Every finding on record at Bradley Health Care & Rehab

Based on facility policy review, medical record review, video surveillance footage review and interview, the facility failed to provide individualized behavioral interventions, and sufficient supervision to prevent wandering, and exit seeking behaviors, for 1 resident (Resident #1) of 4 residents reviewed for behaviors which resulted in actual Harm to Resident #1. The facility's failure to provide sufficient monitoring, supervision, and adequate care plan interventions in response to wandering and exit seeking behaviors, resulted in Resident #1 sustaining fall related injuries during a wandering episode on 4/28/2026. The findings include: Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .Residents determined to be at risk for elopement will be monitored by staff . Review of the facility's undated policy titled, Behavior Management Policy, revealed .It is the policy of [Named Facility] .to minimize challenging and inappropriate behavior .within the facility .so that all residents may enjoy a high level of satisfaction and quality of life .Behavior management .adjusting the environment to meet that resident's needs .should demonstrate a positive approach and be resident-centered .early intervention should be used to prevent behavior from escalating to a higher level .staff will intervene immediately at the first indication of escalating behavior .interventions may include .Distraction .attempt to redirect resident with alternative actions .re-direction .remove resident from the situation by turning towards another area, again offering alternatives .staff will assess resident to attempt to determine a trigger for the behavior .once need is determined .staff will facilitate meeting that need . Review of the medical record revealed Resident #1 was admitted to the facility 3/13/2026 with diagnoses including Dementia, Displaced Comminuted Fracture of Left Tibia, Closed Fracture with Routine Healing, Bipolar Disorder, Macular Degeneration, and Repeated Falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Continued review revealed Resident #1 had impaired thought processes and wandering behaviors 4 to 6 days weekly. Review of the Wandering Risk assessment dated [DATE], revealed Resident #1 scored a14 which was considered at high risk for wandering. Review of the admission care plan for Resident #1 dated 3/17/2026, revealed the resident had a diagnosis of Dementia and Bipolar Disorder with mood problems and Depression, which included interventions including .Administer medications as ordered .Encourage Resident to express feelings .Report .acute episode feelings or sadness Recommend behavioral interventions for staff . Resident has a mood problem r/t [related to] bipolar disorder .currently taking psychoactive meds .Briefly provide supporting listening/conversation the redirect to positive topic/activity . Continued review revealed an individualized person-centered care plan had not been developed or implemented with interventions in place to address Resident #1's dementia behaviors related to elopement risk factors and known history of wandering behaviors. Review of the fall risk assessment dated [DATE], revealed Resident #1 scored a 22 and was considered at high risk for falls. Review of a psychiatric periodic evaluation note dated 3/23/2026, revealed .[Resident #1 is seen today for reassessment of insomnia, anxiety, and restlessness, and sadness with tearfulness .melatonin [sleep aide] was restarted one week ago .Staff report patient [Resident #1] is still not sleeping very well. Patient more confused and more anxious with restlessness and agitation in the evenings and at night c/w [consistent with] sundowning [state of increased confusion, agitation, anxiety, and restlessness that occurs in the late afternoon and lasts into the night] .Today [Resident #1] is sitting on the side of her bed, eating lunch and visiting with her daughter who is sitting at the bedside .She is alert .interactive .calm .comfortable .She is confused and oriented to person only .she does not know who her daughter is .cognition is severely impaired .spoke with daughter at length today .she states patient has been more confused, more anxious, more sad, and more tearful since admission .she states she [Resident #1] is not sleeping well and is often acting crazy at night .discussed recent anesthesia, recent moves from home to hospital to this facility, as well as having to take new pain medication for acute pain, all are likely causing .increased confusion, behaviors, anxiety and worsening mood .Patient is on medication for Bipolar or Delusional Disorder, Major Depressive Disorder with Psychotic Features, Adjunctive Treatment for Treatment-Resistant Depression, Parkinson's Disease Psychosis, Delirium, Brain Injury, or Dementia Related Indications .Gradual Dose Reduction of the patient's antipsychotic medication was not recommended or ordered during this visit . Review of the nurse's notes for Resident #1 dated 3/13/2026 - 4/13/2026, revealed Resident #1 fell on 3/13/2026, 3/22/2026, 4/2/2026, 4/10/2026, and 4/13/2026 which were most likely attributed to resident behaviors, confusion, and Dementia diagnosis. Continued review revealed Resident #1 was transferred to a local hospital emergency department by ambulance on 4/13/2026 for treatment of lacerations and bruising to the forehead sustained from the fall on 4/13/2026. Review of the Pre-admission Screening and Resident Review (PASRR) Level 1 screening for Resident #1 dated 4/16/2026, revealed .Your [Resident #1] neurocognitive disorder/dementia, is so progressed that is considered to be the primary condition requiring treatment at the time of this review .and you are not likely to benefit from disability related services at this time . Review of the facility reported incident (FRI) investigation report dated 4/28/2026, revealed on 4/28/2026 Resident #1 entered Resident #2's room, undetected by staff, remained in the room for approximately 44 minutes, and was involved in a fall with injuries, which required emergent care to address the fall related injuries. Continued review of the FRI revealed in response to the incident, a removeable door barrier (stop sign) was added to the doorway of Resident #2's room to prevent Resident #1 from wandering into the room again. Review of the FRI report and investigation notes for Resident #1 dated 4/28/2026, revealed the facility determined Resident #1 had fallen during a wandering episode in which the resident wandered from the hallway into Resident #2's room by wheelchair, closed the door, and remained in Resident #2's room for 44 minutes undetected by staff on the unit, until Resident #1 was found crawling on the floor out of the room, bleeding from the forehead. Trails of blood droplets found on the floor of the room, indicated Resident #1 had traversed Resident #2's room from the door to the window. Review of facility video surveillance footage of the incident time stamped 4/28/2026 from 6:19 PM until 7:45 PM, revealed Resident #1 was observed wandering about the unit seated in a wheelchair. Resident #1 was observed in the hallway, and began to push the wheelchair from behind, to the nurse's station where a staff member was seated and did not notice Resident #1 until the resident came into close proximity to the nurse's desk. The staff member redirected Resident #1 back to the wheelchair. Resident #1, who was seated in the wheelchair, proceeded to wander away from the nurse's station and was observed on the video footage to wander the hallway near the nurse's station and an exit door where visitors were entering and exiting the facility, without staff supervision or redirection. Continued review revealed at 6:49 PM, Resident #1 attempted to follow visitors out the door and was redirected away by the visitors. Staff present at the nurse's station and in the general vicinity of the resident continued their tasks, without redirecting the resident, as Resident #1 proceeded wandering to the [NAME] Hallway and away from the nurse's station. Resident #1 was then observed to test doors to the locked storage room and at 6:21 PM the resident opened the door to a charting kiosk, rolled inside the doorway, then backed out, as staff present on the unit continued their tasks, and did not redirect Resident #1's behaviors. Further review revealed Resident #1 was observed in the wheelchair and continued to wander in the [NAME] Hallway. At 6:53 PM, Resident #1 entered Resident #2's room, closed the door behind her, and went undetected or redirected by staff. Further review of the video footage from 6:53 PM to 7:37 PM (44 minutes), revealed multiple staff present on the unit carrying out various tasks. Staff appeared to be unaware of Resident #1's whereabouts, until 7:37 PM, when Resident #1 was seen crawling on the floor away from Resident #2's room, with blood visible on the forehead. 2 staff who were present in the hallway immediately responded to Resident #1, and after a brief assessment, were observed running down the hallway towards the nurse's station. The 2 staff members who responded, left Resident #1 unattended by staff, still in the floor crawling and bleeding from the forehead. Approximately 1 minute later multiple staff were seen rushing to render aid to Resident #1. Continued review of the video footage revealed Emergency Medical Services (EMS) arrived approximately 4 minutes after the facility staff rendered aid to Resident #1. The video footage revealed EMS personnel transported the resident out of the facility on a gurney. Further review of the video footage revealed Resident #1 was observed with visible bruising and blood on the forehead as she was transferred to an ambulance outside. Review of the hospital records for Resident #1 dated 4/28/2026, revealed the resident was evaluated by the emergency physician who documented the bleeding on Resident #1's forehead was due to a reinjury of scabbed laceration sites (previously sutured) at the same local emergency department (ED) related to a fall sustained 2 weeks prior while at the facility. Resident #1 was released back to the facility for continued care after computer assisted tomography studies (CAT Scan) performed at the hospital ruled out acute head injuries. Review of psychiatric hospital records for Resident #1 dated 5/8/2026 - 5/11/2026, revealed Resident #1 was transferred from the facility to an acute mental health center for evaluation due to behaviors on 5/8/2026, (10 days after the facility reported incident) and was discharged back to the facility on 5/11/2026 for continued care after medication adjustments from the psychiatric hospital. Review of the comprehensive care plan for Resident #1 dated 5/18/2026, revealed the care plan had not been revised to address Resident #1's recent psychiatric hospitalization from 5/8/2026-5/11/2026, or new interventions to address Resident #1's behaviors, including the wandering behaviors demonstrated on 4/28/2026 with the subsequent fall. Continued review revealed no changes were documented in the care plan regarding the psychiatric hospital recommendations related to medication changes, or any additional new interventions added to the care plan to address Resident #1's frequent falls. During an interview on 5/18/2026 at 8:20 PM, Licensed Practical Nurse (LPN) A (the unit manager) stated she had provided care for Resident #1 since admission and was aware the resident was considered a high risk for falls. LPN A stated the resident had sustained multiple falls prior to 4/28/2026 due to poor safety awareness, severe cognitive impairment, non-compliance with safety measures, and behaviors related to the resident's Dementia diagnosis and was known to frequently wander. LPN A stated the resident's behaviors were worse in the evening or nighttime hours and staff usually monitored Resident #1 closely at the nurses' station or maintained the resident in close proximity to the nurse during medication rounds as an intervention for the wandering behaviors. LPN A further stated on 4/28/2026 at the time of the resident's fall, the nurse and staff had lost track of Resident #1's whereabouts while attending to other tasks. LPN A confirmed she and the facility staff on duty were not aware Resident #1 had wandered into another resident's room, had been left unattended for 44 minutes, and had fallen until Resident #1 was observed crawling out of the doorway out of the other resident's room on 4/28/2026. During an interview on 5/18/2026 at 3:49 PM, the Social Worker stated Resident #1 was admitted to the facility from a local hospital after the treatment for fall-related injuries sustained at home. The Social Worker stated Resident #1's family had not reported any behaviors of Resident #1 during the admission initial family interview or the care planning meetings. The Social Worker stated after admission to the facility, the resident began to exhibit wandering behaviors, had sustained several falls since admission to the facility, and was known to be combative with staff during ADL care. The Social Worker stated she had no explanation as to why Resident #1's diagnosis of Dementia with risk factors identified on the admission MDS assessment and the PASRR level one screening had not been developed or implemented on the resident's care plan. The Social Worker confirmed an individualized person-centered Dementia care plan for Resident #1's known high risk factors for falls, wandering and combative behaviors, or exit seeking and elopement risk behaviors, had not been developed or implemented with intervention on the care plan. During an interview on 5/18/2026 at 4:30 PM, the Director of Nursing (DON) confirmed the facility had not revised Resident #1's person-centered behavioral care plan with interventions to address the resident's wandering behaviors, the intervention of using the stop sign after the incident on 4/28/2026, or the psychiatric hospitalization on 5/8/2026-5/11/2026 with appropriate interventions. During an interview on 5/18/2026 at 6:55 PM, the Director of Nursing (DON) confirmed the facility failed to develop and implement a person-centered Dementia care plan for Resident #1 with specific interventions to reduce the wandering and exit seeking behaviors. During interview on 5/19/2026 at 10:30 AM the DON confirmed the facility failed to adequately supervise, monitor, and redirect Resident #1's behaviors on 4/28/2026. The DON confirmed the facility's failure resulted in the facility staff not having an awareness of Resident #1's whereabouts for approximately 44 minutes resulting in an unwitnessed fall with injury and transport to the local ED for evaluation and treatment.

