pressure had been low. Urine output had also been minimal. He was a DNR. Resident #22 expired at 8:32 p.m. the note stated, "The family had been made aware of this possible complication in an elderly patient and understood that this might happen and seemed to very understanding. " Review of the facility policy titled - Change in a Resident's Condition or Status dated [DATE] states the following: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.) 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: c. A reaction to medication d. A significant change in the resident's physical/emotional/mental condition e. A need to alter the resident's medical treatment significantly i. Instructions to notify the physician of any changes in the resident's condition Review of the facility policy titled - Abuse Prevention Program dated [DATE] states the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Review of the facility policy titled - Reporting/Investigation Resident Accidents/Incidents dated [DATE] states the following: All accidents/incidents involving residents must be reported to the administrator or his/her designee. The facility administrator was notified on [DATE] at 6:30 p.m. that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 8:05 p.m. The Plan of Removal was accepted on [DATE] at 5:55 p.m. The facility took the following actions to remove the IJ: 1. Nursing staff will check that all interventions that are care planned are in place and properly functioning. 2. Fall risk assessments on all residents will be updated 3. All quarterly risk assessments will be updated the week the MDS is due 4. The RAC nurse will notify the DON/ADON if the assessments are not being done 5. In-service staff on appropriately filling out Fall Assessments - anti-slip socks, fall mat, personal alarm, bed alarm, physical therapy evaluation, cradle mattress 6. Shift to shift report will be given away from the nurse's station and family interruptions either in the family room or medication room 7. 24 hour report monitored daily by DON/ADON/RAC or combination of all 3 depending upon who is present in the building 8. All pertinent information happening on 8 hour shift will be responsible for being put on the 24 hour report - significant labs, changes in LOC, changes in resident ' physical condition, any new medication changes 9. The DON/ADON/RCA will pick up the 24 hour report on Saturday and Sunday and check the documentation on the weekends. 10. The 24 hour report is filed in the DON office 11. Contact physician with current vital signs, any changes in LOC, adverse effects of medications, lab abnormalities if available and neuros if appropriate. 12. Any falls resulting in an obvious significant injury will be transferred immediately. 13. In-service on change of condition, notifying physician, proper use of 24 hour report, proper use of alarms and functioning starting with the ,[DATE] shift followed by ,[DATE] shift. 14. In-service training on change of condition on resident to include the following: changes in LOC, changes in v/s, abnormal labs, adverse effects of medications, etc. 15. In-service all non-nursing personnel on who to alert in the event they find a resident has fallen 16. The charge nurse for that resident will be held responsible for notifying the physician of any and all incidents in regards to that resident. Per policy except in emergencies, notification will be made within 24 hours of a change occurring in the resident's medical/mental condition or status 17. Nurses will initial each shift for proper alarm functioning. 18. In-service to check for batteries, placement, lights flashing, and sound functioning of bed alarms. 19. Any changes of condition/risk for falls will be placed on the 24 hour report and passed on to all nurses coming on. The nurse will be expected to make the necessary interventions at this time. The DON/ADON/RAC will review the 24 hour report and follow up to ensure interventions were done. If further issues arise the Regional Nurse will be contacted. 20. The 24 hour report is used to communicate changes to nurses in regards to residents medical or mental condition, new admission, changes in medication regiment, lab values beyond the norm, changes in behavior, any significant illness or change in v/s or LOC, fall with or without injury, etc. 21. All medical emergencies requiring transport to the hospital the ADM/DON will be notified. 22. All other issues will be discussed in the morning stand up meeting when the DON goes over the 24 hour report 23. In-service staff on properly reporting any falls, injuries, that they witness or se on a resident to the nursing department while insuring the safety of the resident 24. In-service all staff on change of condition and who they are to contact each time 25. In-service all staff on reporting immediately any changes to MD and responsible party 26. In-service staff on correct way to fill out incident and accident form 27. Compliance rounds to be made by DON/ADON daily comparing list of alarms to the list on Matrix 28. Supervision of staff to insure that they are monitoring the alarms and checking for proper functioning 29. All interventions for falls are kept on the nurses treatment record to be checked every shift 30. Out of cycle Quality Assurance and Assessment on falls 31. DON/ADON/RAC will review all clinical records fir a resident with a fall 32. Compliance rounds will be checked to make sure that batteries are in the personal alarms, alarms sound, turned on, switched on 33. All falls will be followed up in QAA for 6 months Record review of the in-service for the dates of [DATE] and ,[DATE] indicate that seven staff members have been in-serviced on change in condition and neglect. A checklist of all residents showing that fall assessments had been updated and all prescribed fall prevention equipment was in place and functioning, was provided by the DON on [DATE] at 11:10 a.m. for review. Record reviews of the additional 10 residents added to the resident sample were completed on [DATE]. The proper incident reports had been filled out for these residents who had falls in the last 30 days. There were care plans in place for fall risk on all of these residents and updated fall risk assessments. Each of these 10 resident rooms were checked to ensure that all equipment to prevent falls was in place and in working order. In an interview with LVN 1 on [DATE] at 5:40 p.m. she said that she had been in-serviced on the promptness of responding to alarms, use of fall mats, documentation and notification of physicians. She also stated that LVN 5 was also present for this in-service. On [DATE] at 6:00 p.m. the facility Administrator and DON were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at severity level of actual harm, and a scope of pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that have been put into place. Review of a document provided by the facility on [DATE] showed there were 37 residents in the facility evaluated at risk of falls. The CMS Form 672 dated [DATE] showed a census of 46 residents.