Based on review of the facility policy, observation, and interview, the facility failed to remove resident plates and utensils from serving trays, to promote a dignified dining experience for 8 of 8 residents observed in the [NAME] 1 dining room and delayed assistance to 1 dependent resident (Resident #13) for 20 minutes who was seated at the same table as other residents received and finished their meals.The findings include: Review of the undated facility policy titled, Promoting/Maintaining Resident Dignity, revealed .It is the practice of this facility to .promote .and treat each resident with respect and dignity .care for each resident in a manner and in an environment, that maintains or enhances quality of life .Each Resident will be provided equal access to quality of care, regardless of diagnosis, severity of condition . Review of the medical record revealed Resident #13 was admitted to the facility 11/25/2025 with diagnoses including Adjustment-Disorder with Depressed Mood, Mild Cognitive Impairment, Generalized Anxiety, Unspecified Tremor, Moderate Malnutrition, and Muscle Weakness. Review of admission and Quarterly Minimum Data Set (MDS) assessments dated 11/25/2025, revealed Resident #13 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated Resident #13 was cognitively intact. Continued review revealed Resident #13 required set up and supervision with eating. During multiple observations of Resident #13 and other peers seated in the main dining room on 5/18/2026 and 5/19/2026 during the lunch meal service, revealed on both dates, meals were served to residents atop service trays. The plates and utensils were not removed from the service trays throughout the meal. Resident #13 was observed on 5/18/2026 and 5/1/2026 seated at a time during the lunch meal and waited for over 20 minutes while others seated at the same table, received and finished their meals, before staff served and assisted Resident #13 with his meal. During an observation and interview on 5/19/2026 at 6:05 PM, in the dining room, Resident #13 was observed to have finished his meal, and sat at a table with another resident. Resident #13 stated he had frequently observed other residents being served their meals and had watched as the other residents sat at the same table consume the meals as he waited for assistance. Resident #13 (who was alert and oriented in all spheres) stated the practice of having to wait to be served and assisted with meals was customary for him and further stated .I am real easygoing, but sometimes it makes me feel left out . During interview on 5/19/2025 at 6:30 PM, the Director of Nursing (DON) confirmed the facility failed to maintain Resident #13's dignity, in accordance with expectations of the facility policy, during the meal services.

Based on review of the facility abuse policy, review of facility investigations, and interviews, the facility failed to ensure facility reported incidents (FRI) related to allegations of abuse were reported within a timely manner for 4 residents (Residents #1, # 2 #3 and #4) of 11 residents sampled for abuse or neglect.The findings included: Review of the facility policy and procedure Resident Abuse revealed .When an incident of suspected resident abuse, mistreatment, or neglect is reported the following will occur .The case of suspected abuse will be reported per regulation to the Department of Health by Administrator or Designee .If you have witnessed or have knowledge of such actions in this facility, please give an immediate report to Administration .Resident Abuse May Also Be Reported to . (State Agency) . (Ombudsman) . Review of the facility FRI (incident 2998873) dated 4/29/2026 revealed the incident referenced in the FRI included allegations of potential resident versus resident abuse, which was documented to have occurred on the evening of 4/28/2026 around 7:50 PM between Residents #1 and #2. Continued review of the documents revealed the allegations were received by the state agency on 4/29/2026 at 2:01 PM, 18 hours after the incident occurred. Review of facility FRI (incident 2998805) dated as received by the state agency on 4/29/2026 at 1:41 PM, showed the incident referenced in the FRI occurred on the evening of 4/23/2026 (6 days earlier), and included allegations of potential resident versus resident physical abuse between Residents #3 and #4. Continued review showed the facility abuse coordinator was not made aware of the allegations of potential resident on resident abuse, until the morning of 4/24/2026, (the day after the allegations were to have occurred) at which time the facility formally launched an investigation, which was not reported to the state agency until 5 days later. During interview on 5/19/2026 at 10:30 AM, the Director of Nursing (DON) confirmed the facility failed to report allegations related to potential resident versus resident abuse to the state agency within 2 hours of the facility becoming aware of them, as mandated by state and federal requirements for both incidents.

Based on review of facility policy, medical record review, review of the facility investigation, observation, and interviews, the facility failed to prevent abuse for 1 resident, (Resident #2) of 7 residents reviewed for abuse or neglect. The facility's failure to prevent abuse with subsequent injuries of Resident #2 after an assault by Resident #3, resulted in actual Harm of Resident #2. F 600 was cited at a Harm as past non-compliance. The facility is not required to submit additional corrective actions. The findings included: Review of the facility titled, Abuse Policy, revised [DATE], showed .It is the policy of this facility to provide protections .and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .resulting physical harm .which can include .certain resident to resident altercations . Medical record review showed Resident #2 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia with Severe Agitation and Behaviors, Thrombocytopenia (low platelet counts), Generalized Anxiety Disorder, Hypertension, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 had a Brief interview for Mental Status score (BIMS) of 4 which indicated severe cognitive impairment. Resident #2 had hearing and visual impairments, communication deficits, inattention, and disorganized thinking but no history of aggressive behaviors directed towards others. Resident #2 required ,d+[DATE] staff assistance with all activities of daily living. Review of the care plan dated [DATE], for Resident #2 showed the interventions for Dementia with Behaviors included non-pharmacologic interventions to address Agitation, Delusions, and Anxiety. Review of the Physician Orders dated [DATE], for Resident #2 showed, .Monitor for side effects associated with Benzodiazepine medications [Xanax/Alprazolam] [antianxiety medication] .new onset or increased severity of .aggressive/impulsive behavior . Monitor for Side Effects associated with antipsychotic Medications .[Seroquel] .new onset or increase in severity of .disorientation, confusion .restlessness .every shift Review of the Medication Administration Record (MAR) dated ,d+[DATE], for Resident #2 showed .Alprazolam 0.25 milligram [mg] tablet, 1 tablet by mouth every 12 hours as needed for anxiety, agitation .every shift .Seroquel Oral Tablet .Give 25 milligram by mouth in the evening for psychosis, agitation and aggression . Review of Physician's orders dated [DATE], for Resident #2 showed to change the Alprazolam 0.25 mg from every 12 hours to every 6 hours as needed (PRN) for Anxiety. Medical record review showed Resident #3 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia with Behaviors, Generalized Anxiety Disorder, Cardiomegaly (enlarged heart), Stage 2 Chronic Kidney Disease, Major Depressive Disorder, Restlessness and Agitation, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], showed Resident #3 had a BIMS score of 1 which indicated the resident had severe cognitive impairment. The resident had impaired attention, disorganized thinking, delusions, and wandering, but no verbally or physically aggressive behaviors directed towards self or others. Resident #3 required 1 person staff assistance with all activities of daily living. Review of the [DATE]-[DATE] daily nursing notes showed Resident #3 showed no signs of aggression to self or others until [DATE]. Review of the facility investigation dated [DATE] showed Resident #2 and Resident #3 ambulated to the common day/dining area around 6:00 PM. Resident #2 became agitated and began to yell. Resident #3 spoke to Resident #2 who became verbally aggressive towards Resident #3. Resident #3 slapped Resident #2 on the face and grabbed her upper arm in response. Resident #4 who was inside the day area and saw the incident, reported the altercation to nursing staff who immediately interceded and separated the two residents. Resident #3 was taken to her room and placed on 1 to 1 supervision. Resident #2 was taken to her room and assessed by Licensed Practical Nurse (LPN) #1 who documented Resident #2 sustained 2 small skin tears to her upper right arm which were treated with steri- strips (adhesive bandages). Resident #3 was transferred to a local hospital for psychiatric evaluation and returned to the nursing home approximately 4 hours later with no changes in her orders. Resident #3 continued 1 to 1 supervision until [DATE] when the resident was admitted to a geriatric mental health center for acute treatment. Resident #2 received neurological checks for 72 hours with no adverse findings. Resident #2 developed a faint bruise on her lateral right forehead where she had been struck by Resident #3. Review of the Psychiatric Periodic Evaluation for Resident #3 dated [DATE], showed .persisting behaviors .dementia, anxiety, restlessness, agitation, irritability .aggression .distressing psychosis .patient is being cross tapered from .Seroquel to Brexpiprazole [an antipsychotic drug indicated for use in dementia] due to ineffectiveness of Seroquel .staff reporting tolerating this change .but do not report any improvement in patients restlessness, agitation, aggression .patient hit another resident yesterday .continues to have intrusive behaviors .today she is alert and interactive .is calm and pleasant .she is confused, delusional and oriented to person only .cognition remains severely impaired .Most recent GDR [gradual dose reduction] [DATE] cross taper to .Brexpiprazole . Continued review showed .patient needs .secure behavioral unit . Review of the care plan for Resident #3 updated on [DATE], showed .Behavior Problem .Physically abusive, socially inappropriate, verbally abusive, wandering .intervention . address wandering by walking with resident .redirect from inappropriate areas .engage in diversional activity .assess identification of unmet needs .identify events that trigger behaviors . Review of Psychiatric Hospital Records dated [DATE], showed Resident #3 was admitted and was diagnosed with Acute Urinary Tract Infection (UTI) and Unspecified Dementia with Behaviors and Agitation. Resident #3's UTI was treated with oral antibiotics and the resident's behaviors stabilized. Resident #3 was discharged back to the facility for continued long term care on [DATE]. During observations and interviews with Resident #3 which were conducted throughout the survey between [DATE] and [DATE] and included brief interviews at varied times of day. Resident #3 who was confused had no recall of the altercation and showed no signs of agitation or aggression. Resident #3 was observed on [DATE] at 1:06 PM, [DATE] at 5:02 PM and [DATE] at 3:20 PM, with 1 to 1 supervision during assistance with large group activities in which the environment was more stimulating or while in common areas socializing with other residents and staff and the intervention was effective. During an interview on [DATE] at 1:10 PM, LPN #1 (the unit charge nurse) reported she was not on duty at the time of the incident. LPN #1 reported she was updated on the situation by the DON on her return to work. LPN #1 reported she participated in a Quality Assurance review of the incident and Resident #3 had been placed on 1 to 1 supervision until she was transferred to Psychiatric Care. LPN #1 reported Resident #3 was free of verbal or physical aggression towards others. LPN #1 reported Resident #3 was profoundly confused at baseline and had poor safety awareness. LPN #1 stated the facility provided close supervision of the resident. LPN #1 reported the facility revised Resident #3's care plan to always include monitoring of her location and 1 to 1 supervision when in groups or socializing on the unit if she became anxious or agitated. LPN #1 reported thus far increased monitoring of Resident #3 had prevented any recurrent altercations or falls or severe agitation due to overstimulation. During an interview on [DATE] at 1:44 PM, Resident #4 (witness to the altercation between Resident #2 and Resident #3) was alert and oriented to time, place, and circumstances. Resident #4 stated Resident #2 was in the day area and suddenly became agitated and began to yell and repeatedly made Indian sounds (inappropriate ethnic and racist sounds) which caused Resident #3 to become agitated. Resident #3 walked over to Resident #2 and Resident #2 yelled out at Resident #3 which triggered Resident #3 to grab Resident #2's arm and then slapped Resident #2 on the side of the face. Resident #4 stated after Resident #3 slapped Resident #2, Resident #3 stepped away, and Resident #2 sat on a chair and continued to yell incoherently. Resident #4 called for nearby staff to intercede and the two residents were separated. During an interview on [DATE] at 1:52 PM, LPN #2 stated she was not on duty when the incident occurred but was briefed by the DON about the altercation on her return to work the next day. LPN #2 reported Resident #2 was very demented, continuously confused and would often wander the unit looking for lost children, or going to board a train, and required frequent redirection and often called out or yelled randomly. LPN #2 stated Resident #3 had severe cognitive decline, poor impulse control and had intermittent agitation was prone to wandering in the facility and frequently attempted to help other residents. LPN #2 reported several weeks after the altercation Resident #2 expired at the facility of complications of COVID 19 and renal disease. LPN #2 reported Resident #3 had not experienced recurrent resident versus resident altercations since her return from psychiatric care but still required close monitoring when interacting with peers or in group activities or in situations in which the environment was noisy to avoid overstimulation. LPN #2 reported Resident #3 still tried to help other residents and had periods of increased confusion and intermittent agitation, but was care planned for 1 to 1 supervision during those times which had been effective LPN #2 reported Resident #3 was followed by the Psychiatric PA weekly. During interview on [DATE] at 2:02 PM Certified Nurse Aide (CNA #3) reported she regularly cared for Resident #3 and had separated her from Resident #2 during the altercation on [DATE]. CNA #3 reported Resident #3 was a former counselor and believed she was still working at a rehabilitation center frequently. CNA #3 reported since Resident #3 had returned from the Psychiatric Hospital she had not been involved in any resident versus resident incidents. CNA #3 reported staff were trained to monitor Resident #3's whereabouts when on the unit and to provide 1 to 1 as needed during periods of increased confusion or agitation after the Resident returned from the hospital and stated it had been effective. CNA #3 reported staff had incorporated a daily nap after lunch for Resident #3 into her daily routine which appeared to reduce her evening and nighttime confusion and bouts of agitation. During interview on [DATE] at 2:13 PM CNA #4 reported she was working another unit on the day of the incident but was advised of 1 to 1 for Resident #3 the next day when she staffed the 400 wing. CNA #4 reported Resident #3's behaviors had improved since her return from the hospital, but the resident still required close monitoring and redirection at times especially when in the day area or when wandering. CNA #4 reported she had not observed Resident #3 with aggression since the resident's return to the facility. CNA #3 confirmed she had received training related to the incident and was able to discuss interventions in place to prevent agitation or aggression in Resident #3 in response to the incident. During an interview on [DATE] at 2:26 PM, in the conference room, DON and Administrator confirmed the facility investigation determined Resident #3 was the aggressor in the altercation on [DATE]. The Administrator and DON confirmed Resident #3's actions were willful and the facility had failed to prevent abuse of Resident #2. During an interview on [DATE] at 2:00 PM, the Medical Director confirmed the facility Quality Assurance review of the altercation was discussed with him as reported by the DON and Administrator and ongoing QA reviews of the corrective actions implemented in response to the altercation were planned to maintain sustained compliance. The facility submitted an acceptable Plan of Correction on [DATE] which was validated onsite by the surveyor on [DATE]-[DATE]. Non-compliance was noted from [DATE]-[DATE]. The Plan of Correction was summarized as follows: 1. At the time of the incident, the facility immediately separated and performed physical examinations on both residents. Resident #2 suffered 2 small skin tears on her upper right arm which were treated with steri strips. Neurological checks for Resident #2 were implemented and performed. Resident #3 was placed on direct 1 to 1 supervision until transferred to the local hospital for psychiatric evaluation after interview by local law enforcement officers. No other residents were impacted by the incident. 2. The facility Administrator, Director of Nursing, and Medical Director held an ad hoc Quality Assurance Meeting by telephone to discuss the incident once the facility investigation was underway on [DATE]. The Physician ordered Resident #3 transferred by ambulance to a local hospital for psychiatric evaluation. 3. Resident #3 was examined in the local hospital emergency roiagnom on the night of [DATE] where it was determined she did not require acute psychiatric care by the emergency room physician. Resident #3 was discharged back to the nursing home with no changes to her regimen ordered. Resident #3 was placed back on direct 1 to 1 supervision pending referral to acute mental health care by the facility. 4. Resident #2 was examined by the Psychiatric Physician Assistant (PA) on the morning of [DATE] and adjustments to her psychotropic regimen were made. Resident #2 had no recall of the incident when examined by the Psychiatric PA. Medication adjustments were implemented to address continued behavioral and psychological symptoms of dementia (BPSD) which pre-existed the incident and were identified as possible triggers for the altercation in the facility investigation. The facility social worker assessed both Resident #2 and Resident #3 on [DATE] and neither resident recalled the altercation. The social worker referred Resident #3 to a geriatric mental health hospital for acute care on the afternoon of [DATE] at the directive of the Psychiatric PA. The mental health hospital agreed to admit Resident #3 on [DATE] when a bed became available. Resident #3 was maintained on direct 1 to 1 supervision without incident until the transfer was executed. The social worker began to seek secure unit placement resources over a multi-county area for Resident #3 with consent of Resident #3's responsible party in the event her behaviors could not be stabilized. 5. Resident #3 was transferred to acute mental health care by the facility van on [DATE] without incident. Resident #3 had no recall of the altercation. Resident #3 was admitted to geriatric mental health for acute care. The facility Administrator and DON held a second Ad Hoc QA meeting to discuss the investigative findings and interventions ongoing. 6. Neurological checks for Resident #2 were completed on [DATE] with no negative findings. Care Plans for both residents previously updated on [DATE] were reviewed by members of the Quality Assurance Team which included the DON, Social Worker and Administrator. The altercation was added to the agenda for follow up by the Quality Assurance Team for February 2024. Brief Staff in-services related to the facility abuse policy and behavioral monitoring for Resident #2 were completed. 7. The facility completed 5 day follow up documentation and transmitted additional findings as requested to the State Agency on the morning of [DATE]. 8. Resident #3 was stabilized and returned to the facility from the mental health hospital on the afternoon of [DATE]. Resident #3's care plan was updated to reflect enhanced behavioral monitoring/ precautions while in common areas outside her room and additional 1 to 1 supervision as needed when changes in behavior occurred. Staff training related to the new interventions were completed the same day by the Director of Nursing. The facility social worker and administrator contacted a total of 5 alternate facilities with secure memory care units, all of whom declined to admit Resident #3 between [DATE] and [DATE]. 9.Resident #3 was examined by the Medical Director on [DATE] and the Psychiatric PA on [DATE] for routine follow up care and no new issues with behaviors or medical co-morbidities were noted. The Psychiatric PA conferred with Resident #3's responsible parties and additional titration of psychotropic medications were implemented along with routine lab monitoring related to new medications put in place by the mental health hospital were completed. Resident #3 remained free of aggressive behaviors and remained in the facility with regular follow up by the mental health service. Resident #3 continues to receive weekly follow up visits by the Psychiatric PA for medication management and behavioral monitoring. The facility has on call access to services with the mental health provider 7 days weekly. During interviews 4 staff which, included LPNs #1 and #2, Certified Nurse Aides CNAs #3 and #4, interviewed were knowledgeable of the incident of [DATE], the new care plan interventions in place to prevent recurrent altercations for Resident #3, as needed line of sight monitoring for the resident when in common areas or in activities with peers, appropriate situations to implement 1 to 1 supervision and all reported her condition had substantially improved since return to the facility from acute care. Abuse interviews with 6 clinical personnel and 3 non-clinical personnel showed all were aware of the facility abuse prohibition policy and reporting requirements. All personnel interviewed could define abuse and neglect as defined in Federal Requirements and confirmed in-service training was provided them after the incident between Resident #2 and Resident #3 as reported by the DON. All interviewed staff were knowledgeable of non-pharmacological interventions related to behaviors. Review of incident logs showed no evidence Resident #3 was involved in additional altercations since [DATE]. No other resident versus resident altercations were noted to have occurred at the facility in the prior 6 months of records reviewed. At the time of the survey, efforts by the facility to obtain secure unit placement for Resident #3 remained ongoing. The facility had expanded the search for secure unit placement for Resident #3, to facilities throughout the region with consent of Resident #3's responsible party.

Based on review of medical record reviews, and interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for 1 resident (Resident #8) and the facility completed a 5-day MDS assessment for 1 resident (Resident #62) after discharged from the facility of 20 residents reviewed for MDS assessments. The findings include: Resident #8 was admitted to facility on 1/31/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] showed Resident #8 was currently admitted in the facility. Continue review showed a discharge assessment was not completed on 5/26/2022 by the facility upon discharge. Review of a nurses' notes dated 5/26/2022, showed Resident #8 was transferred to the Emergency Department (ED) for evaluation and treatment. Review of a nurses' note dated 6/1/2022, showed the resident's daughter called the facility and was taking Resident #8 home on hospice services from the hospital. During an interview on 11/2/2022 at 1:29 PM, the MDS Coordinator #1 and the Director of Nursing (DON) confirmed a discharge MDS assessment was not completed for Resident #8. Resident #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an entry MDS dated [DATE] showed Resident #62 was admitted to the facility from an acute hospital. Review of a nurse progress note dated 6/17/2022 showed Resident #62's spouse arrived to the facility at 6:45 AM and stated he was taking the resident home. The resident and spouse were encouraged to wait for a safe discharge plan and the resident stated she wanted to go home. A release from responsibility for discharge was signed by the resident and the spouse. The resident left via personal vehicle. Review of a discharge MDS dated [DATE] showed Resident #62 was discharged to the community on 6/17/2022. Review of a 5-day MDS dated [DATE] showed the assessment was transmitted after the discharge MDS assessment (21 days after the resident discharged home). During an interview on 11/2/2022 at 1:30 PM, the DON stated a 5 day MDS assessment was transmitted 21 days after the resident was discharged .the billing office told us [MDS Coordinators] we had to do one [a 5 day MDS assessment] .

Based on hospice contract review, medical record review, and interview, the facility failed to ensure timely and collaborative communication between the hospice provider and the facility for 1 resident (Resident #24) of 6 residents reviewed for hospice services. The findings include: Review of the hospice contract titled, HOSPICE AND SKILLED NURSING FACILITY AGREEMENT, dated [DATE] and renewed annually, showed .Hospice shall provide Facility with the following information immediately upon the information becoming available to Hospice .the most recent hospice plan of care specific to each Resident under Hospice's care .Hospice physician and attending physician .orders specific to each Resident .All physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Hospice shall comply with the Coordination of Services .Communication Protocol .Hospice and Facility shall work together to develop a written communication protocol governing how they will communicate all information needed for the Hospice Patient's care (such as physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .The communication protocol shall include .a procedure that clearly outlines the chain of communication between the parties in the event .changes to the Hospice Plan of Care .how Hospice Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #24's end of life wishes was Cardiopulmonary Resuscitation (CPR). Review of a Physicians Order dated [DATE] showed Resident #24 was admitted to hospice services. Review of a nurse's progress note dated [DATE] showed Resident #24 was transported to an outpatient cardiology appointment. Review of a cardiology consult report dated [DATE] showed the resident was transferred to the hospital emergency room for evaluation. Review of a hospice Nurse Practitioner telephone order titled, [NAME OF HOSPICE] HOSPICE PHYSICIAN ORDERS [MEDICAL RECORD OR PHYSICIAN ORDER] .Code Status: DNR [Do Not Resuscitate] . (the orders were suspended due to Resident #10's transfer to the hospital). Review of a hospital Discharge Summary dated [DATE] showed Resident #24 was returned to the facility and admitted back to hospice. Review of a POST form dated [DATE] showed Resident #24's code status had changed to a DNR code status after hospice had admitted the resident on [DATE]. Continued review showed the POST form was not provided to the facility until [DATE]. During an interview on [DATE] at 4:25 PM, the Director of Nursing (DON) and the Infection Preventionist stated the resident was admitted to hospice services on [DATE] and on the same day the resident was transported to an outpatient appointment and later transported to the hospital. The DON stated the resident returned to the facility on [DATE] and hospice services were resumed. The DON and the Infection Preventionist stated the hospice physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the updated POST form dated [DATE] was not provided by hospice to the facility until [DATE]. The DON and the Infection Preventionist agreed the facility had failed to effectively and timely communicate with the hospice provider and to collaborate services related to the change in the resident's code status after the resident returned from the hospital on [DATE].

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper storage of oxygen cylinders (tanks) (metal container filled with compressed gas and held under high pressure) in 1 resident's room (Resident #10) of 9 residents reviewed for oxygen usage. The findings include: Review of the undated facility policy, titled, POLICY AND PROCEDURE OXYGEN CYLINDERS, showed .Never drop cylinders or permit them to strike each other .Store cylinders of oxygen in a cool place, away from radiators . Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #10 received oxygen and hospice services. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan dated 10/27/2022, showed Resident #10 had a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had altered respiratory status and difficulty breathing related to [CONDITION(S)] and was oxygen dependent. During observations on 10/31/2022 at 12:05 PM and 2:47 PM, Resident #10's room contained 1 E size (4.3 inches in diameter by 25.5 inches in height) portable oxygen cylinder and 3 C size (4.3 inches in diameter and 12 inches in height) portable oxygen tanks located on the resident's floor, near the wall, and 1 C size portable oxygen tank located on the resident's counter near the sink. The oxygen tanks were not secured in a stand or holder. During an observation and interview on 10/31/2022 at 12:48 PM, Licensed Practical Nurse (LPN) #2 confirmed the portable oxygen tanks located in Resident #10's room were positioned on the floor and on the sink and were not secured in a rack, stand, or holder. During an observation on 10/31/2022 at 3:00 PM, Resident #10's room contained 1 E size portable oxygen tank and 4 C size portable oxygen tanks positioned on the floor, near the wall, and were not secured in a stand or holder. During an observation on 11/1/2022 at 1:25 PM, Resident #10's room contained 1 E size portable oxygen tank and 4 C size portable oxygen tanks positioned on the floor, near the wall, and were not secured in a stand or holder. During an interview on 11/1/2022 at 1:45 PM, the Director of Nursing (DON) stated it was her expectation only 1 oxygen tank be stored in the resident's room for the resident's use and was to be secured in a holder or on the resident's wheelchair. The DON confirmed the oxygen tanks were to be secured in a rack or holder when not in use and the portable oxygen tanks stored in Resident #10's room were not stored correctly.

Based on Centers for Medicare and Medicaid (CMS) guidelines, facility policy review, facility COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) vaccination documentation, and interview, the facility failed to ensure COVID-19 vaccination medical exemption documentation included all required components for 2 of 3 staff with medical exemptions for the COVID-19 vaccination. The findings include: Review of the CMS Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (QSO-22-07-ALL) memorandum titled, Guidance for the Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination, dated 12/28/2021, showed .Medicare and Medicaid-certified facilities are expected to comply with all regulatory requirements .Long-Term Care and Skilled Nursing Facility Attachment A .Medical Exemptions .Medical exemption documentation must specify which authorized or licensed COVID-19 vaccine is clinically contraindicated for the staff member and the recognized clinical reasons for the contraindication. The documentation must also include a statement recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements based on the medical contraindications. A staff member who requests a medical exemption from vaccination must provide documentation signed and dated by a licensed practitioner . Review of facility's policy titled, Employee COVID-19 Vaccination Exemption, dated 11/5/2021 and revised on 5/31/2022, showed .It is the policy of this facility that employees may request an exemption based on disability, sincerely held religious beliefs, practices or observances, or medical reasons for the required COVID-19 vaccination in accordance with Federal laws .Requests for medical exemptions to the COVID-19 vaccination must include the following documentation .All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the employee to receive, and the recognized clinical reasons for the contraindications; and .A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; and .The signature and date by a licensed practitioner who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws . Review of the COVID-19 Vaccination Record Card dated 11/30/2021, showed the Registered Occupational Therapist (OTR) received 1 dose of the Pfizer COVID-19 vaccine on 11/30/2021. Review of the OTR's Medical Declaration for Vaccination Exemption form dated 2/24/2022, showed .Please list the authorized COVID-19 vaccine(s) that are clinically contraindicated for the person named above to receive and the clinical reasons for the contraindication .COVID vaccine #2 contraindicated due to chest pain and palpitations .This exemption should be .Permanent . The documentation was signed by a Licensed Practitioner and did not include which authorized COVID-19 vaccinations were clinically contraindicated. Review of the Request for Exemption/Accommodation for Medical Reasons to the COVID-19 Vaccination dated 5/23/2022, showed Licensed Practical Nurse (LPN) #1 requested a medical exemption for the COVID-19 vaccine and noted .Heart issues . as the reason for requesting the medical exemption. The form was signed by a Licensed Practitioner on 5/23/2022 and did not include which authorized COVID-19 vaccines were clinically contraindicated, the reasons for the contraindications, or a statement from the Licensed Practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements based on the clinical contraindications. During an interview on 11/2/2022 at 1:03 PM, the Administrator stated COVID-19 vaccination exemptions were available for legitimate medical and religious reasons. Staff were responsible to get the required paperwork filled out for medical and religious vaccination exemption. The Administrator was responsible for reviewing the documentation and determining if the exemption was granted. The Administrator stated medical exemptions were granted if the documentation included a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It was the expectation of the Administrator that the facility policy was followed. The Administrator confirmed LPN #1's Request for Exemption/Accommodation for Medical Reasons to the COVID-19 Vaccination documentation did not include which COVID-19 vaccines were contraindicated or a statement from the practitioner recommending LPN #1 be exempt based on clinical contraindications. Continued interview confirmed the OTR's Medical Declaration for Vaccination Exemption did not include which COVID-19 vaccinations were contraindicated. The Administrator confirmed the facility's medical exemption policy was not followed for the OTR and LPN #1.

Based on facility policy review, review of the facility Fall Checklist, medical record review, and interview, the facility failed to follow their Fall Checklist to complete neurological checks, failed to complete an accurate falls risk assessment, failed to implement a new falls intervention to prevent further falls, and failed to supervise a resident after a fall for 1 resident (#1) of 4 residents reviewed for falls. The facility's failure resulted in Resident #1 sustaining fractures and a laceration to the left side of the forehead, resulting in Harm to Resident #1. The findings include: Review of the facility's policy, titled Falls and Fall Risk, Managing, revised 3/2018, showed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .Fall Risk Factors .[CONDITION(S)] and other cognitive impairment .pain .lower extremity weakness .functional impairments .incontinence .balance and gait disorders .implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . Review of the facility's policy titled Assessing Falls and Their Causes, revised 3/2018, showed .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Falls are the leading cause of morbidity and mortality among the elderly in nursing homes .Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors .Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .After a Fall .Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record .When a resident falls, the following information should be recorded in the resident's medical record .Assessment data .Appropriate interventions taken to prevent future falls . Review of the facility's Fall Checklist, dated 6/2013 showed .Neuro Checks [neurological assessment for indication of head or neurological injures] .(If fall unwitnessed or hit head) (Q [every] 15 minutes x [times/for] 1st hour, Q 30 minutes x 2nd hour, Q 2 hr [hours] x 3 [3 times], Q 4hr x 4, Q 8 hours to completed 72 hour process . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including End Stage [CONDITION(S)], Mood Disorder, [CONDITION(S)], Diabetes, History of Falls, and Abnormal Involuntary Movements. Review of Resident #1's Falls Risk assessment dated [DATE] showed Resident #1 was at high risk for falls. Review of a Falls Risk assessment dated [DATE] showed Resident #1 was at high risk for falls. Review of facility documentation dated 3/17/2020 at 6:02 PM, showed Resident #1 had an unwitnessed fall in the resident's room with no injuries noted. Review of Resident #1's Neuro Check Flowsheets dated 3/17/2020-3/20/2020 showed the Neuro Checks were not completed Q 15 minutes x 1st hour, Q 30 minutes x 2nd hour, Q 2 hr x 3, Q 4hr x 4, Q 8 hours to completed 72 hour process as indicated in the facility's Neuro Check protocol. Review of a Nurse Practitioner's note dated 3/18/2020 showed .alert .short-term memory impaired . Review of facility documentation dated 3/30/2020 at 10:00 PM, showed Resident #1 had an unwitnessed fall in the resident's room and sustained a skin tear to her right elbow. Review of Resident #1's Neuro Check Flow Sheets dated 3/30/2020 and an undated Neuro Check Flow Sheet showed the Neuro Checks were not completed Q 15 minutes x 1st hour, Q 30 minutes x 2nd hour, Q 2 hr x 3, Q 4hr x 4, Q 8 hours to completed 72 hour process as indicated in the facility's Neuro Check protocol. Review of Resident #1's Care Plan revised 4/2/2020 showed the resident was at high risk for falls related to decreased cardiac output, changes in blood sugar, abnormalities of gait and mobility, muscle weakness, cognitive impairment, and lack of coordination. Interventions included to keep the resident's shoes within reach and dycem (non-slip material) to be placed on the cushion in the resident's wheelchair. Review of an Occupational Therapy Discharge Summary dated 4/24/2020, showed .Patient .continues to demonstrate noncompliance with all safety strategies .and fall prevention strategies .Assist from staff to transfer to toilet .due to noncompliance with fall prevention strategies . Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact, and the resident required limited assistance of 1 staff for bed mobility, transfer, toilet use, and dressing. Review of a Weekly LTC (Long Term Care) assessment dated [DATE] showed the resident was incontinent of bowel and bladder. The resident is .able to move all extremities. Balance is poor .Resident is able to self position. Manual Wheelchair .toileting hygiene: Supervision or touching assistance . Review of facility documentation dated 7/4/2020 at 7:20 PM, showed Certified Nursing Assistant (CNA) #1 found Resident #1 on the floor in the resident's room during rounds and called Registered Nurse (RN) #1. Medical record review showed staff completed a Falls Risk Assessment after the resident's fall on 7/4/2020 at 7:20 PM. Staff assessed Resident #1 as a low risk for falls, with a score of 8 (10 or higher is high risk for falls), after the fall that had occurred at that time. Review of the assessment showed staff responded that the resident had not had any falls in the last 90 days. Review of facility documentation dated 7/4/2020 at 7:30 PM, showed .Resident had been sitting in wheelchair in front of mirror at sink, getting ready for bed. CNA [#1] arrived to room to find her lying on her right side in front of the wheelchair. Resident was assisted to a sitting position, complete head to toe assessment performed .Assisted back to bed .denies any pain at this time .Resident .Spoke with MD [Medical Doctor] on call .monitor resident status .have xrays done in facility .send to ER [emergency room ] if status changes or if pain increases .new intervention added to place anti-rollbacks [device to prevent wheelchair from rolling backwards and away from the resident when they move or attempt to get up] to wheelchair. Member of maintenance on call notified immediately by supervisor . Review of an Incident note dated 7/4/2020 at 9:30 PM, showed .Following resident agreement to go to ER to be evaluated, this nurse [RN#1] left resident room with resident sitting up in wheelchair at side of bed [the anti-roll backs had not been applied to the wheelchair], to call resident's daughter and on-call physician to notify them that resident had agreed to go to ER .Upon my immediate return to room, found resident down in floor .lying on left side with blood noted on floor underneath left side of face .Resident had a prior fall this evening following which she had only recently complained of pain to R [right] hip after attempting to go to the restroom with help, during which time she reported that pain is severe and she would like to go to ER for further evaluation. While arrangements were being made, patient had another fall [resident was left unattended in the wheelchair], which I discovered after returning from a 10 min [minute] absence from her room .Resident is now complaining of R hip/leg pain. Large laceration noted to left/middle forehead. EMS [emergency medical services] arrived during assessment .Periods of unresponsiveness noted during this time period . Review of a Nurse's Alert Charting note dated 7/4/2020 at 9:45 PM, showed .Resident transferred to .ER via EMS in stable condition following falls x 2 resulting in laceration to left/middle forehead and R hip pain . Review of a Nurse's Alert Charting note dated 7/4/2020 at 10:30 PM, showed .ER notified facility that resident will be kept for hospitalization .resident has a R hip fracture. Sutures are being placed to L [left] forehead laceration . Review of Resident #1 Hospital Emergency Documentation records showed Resident #1 was admitted to the hospital on 7/5/2020 at 12:38 AM with diagnosis of a hip fracture and facial laceration. Further review showed .Pt [Patient] from [name of facility] with two falls in last 24 hours .Staff reported pt [patient] had positive loc [loss of consciousness] with second fall. Pt c/o [complained of] right hip pain, pt also has skin tear to mid forehead with bruise .Procedure .Laceration repair .Laceration 22 cm [centimeter] in length. Scalp .#5 sutures . Review of a Hospital History and Physical dated 7/5/2020 showed .She has had multiple falls and has had a hip fracture the Dr [doctor] .fixed surgically. In her fall she struck her head and CT scan [computed tomography - views inside body parts] demonstrated non displaced type ll odontoid fracture [area in the cervical spine/neck] which was confirmed to be acute on MRI [magnetic resonance imaging] . Review of a Hospital Neurology progress note dated 7/20/2020 showed a Type ll Odontoid fracture and the resident was scheduled for surgical intervention. During a telephone interview on 8/4/2021 at 8:20 AM, CNA #1 stated Resident #1 required assistance with toileting and transfers of 1 staff. The CNA stated she was on duty when Resident #1 fell on [DATE]. She stated Resident #1 had a history of multiple falls. CNA #1 had assisted Resident #1 to the bathroom and then to her wheelchair and left the resident at the sink doing her nightly routine. CNA #1 returned to the room and found Resident #1 on the floor and the resident had removed her non-slip socks. She called for the Nurse [RN #1] and RN#1 came in Resident #1's room to assess her. The CNA and RN #1 assisted the resident back to her bed. CNA #1 stated she assisted Resident #1 with toileting later on 7/4/2020, after the first fall, and the resident complained of pain. CNA #1 assisted Resident #1 back to the wheelchair and reported this to RN #1. She stated RN #1 went to Resident #1's room to speak with her about going to the hospital, and CNA#1 left Resident #1's room. CNA #1 stated shortly after that time she was called to Resident #1's room because the resident fell a second time. The CNA stated Resident #1 had fallen from her wheelchair and was lying on the floor beside her bed. She stated Resident #1 was bleeding and complained of pain in her hip. During a telephone interview on 8/4/2021 at 9:35 AM, RN #1 stated she was the nurse on duty on 7/4/2021 when Resident #1 had 2 falls. She stated the CNA called her into the room after Resident #1 had an unwitnessed fall from her wheelchair, in the resident's room, and was found on the floor. RN #1 assessed Resident #1. The resident denied pain and refused to go to the hospital for an evaluation. The RN stated 1.5 hours later, CNA #1 attempted to assist Resident #1 to the bathroom and the resident complained of severe pain. RN #1 stated Resident #1 requested to go to the hospital for an assessment. She stated she left Resident #1 seated in her wheelchair by herself, in the resident's room, while she went to the nurse's station to call EMS. RN #1 stated .I thought she would sit there until I came back. I could have used the resident's call light to call for assistance, but I didn't think she was going to move . She stated she returned to the resident's room a few minutes later and found the resident on the floor. RN #1 stated Resident #1 had a cut on her forehead. She completed her assessment and EMS arrived and transferred Resident #1 to the hospital for evaluation. During a telephone interview on 8/4/2021 at 10:15 AM, Nurse Supervisor #1 stated she was the Nurse Supervisor on call on 7/4/2020 and received a call from RN #1 that Resident #1 had sustained a fall. She stated she discussed the fall intervention of anti-roll back tippers with RN #1 and those were to be applied to Resident #1's wheelchair as soon as possible. She stated Resident #1 should not have been put in the wheelchair and left unattended in the wheelchair until the intervention of the anti-tippers were implemented. During an interview on 8/4/2021 at 1:10 PM, the Director of Nursing (DON) stated the Clinical Managers, and the DON are responsible to oversee the falls program. The DON stated the falls intervention after Resident #1's first fall on 7/4/2020 was to apply anti-roll back tippers to the resident's wheelchair. She stated Resident #1 should not have been placed in the wheelchair until the anti-rollback tippers were applied to the wheelchair, and the nurse should have implemented another fall intervention to prevent Resident #1 from falling again. The DON stated there were multiple neurological checks not completed as required after Resident #1's fall on 3/17/2020 and 3/30/2020. The DON stated the falls risk assessment on 7/4/2020 indicated Resident #1 was at low risk for falls, which was not accurate. During an interview on 8/5/2021 at 10:25 AM, Licensed Practical Nurse (LPN) #1/Clinical Operations Manager stated she came into the facility on [DATE], late evening, to help. The LPN spoke with RN #1 about the falls. LPN #1 stated RN #1 had left Resident #1 alone in her wheelchair, in her room, to call EMS. She stated Resident #1 had been transferred to the hospital. LPN #1 stated the anti-rollback tippers had not been applied to Resident #1's wheelchair until after the resident was transferred to the hospital. During an interview on 8/5/2021 at 12:30 PM, the Medical Director stated the facility takes a multidisciplinary approach to falls prevention. He stated he would expect neurological checks to be completed after an unwitnessed fall as per the facility protocol. The Medical Director stated Resident #1 should not have been placed back in the wheelchair until the anti-roll backs were applied. He confirmed Resident #1 sustained 2 falls on 7/4/2021, was hospitalized , and sustained a fracture and head laceration due to the falls.

Based on facility policy review, observation, and interview, the facility failed to ensure housekeeping staff adhered to infection control practices to disinfect the hands after glove removal while cleaning resident rooms on transmission-based precautions (measures used to prevent or control the spread of infection) on 1 of 3 halls observed for use of Personal Protective Equipment (PPE). The findings include: Review of the facility policy titled, Novel Coronavirus Prevention and Response, reviewed/revised 8/18/2020, showed .Support hand hygiene .by making sure .alcohol-based hand rubs (hand sanitizers) are available .Environmental infection control .Housekeeping staff shall adhere to transmission-based precautions . Review of the facility policy titled, Isolation - Categories of Transmission- Based Precautions revised 1/2020, showed .Transmission-based Precautions will be used whenever measures more stringent than Standard Precautions (precaution used will all residents to prevent the spread of infection) are needed to prevent or control the spread of infection .Gloves and Handwashing .wear gloves when entering the room .After removing gloves and washing hands . Review of the facility policy titled, Handwashing/Hand Hygiene revised 2/2020, showed This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene . Observation on 12/8/2020 at 10:30 AM, showed Housekeeper #1 wearing a mask, face shield, gown, and gloves while cleaning in room [ROOM NUMBER] on the yellow zone (area of the facility where residents who were possibly exposed to the Novel Coronavirus who are on transmission-based precautions reside) of the facility. She removed the gown and gloves at the doorway of the room and placed the items in the trash can. Without performing any type of hand hygiene, she then put on a clean gown and clean gloves and entered room [ROOM NUMBER]. The housekeeper then cleaned room [ROOM NUMBER]. When she finished cleaning room [ROOM NUMBER], she removed the gown and gloves and without performing any type of hand hygiene she put a clean gown and clean gloves on and entered room [ROOM NUMBER]. She then began cleaning room [ROOM NUMBER]. All 3 rooms had transmission-based precautions signs on the doors alerting staff of the need to wear personal protective equipment while in the room. During an interview on 12/7/2020 at 2:58 PM, the Director of Nursing (DON) confirmed the facility had 2 halls where COVID-19 (Novel Coronavirus) positive residents were placed and the remaining halls in the facility were considered yellow zones with all residents on those hallways in transmission-based precautions for potential exposure to COVID-19 from either other residents who had tested positive or from employees who had tested positive. During and interview on 12/8/2020 at 10:48 AM, Housekeeper #1 confirmed she had removed her gown and gloves 2 times (after cleaning room [ROOM NUMBER], after cleaning room [ROOM NUMBER]) without performing any type of hand hygiene, .I just hadn't . She further stated that she could not reenter the resident's room to get to the sink to wash her hands once the gown and gloves had been removed. She was aware of hand sanitizer on the wall inside the resident rooms stating .do you want me to use that (hand sanitizer) . During an interview on 12/8/2020 at 12:29 PM, the DON confirmed it was his expectation for staff to perform hand hygiene after the removal of gown and gloves, prior to applying clean gown and gloves, and prior to entering another resident's room.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen free from undated, unlabeled foods, or opened to air food items in 2 coolers; and free from dirt and debris in 1 ice cream freezer, 1 walk in cooler, 1 of 3 steam tables, and on 1 dish in the kitchen, potentially affecting 149 of 151 residents. The findings include: Review of facility policy, Dietary Food Storage Policy with an implementation date of 10/29/18 revealed .It is the policy of this facility to avoid inappropriate storage of food products for the safety and well-being of the residents .Improper food storage may include, but not be limited to .Foods uncovered and/or exposed to air .Foods undated .Foods unlabeled .Broken seals, leakage . Review of the facility policy, Refrigerators and Freezers, dated 10/31/18, revealed .Supervisors will inspect refrigerators and freezers .for .ice buildup .Refrigerators and freezers will be kept clean, free of debris, and mopped .on a scheduled basis and more often as necessary . Review of the facility policy, Dietary Equipment Serviceability Policy with an implementation date of 10/29/18 revealed .Staff members of the Dietary Department must recognize that they have a responsibility to insure the safe and sanitary working condition of all equipment used in the preparation and delivery of food to the residents of our facility .Employees are required to inspect equipment for corrosion, rust, and general cleanliness .In the event that any of the above items are discovered, correction action must take place and the CDM (Certified Dietary Manager) must be notified . Review of the facility policy, Dishwashing Machine Use, dated 10/31/18 revealed .Dishes and utensils are inspected for any debris or unsanitary contact prior to use .Immediate action will be taken and dishes or utensils will be unused until properly cleaned and sanitized . Observation and interview with the Dietary Manager (DM) on 10/29/18 at 9:36 AM, in the kitchen, of the tray line cooler, revealed: A) Nine 4 ounce plastic glasses containing purple liquid undated, unlabeled, and available for resident use. B) Seven 4 ounce plastic glasses with a light tan liquid undated, unlabeled, and available for resident use. Interview with the DM confirmed the liquid drinks were grape juice and apple juice. Continued interview confirmed the drinks were undated and unlabeled and available for resident use. Observation and interview with the DM on 10/29/18 at 9:42 AM, in the kitchen, of the ice cream freezer, revealed: A) 6 loose cardboard pieces 6 to 7 inches long by 2-3 inches wide scattered throughout the bottom of the freezer. B) Seven loose wooden ice cream spoons lying on the bottom of the ice cream freezer. C) 1 piece of red loose tape lying on the bottom of the ice cream freezer. D) Large solid pieces of ice on the bottom of the ice cream freezer. Interview with the DM confirmed the facility failed to inspect the freezer for ice buildup and there was debris scattered throughout the ice cream freezer. Observation and interview with the DM on 10/29/18 at 9:52 AM, in the kitchen, of the walk in cooler, revealed: A) One 5 pound plastic container of shredded white chicken salad open to air, with a broken plastic seal, chicken salad leaking down the sides of the container, available for resident use. B) 3 large onion peels on the floor in the walk in cooler. Interview with the DM confirmed there was open to air food items and debris on the floor of the walk in cooler. Continued interview confirmed the facility failed to inspect the walk in cooler. Observation and interview with the DM on 10/29/18 at 10:59 AM, in the kitchen, of the stand-alone cooler, near the dry storage room, revealed: A) 56 slices of yellow pasteurized American cheese in a 2 gallon plastic bag open to air and available for resident use. Interview with the DM confirmed there was open to air food items in the stand alone cooler. Observation and interview with the DM on 10/29/18 at 11:16 AM, in the kitchen, at the 3 compartment portable steam table, next to the ice cream freezer, revealed: A) Dark brown hardened and rust colored loose debris scattered throughout the 3 compartments of the steam table. Interview with the DM confirmed the facility failed to inspect the steam table for corrosion, rust, and general cleanliness. Continued interview confirmed the facility failed to maintain a sanitary 3 compartment steam table which was used for resident food preparation. Observation and interview with the DM on 10/29/18 at 11:27 AM, in the kitchen, at the 3 bay steam table, with the prepared hot lunch foods revealed: A) One 9 inch 3 divider plate under the front shelf of the steam table, covered in brown and yellow debris and available for resident use. Interview with the DM confirmed the facility failed to inspect dishes for debris.

Based on facility policy review, observation, and interview the facility failed to maintain 1 of 3 three compartment steam tables in safe operating condition in 1 of 1 kitchens potentially affecting 149 of 151 residents. The findings include: Review of the facility policy, Dietary Equipment Serviceability Policy, with an implementation date of 10/29/18, revealed .It is the policy of this facility to maintain proper working equipment .free from .disrepair .Staff members of the Dietary Department must recognize that they have responsibility to insure (ensure) the safe and sanitary working condition of all equipment used in the preparation and delivery of food to the residents of our facility . Observation and interview with the Dietary Manager (DM) on 10/29/18 at 11:16 AM, in the kitchen, of the 3 compartment portable steam table, next to the ice cream freezer, revealed 1 of 3 missing control knobs in 1 of 3 bays. Interview with the DM confirmed the facility used the portable steam table in preparation and delivery of food to the residents in the facility. Continued interview confirmed the control knob button on the compartment steam table should have been replaced, was not in safe working order, and was in disrepair.

Based on review of the facility admission packet, medical record review, review of trust transaction history, observation, and interview, the facility charged the personal fund account for incontinence care items for 1 resident (#72) of 34 incontinent residents reviewed of 44 sampled residents. The findings include: Review of the facility admission packet and resident rights revealed the facility would provide incontinence care supplies for the residents. Medical record review revealed Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #72's Admission Record revealed the resident's primary payer source was Medicaid ICF (Intermediate Care Facility). Medical record review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #72's Brief Interview for Mental Status score was 15, indicating the resident was cognitively intact. Further review revealed the resident required supervision for all activities of daily living, was always continent of bladder, and occasionally incontinent of bowel. Medical record review of a social services note dated 8/23/18 revealed .Daughter and son have been requesting that a prescription be signed regarding (Resident #72's) briefs that she has been receiving from (medical supply company). I (social services) have spoken with (medical supply company), BCBS (insurance company), and her Choices CC (Medicaid Care Coordinator) and because she is in a long term care nursing facility, she can no longer receive the (disposable) briefs and her insurance be charged . Further review revealed the Medicaid insurance company told the facility they would not pay for the briefs because the resident was in a long term care nursing facility and .that is part of her care that we supply the briefs .if we send BCBS a bill for them to pay for her briefs, not only will they not pay for them but that is considered Medicaid fraud and we (facility) could face fraud charges for billing her insurance for something that we provide .(physician) will not sign the paper for this very reason and because the address is the sons address and she does not live with the son in the community. The son has been bringing the (disposable) briefs to (Resident #72) in the facility. The only reason why her insurance has been paying for the briefs is because the address is a community address and not the facilities . Continued review revealed the residents' daughter and son had been notified the resident's insurance would not pay for the briefs because the resident was in a long term care nursing facility. Review of Resident #72's Trust-Transaction History from 6/1/18-9/30/18 revealed $33.33 was withdrawn by the facility from the resident's trust fund on 9/14/18 for the cost of disposable briefs. Observation and interview with Resident #72 on 10/29/18 at 12:42 PM, in the resident's room, revealed the resident was wearing a disposable brief. Interview with the resident revealed the resident did not like the cloth briefs offered by the facility, and preferred disposable briefs. Interview with the Business Office Manager on 10/30/18 at 4:20 PM, in the Business Manager's office, confirmed Medicaid residents were charged for disposable briefs, or the facility would provide cloth briefs at no cost to residents who did not want to pay for disposable briefs. Continued interview confirmed the facility supplied disposable briefs for Medicare residents because the briefs were considered medical supplies for those residents.

Based on medical record review and interview, the facility failed to obtain consent and notify the resident representative of changes to the psychiatric drug regimen of 1 resident (#82) of 5 residents reviewed for unnecessary medications of 44 residents sampled. The findings include: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating Resident #82 was moderately cognitively impaired. Medical record review of the Order Listing Report, dated 10/31/18, revealed .[MEDICATION NAME] (antianxiety and antidepressant medication) 5 MG (milligrams) Give 1 tablet by mouth one time a day .Last Order Date .01/26/18 . Medical record review of the Psychiatric Progress Note, dated 1/26/18, revealed .Treatment Plan .1.) Start [MEDICATION NAME] 5 mg PO (by mouth) QDAY (daily) . Medical record review of the Psychiatric Progress Note dated 5/17/18, revealed .family wants patient taken off of [MEDICATION NAME] .upset that they never gave consent for it to be started 1/2018 . Medical record review of Resident #82's signed consents revealed no documentation of a signed consent, or verbal notification to the family, prior to the addition of [MEDICATION NAME] to the drug regimen on 1/26/18. Interview with the Director of Nursing (DON) on 10/31/18 at 3:55 PM, in the DON's office, confirmed there was no signed consent or documentation of notification to the resident representative of changes to the psychiatric drug regimen for Resident #82.

Based on facility policy review, medical record review, and interview, the facility failed to refer to the state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review), after the resident was identified with a possible serious mental disorder, for 1 resident (#112) of 7 residents reviewed for PASARR. The findings include: Review of facility policy Admission Criteria, revised (MONTH) (YEAR), revealed .Any new psychiatric [DIAGNOSES REDACTED]. Medical record review revealed Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the PASARR form dated 7/26/17 revealed Resident #112's [DIAGNOSES REDACTED]. Further review revealed the resident was negative for the level one screening, and if the nursing facility determined any inaccuracies in diagnoses, a Status Change review would be required. Medical record review of the [DIAGNOSES REDACTED]. Medical record review of a psychotherapy progress note dated 7/25/18 revealed the resident was sad, intermittently tearful, and expressed feelings of loneliness, hopelessness, and emotional isolation. Medical record review of the [DIAGNOSES REDACTED]. Interview with Minimum Data Set (MDS) nurse #1, responsible for completing PASARR's at the facility, on 10/30/18 at 8:36 AM, in the MDS office, revealed the most recent PASARR completed was on 7/26/17, prior to the addition of 2 mental health diagnoses. MDS nurse #1 stated another PASARR was completed for Resident #112 on 8/19/18 but .was canceled . MDS nurse #1 confirmed PASARRs had not been completed after the new mental health [DIAGNOSES REDACTED].

Based on facility policy review, observation and interview, the facility failed to dispose of garbage and refuge in a sanitary manner in 3 of 3 dumpsters observed. The findings included: Review of a facility policy Garbage and Rubbish Disposal dated 4/2004 revealed .Garbage and rubbish containing food waste shall be stored so as to be inaccessible to vermin .Outside dumpsters .must be kept .free of litter around the dumpster area . Observation with the Certified Dietary Manager (CDM) on 10/16/17 at 10:10 AM, outside at dumpster area, revealed the following items on the grounds surrounding the dumpsters: a). Two cardboard boxes b). Disposable Plastic ware c). Various pieces of paper, partial plastic aprons, and strips of packaging tape Continued observation with the CDM behind the dumpsters revealed a thick wet greasy type substance under, and behind the dumpsters appearing to come from 2 of 3 dumpsters observed. Interview with the CDM on 10/16/17 at 10:15 AM, outside of the kitchen confirmed the facility failed to dispose of garbage and refuge properly, and failed to maintain the dumpster area in a sanitary manner.

Based on review of facility policy, medical record review, and interview, the facility failed to follow facility policy during an investigation of an allegation of abuse for 1 resident (#1) of 3 residents review for abuse. The findings included: Review of the facility's Policy and Procedure for Resident Abuse, last revised 11/6/11, revealed .any employee suspected of resident abuse .will be promptly removed of duty until the supervisor and/or administrator and abuse coordinator completes an investigation .nursing staff will thoroughly examine the resident for any signs of injury or abuse . Medical record review revealed Resident #1 was admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. Medical record review of a Nurse's Progress Notes dated 7/18/17 at 4:00 AM revealed .At 0300 (3:00 AM) CNA's (Certified Nurse Assistants) .entered room to change resident after small BM (bowel movement) .CNAs were administering peri-care when resident states 'they are hurting me' . (Licensed Practical Nurse (LPN) #4) and CNA entered the room to check on resident and resident stated 'I want my door closed because my private area has just been abused' .Notified abuse coordinator and investigation process stated (started) . Review of CNA #1 and CNA #2's time card report dated 7/18/17 revealed CNA #1 and CNA #2 left the facility at 6:23 AM (3 hours and 23 minutes after the allegation was made). Interview with the Director of Nursing (DON) on 8/7/17 at 3:20 PM, in the conference room, revealed she was not sure when the CNAs exited the facility. Telephone interview with LPN #4 on 8/7/17 at 3:44 PM confirmed CNA #1 and CNA #2 remained on the unit and continued to provide care to other residents during the investigation. Interview with the Administrator on 8/7/17 at 6:01 PM, in the conference room, revealed .talked to (Registered Nurse (RN) #1) .was told the CNAs were removed .CNAs not to do care .felt it (allegation of abuse) was not valid .if it were a situation where we immediately felt like resident were abused they'd be sent home immediately .I know they were not to perform care . Continued interview confirmed CNA #1 and CNA #2 were not removed from resident care during an investigation of an allegation of abuse and the facility failed to follow facility policy.

Based on review of facility policy, observation, and interview, the facility failed to maintain a proper temperature for 1 of 3 reach-in coolers, to label and date repackaged foods for 2 of 3 reach-in coolers, and to separate staff and resident food for 1 of 3 reach-in coolers reviewed. The findings included: Review of the facility policy, Purchasing, Receiving and Storage, dated 3/27/07 revealed .all perishable foods will be stored at proper temperatures refrigerated, 40 degrees (Fahrenheit) or below . Review of the facility policy, Food Preparation and Service, undated, revealed '' .leftovers will not be held longer than 48 hours .left-overs will be stored in container or bags-which has been labeled, dated-covered . Observation with the Certified Dietary Manager (CDM) on 10/30/16 at 10:50 AM, of the front cooler revealed a thermometer with a temperature of 48 degrees. Further observation revealed the following items unlabeled and undated: 15 pimento cheese sandwiches, 7 chicken salad sandwiches, 3 peanut butter/jelly sandwiches, 3 tossed salads with cheese, 6 trays of puddings, applesauce, and pureed fruits in individual bowls, and 17 poured milks. Observation with the CDM on 10/30/16 at 11:10 AM, of the clean pot/pan rack located above the 3 compartment sink and available for use revealed 1 sauté pan with congealed grease and 1 skillet pan with food debris. Observation with the CDM on 10/30/16 at 11:15 AM, of the #1 stand-up cooler revealed the following opened items not labeled or dated: sliced American cheese, sliced turkey breast, and half of a peeled onion. Continued review revealed an unlabeled 48 ounce container of iced coffee. Interview with the CDM on 10/30/16 at 11:25 AM, in the kitchen confirmed the facility failed to maintain a refrigerated cooler of 40 degrees Fahrenheit or less, to label and date opened and prepared foods, to thoroughly clean kitchen utensils available for use, and to maintain personal drinks in a separate area from resident use.

Based on review of facility policy, review of facility medical records, review of facility log books, and interview, the facility failed to promptly notify the physician of a change in condition for 1 resident (#104) of 35 residents reviewed. The findings included: Review of the facility policy Change in Resident's Condition or Status, undated, revealed .notify the resident's attending physician/MLP (Medical Licensed Practitioner) .deemed necessary or appropriate is the best interest of the resident . Medical record review revealed Resident #104 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Progress Notes, dated 9/6/16 at 4:30 PM revealed .complaint of right arm pain. Elbow is swollen and warm to touch .note placed in MD/NP (Medical Doctor/Nurse Practitioner) . Review of the facility log book Nursing Home Patients to be Seen, not dated, revealed Resident #104 R (right) elbow swollen & (and) warm to touch c/o (complain of) pain. Medical record review of the Physician's Orders for Resident #104, dated 9/8/16 at 5:00 PM, revealed an order for [REDACTED]. Medical record review of the Radiology Report of the elbow AP (anteroposterior) and LAT (lateral) dated 9/8/16 at 6:10 PM revealed .[MEDICAL CONDITION] of the right elbow .could indicate a subtle fracture . Medical record review of the Progress Notes, dated 9/9/16 at 10:23 AM revealed .received results. MD notified. Received new order for orthopedic consult . Medical record review and interview with the NP on 10/31/16 at 2:45 PM, in the Conference Room confirmed she reviewed the Nursing Home Patients to be Seen log book by drawing a line through the entry and documenting the review date. Continued review and interview confirmed the complaint of elbow pain and swelling from Resident #104 was reviewed on 9/13/16. Medical record review and interview with Licensed Practical Nurse (LPN) #4 on 10/31/16 at 3:00 PM, in the Conference Room, of the Nursing Home Patients to be Seen log book, confirmed he did not date Resident #104's complaint of right elbow swelling and pain. Continued interview confirmed .it was probably September 6 .can't remember if I called the doctor . Telephone interview with Resident #104's physician on 10/31/16 at 4:15 PM, confirmed she was not notified of Resident #104 complaint of right elbow pain and swelling until 9/8/16. Continued interview confirmed she expected the facility to notify her promptly of any resident significant changes. Interview with the Director of Nursing (DON) on 10/31/16 at 4:45 PM, in the DON office confirmed the facility failed to notify the physician of changes in resident condition as per facility policy.

Based on observation and interview the facility failed to maintain dignity for 1 resident (#105) of 62 residents observed for dining in the 400 Unit dining room of 4 dining rooms observed. The findings included: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of dining on 10/30/16 at 12:39 PM, in the 400 Unit dining room revealed Resident #105 eating lunch at the dining room table with one other resident at the table. Further observation revealed Resident #105 had an open skin tear on his right forearm. Continued observation revealed Resident #105's skin tear was actively bleeding. Observation on 10/30/2016 at 12:45 PM, in the 400 Unit dining room, revealed Licensed Practical Nurse (LPN) #1 applied a wound dressing to Resident #105's arm at the dining room table. Interview with Registered Nurse (RN) #1 on 10/30/16 at 12:49 PM, in the 400 dining room, confirmed LPN #1 had performed wound care to the resident's arm and failed to maintain the dignity of the resident during during meal service.

Based on medical record review, review of facility fall investigation documentation, interview, review of manufacturer's recommendations, observations, review of facility restraint committee meeting minutes and review of the facility policy for Sunshine Room Guidelines, the facility failed to provide supervision to prevent accidents for ten residents (#134, #37, #58, #71, #95, #111, #52, #193, #2, #18) of fifty-six residents reviewed and failed to a apply soft belt restraint according to manufacturer's instructions for one resident (#13) of five soft belt restraints reviewed. The facility's failure placed four residents (#134, #37, #58, #71) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) of eighteen residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room, on June 13, 2013, at 2:40 p.m. The Immediate Jeopardy was effective June 11, 2012, and is ongoing. An extended survey was conducted on June 18, through June 19, 2013. The Immediate Jeopardy for F-323 "K" constitutues Substandard Quality of Care. The findings included: Resident #134 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Significant Change Minimum Data Set (MDS) dated [DATE], revealed the resident had severely impaired cognition; behaviors placed the resident at significant risk for injury; required extensive assistance with transfers and toilet use; balance not steady, only able to stabilize with staff assistance during transition and walking; and had two falls with injury since the previous MDS assessment on April 2, 2012. Medical record review of the Care Plan originally dated September 15, 2011, revealed, "...Falls...Falls will be avoided and safety will be maintained...will not sustain serious injury if fall occurs...bed should be in a low position with wheels locked...Check environment for fall risk factors and take corrective action as needed...wears nonskid shoes...May use personal alarms. Chair pad alarm..." Further review of the Care Plan revealed updates as follows: "...11/4/11 make positive chair alarm is in contact c (with) res (resident's) clothing & (and) operational. 11/9/11 add alarming seat belt to recliner along c chair pad alarm & alarming seat belt to w/c (wheelchair)...2/19/12 q (every) 15 min (minute) visual (checks) while in w/c during 11p-7a (11:00 p.m. to 7:00 a.m.)...2/20/12 psych (psychiatric) NP (Nurse Practitioner) d/t (due to) (increased) confusion/agitation...5/5/12 inst (instruct) res to use call light before getting (up)..." Medical record review of a Nurse's Note dated June 11, 2012, at 4:00 p.m., revealed, "At aprox (approximately) 1:15 CNA (Certified Nursing Assistant) called nurse into room...Resident noted laying on (R) (right) side on floor in front of recliner. Head on floor...Resident has a large knot to (R) side of head above ear...Send resident to ER (emergency room )..." Further review of the Nurse's Note revealed the resident was sent back to the facility with no fractures noted and no new orders. Review of a fall investigation dated June 11, 2012, revealed, "...safety device in place prior to fall alarming chair pad et (and) alarming seat belt...chair pad alarm et seat belt alarm sounding..." Review of the fall investigation 72 Hour Follow-up dated June 14, 2012, revealed, "...S.S. (Social Service) to request family meeting to discuss alarms and interventions..." Interview with the Director of Nursing (DON) on June 12, 2013, at 10:09 a.m., in the conference room, confirmed the facility failed to request and conduct a family meeting and no other new interventions were put in place. Interview with LPN #4 on June 17, 2013, at 3:50 p.m., in the administrator's office, revealed the resident "...would remove the seatbelt...that was why the (alarming) pad was under the resident..."Continued interview confirmed the resident could turn off/remove the alarm, and stated, "staff tried to keep (the alarm attachment) out of reach..." Medical record review of a Nurse's Note dated July 1, 2012, at 10:00 a.m., revealed, "...heard a alarm and I went running down the hall...when I entered the room I found (resident) sitting in...recliner with...seatbelt unhooked and pt (patient) was sitting on...leg rest of...extended recliner and pt body was still sitting in the recliner chair...instructed the pt to press call light before getting up..." Review of a facility fall investigation dated July 1, 2012, revealed "...heard alarm...found resident sitting on the end of the recliner on the foot rest...resident's mental status before incident disoriented..." Medical record review of the Falls Prevention Program Interventions (form on which a record of the residen't falls was documented) dated July 1, 2012, revealed, "...inst (instructed) to use call light. Placed on list for psych (interventions which were already on the Care Plan May 5, 2012, and February 20, 2012, respectively)..." Review of the fall investigation 72 hour Follow-Up dated July 4, 2012 (for the incident on July 1, 2012), revealed, "...Instructed Resident on use of call light. Placed on list for psych..." Medical record review of a Nurse's Note dated July 2, 2012, at 3:45 p.m., revealed, "...Pt (patient) was witnessed falling on floor...CNA...heard alarm so...went to see and saw pt standing up in front of...w/c try to turn off...w/c alarm. Pt looked at CNA and fell and hit...head on bedside table and buttocks on floor...Redness observed to (L) (left) midback..." Review of a facility fall investigation dated July 2, 2012, revealed "alarm sounding...pt was standing up in front of w/c (wheelchair) trying to turn alarm off...resident's mental status before incident disoriented..." Medical record review of the Care Plan updated on July 2, 2012, revealed "...enc (encourage) to use call light." Review of the fall investigation 72 Hour Follow-Up dated July 5, 2012 (for the fall on July 2, 2012), revealed, "...Red area to (L) posterior thoracic. Encouraged to use call light. Request M.D. (physician) work (up)..." Interview with the Director of Nursing (DON) on June 12, 2013, at 10:09 a.m., in the conference room, confirmed the resident had been disoriented at the time of the incident and encouraging the resident to use the call light had not been an appropriate intervention. Medical record review of a Physical Therapy Screening Tool dated July 2, 2012, revealed, "Pt fell ,[DATE] from recliner trying to transfer...self & 7/2/12...stood up from...w/c p (after) removing...seatbelt alarm & turned to refasten...seatbelt & fell . Just got off antibiotics 6/30/12 for UTI (Urinary Tract Infection). Recommend medical work up prior to beginning PT (physical therapy) rescreen...Rescreen PRN (as needed)..." Medical record review of a Nurse's Note dated July 3, 2012, at 3:00 p.m., revealed, "...At aprox 12:15 pm this nurse was called to resident's room. CNA c resident. Resident observed sitting on floor, c back against hand rail, on (resident's) bottom in bathroom floor...0 (no) injuries noted..." Review of a facility fall investigation dated July 3, 2012, revealed "...resident was found sitting on floor in bathroom...resident turned chair alarm off...Safety Device in place prior to fall alarming seat belt...resident trying to transfer self to toilet...q 15 min x 3 hrs (every 15 minute checks for 3 hours) - then order for soft belt. Complete medical work up...therapy to attempt strengthening exercise..." Medical record review of the Falls Prevention Program Interventions dated July 3, 2012, revealed, "...q 15 min (checks) x 3 hrs. Soft belt when up in w/c - complete medical work up." Medical record review of the Care Plan revealed it was updated July 3, 2012, "...Med (medical) workup. Q 15 min x 3 hrs" and the soft belt when up in the wheelchair was not included on the care plan. Review of the fall investigation 72 Hour Follow-up dated July 6, 2012 (for the fall July 3, 2012), revealed, "...No injury. (Increased) confusion noted. Q 15 min (checks) x 3 (hours). Soft belt when (up) in w/c. Requested complete medical work (up)..." Medical record review revealed the medical workup was not completed until July 5, 2012, with orders for labwork. Continued medical record review revealed the resident had a urinalysis collected on July 6, 2012, with results of a UTI on July 9, 2012, and antibiotics were started July 9, 2012. Medical record review of a "Hey Therapy" (form used to request therapy screening) form dated July 9, 2012, revealed "frequent falls 7/1, 7/2, & 7/3..." Interview with the Rehabilitation Manager on June 12, 2013, at 11:00 a.m., in the 100 hall, revealed therapy had not evaluated or treated the resident related to the referral on July 9, 2012, and no new screen had been completed after the medical work up on July 5, 2012, had been completed. Medical record review of a Nurse's Note dated July 30, 2012, at 5:20 p.m., revealed, "...According to CNA...while passing out trays for dinner...heard a chair alarm sounding...was right by the room when the alarm started sounding...opened the door to investigate from the doorway...observed (resident #134) standing hunched over @ (at) the foot of (resident's) bed the chair alarm on (resident's) recliner was sounding...rushed to assist resident but before (CNA) could reach (resident) fell on to the bed and slid down to the ground..." Review of a facility fall investigation dated July 30, 2012, at 5:20 p.m., revealed "...slide down into floor...assessed for injuries - none noted...Pt between recliner and bed...resident's mental status before incident disoriented..." Medical record review of the Falls Prevention Program Interventions dated July 30, 2012, revealed, "Res to be (up) in w/c for all meals in DR (dining room). Dep D/C (Depakote (medication used for seizures or psychiatric disorders) discontinued) 7/27/12" and no other new interventions to prevent falls. Medical record review of the fall investigation 72 Hour Follow-Up dated August 3, 2011 (for the fall July 30, 2012), revealed "...No injury. Resident to be encouraged to be (up) for meals..." Medical record review of a Nurse's Note dated August 2, 2012, at 11:00 a.m., revealed, "...At aprox 7:50 AM...went to resident's room immediately upon entering Resident was observed sitting on bottom in front of recliner c w/c on it's back in front of resident. Resident stated...was going home..." Review of a facility fall investigation dated August 2, 2012, revealed, "...0 injuries noted at this time...chair alarm was sounding...slid down front of chair...resident on floor in front of recliner. W/C in front of resident on its back...resident's mental status before incident disoriented..." Medical record review of the Care Plan updated August 2, 2011, revealed, "Res gotten (up) in w/c for day..." Medical record review of the fall investigation 72 Hour Follow-Up dated August 5, 2012 (for the fall on August 2, 2012), revealed, "...No injury noted. Resident assessed & assisted to w/c vs (versus) recliner..." Interview with the Director of Nursing (DON) on June 12, 2013, at 10:09 a.m., in the conference room, confirmed the resident had been placed in the wheelchair for the day after the fall on August 2, 2012. Continued interview confirmed no other intervention had been put in place to prevent the resident from falling from the recliner and the intervention for "up at meals" had not been followed. Medical record review of a Nurse's Note dated August 3, 2012, at 4:00 p.m., revealed, "...found pt (patient/resident #134) sitting outside...bedroom doorway. Upon arrival to area, Pt has knot c bruise to (L) eyebrow area... Review of a facility fall investigation dated August 3, 2012, revealed "...found pt on floor sitting outside (resident's) bedroom doorway...alarm not sounding...connected properly...no...resident's mental status before incident disoriented..." Medical record review of the Care Plan updated August 3, 2012, revealed "Redirection of CNA (Certified Nurse Assistant) - q 15 min (checks)." Review of the fall investigation 72 Hour Follow-Up Report dated August 6, 2012, revealed, "...CNA redirected r/t (related to) alarm..." Interview with the Director of Nursing (DON) on June 12, 2013, at 10:09 a.m., in the conference room, confirmed the staff failed to ensure the resident's alarm was in place prior to the fall on August 3, 2012, and no new intervention was implemented after the fall on August 3, 2012. Continued interview confirmed the staff were to check safety alarms with each resident contact. The DON stated this had not been done due to "human error." Medical record review of a Nurse's Note dated August 12, 2012, at 5:20 p.m., revealed, "...I was called into pt room pt was found laying on back in floor w/ (with) head @ bathroom door feet toward recliner where res was sitting prior to fall...no hip pain noted...Lg (large) ST (skin tear) to (R) elbow...ROM (range of motion) WNL (within normal limits) to legs...Pt denies any pain pt instructed to not get up unast (unassisted) and to press call light for ast (assistance) pt up in...w-chair (wheelchair) @nurse's station with soft belt in place @ present..." Medical record review of a nurse's note dated August 12, 2012, at 10:45 p.m., revealed, "...Resident has been c/o (increased) back and (R) hip pain. Had difficulty c transferring from w/c to Recliner & toilet this shift. Call made to (physician) and he stated 'give one hydrocodone (narcotic pain medication) 7.5/325 mg (milligrams) now and continue c scheduled PRN dosage' also stated that 'I will make a decision on (resident) tomorrow.' Pain pill given...Mobility to (R) leg is limited, pt c/o pain when trying to move leg..." Medical record review of Nurse's Notes dated August 13, 2012, at 3:30 a.m., revealed, "...Res cont (continue) to c/o pain to (R) hip...10:00 a.m. - resident c/o pain when being moved, called (physician) received new order x-ray right hip and leg...11:00 AM...mobile here to xray resident- Resident very uncomfortable being turned and repositioned...1:00 PM...There is a complete acute - to subacute fracture involving right femoral neck at the subcapital region with largest distal fragment displaced superolaterally 1 cm (centimeter) appearing new in the interval. Called (physician)...4:00 PM - received new order per (physician) - Send to ER immediately..." Review of a facility fall investigation dated August 12, 2012, revealed "...click seat belt was not sounding. CNA...states 'I put it on'...resident's mental status before incident disoriented..." Medical record review of the Care Plan updated August 12, 2012, revealed "...low bed - removed recliner from room." Medical record review of a Consultation from the hospital admitted d August 13, 2012, revealed "...patient...fell last night...put in bed...this morning they tried to get (resident) up had excruciating pain in...hip, unable to walk...history of frequent falls...X-Ray: subcapital fracture, right femur...Assessment and Plan: 1. Fall with hip fracture...Will go ahead and clear (resident) for surgery..." Medical record review revealed the resident was readmitted to the facility August 17, 2012, following surgery for [REDACTED]. Interview with the Director of Nursing (DON) on June 12, 2013, at 10:09 a.m., in the conference room, confirmed resident #134 had a total of seven falls prior to the fractured right hip; the facility had knowledge the resident removed the alarming seat belt; the resident had been disoriented at the time of each fall and the facility instructed the resident to use the call light as an intervention for two of the falls. Continued interview revealed the interventions put in place for "up at meals" and "chair alarm" had not been followed. Interview with Licensed Practical Nurse (LPN) #2 on June 17, 2013, at 10:19 a.m., by telephone, revealed the nurse had been aware the resident had confusion, history the resident removed the alarming seat belt, and had a history of [REDACTED]. Continued interview revealed, "we just tried to watch (the resident) as much as we could." Review of a fall investigation dated September 14, 2012, revealed resident #134 fell at 3:40 p.m., "...resident was observed on floor near bed...bed alarm was in place...Bed alarm was not working when touched...Bed alarm malfunctioning when alarm box button pushed - Alarm was working wires were tangled around bed rail. After untangling Bed alarm worked then stopped. New bed alarm placed..." Review of manufacturer's recommendations for the alarm revealed "the alarm and sensor pad should be checked prior to each use for proper functioning...install batteries...affix Alarm holder securely to side of bed out of sight and reach of the resident...secure excess cord to avoid damage...Caution!...this product is designed to be a monitor, alerting staff when a patient has risen from their bed or chair...to be used in conjunction with a total fall prevention program...Do Not assume!...This product must be tested each time it is used with a patient to make sure it functions properly...12 Month Limited Warranty Personal Safety Corporation warrants this product to be free from factory defects in materials and workmanship for a period of 12 months from the date of the product..." Observation and interview with Certified Nurse Assistant #2 on June 17, 2013, at 1:23 p.m., in the resident's room, revealed an alarming bed pad on the resident's bed in use for the resident. Continued interview confirmed the manufacturer's date on the bed alarm pad was June 2011 and no other date was visible on the pad. Interview with the DON on June 17, 2013, at 5:00 p.m., in the DON office, revealed the facility did not designate one person to monitor the alarm pads for proper functioning/usage and was not aware the staff did not put batteries in the bed alarms. Continued interview revealed the facility had not developed a policy and procedure for the alarming pads. Continued interview confirmed the facility had knowledge resident #134 had a history of [REDACTED]. Continued interview confirmed the facility continued to place the resident back in the recliner in the resident's room after the resident had fallen four times and failed to provide adequate supervision to prevent accidents and on the fifth fall the resident fractured the right hip. Resident #37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Further review revealed the resident required limited assistance of one person for transfers, ambulation, and toileting, and was occasionally incontinent of bowel and bladder. Review of the resident's Activities of Daily Living (ADL) Care Plan dated August 24, 2011, and last updated on March 19, 2013, revealed "...use a gait belt for all transfers...insure that...footwear is non-slip...assist...in transfer with extensive performance with assist of 2 staff assist..." Review of a facility fall investigation dated February 3, 2012, at 8:00 p.m., revealed the resident had a bruise to the left ring finger and reported the bruise to the staff. Continued review of the investigation revealed "...the bruise was caused by a fall...this morning...no fall was reported...told nurse...hit hand on the side rail...no evidence of fall..." Medical record review of a Nurse's Note dated February 13, 2012, at 12:30 p.m., revealed, "Res (resident) found in floor on knees in front of sink...Res has increased confusion...Res had removed chair alarm box et (and) removed batteries. Placed box where res couldn't reach it...1:45p (p.m.) res up amb (ambulating) around room. Res turned off alarm on chair. CNA assisted res to sit down...2pm Res up walking. When CNA tried to redirect res, res became agitated..." Review of a facility fall investigation revealed "...the resident was attempting to use garbage can as toilet et fell on ...knees in front of can...res removed alarm from chair et removed battery...c/o pain to L (left) ring finger...Safety Device in place prior to fall Chair alarm pad..." Further review revealed "...xray done 2-14-12 results: 4th middle finger phalanx (bone) with slight displacement...buddy tape finger (taping the broken finger to the finger next to it)..." Medical record review of the resident's Falls Risk assessment dated [DATE], revealed "...total score 24...total score of 10 or above represents high risk..." Medical record review of the Falls Prevention Program Interventions dated February 13, 2012, revealed "...reposition chair alarm...q1h (every one hour) toileting, PT/OT/SS (Physical Therapy/Occupational Therapy/Social Services) eval...1:1 (one to one means one staff person to one resident for direct supervision) c (with) resident d/t (due to)...depressed state..." Medical record review of an OT evaluation dated February 14, 2012, revealed "...continue with restorative services...recommend supervision for fall prevention..." Review of the facility's fall investigation 72 Hour Follow-Up (for the fall on February 13, 2013) dated February 16, 2012, revealed the facility interventions were chair alarm (which was in place prior to the fall), every one hour toileting, one-to-one (1:1) supervision, and Physical Therapy (PT) evaluation, Occupational Therapy (OT) evaluation. Medical record review of a Nurse's Note dated February 24, 2012, revealed, "3:50 AM - resident (#37) attempted to transfer self to BR (bathroom), before staff could get to res room, resident fell in room. Resident c/o (R) (right) hip pain..." Review of a facility investigation dated February 24, 2012, at 3:50 a.m., revealed "...resident attempted to ambulate to BR (bathroom) s (without) assistance resulting in a fall...c/o hip pain...sent to ER (emergency room )...hip fx (fracture) r (right)...." Further review of the investigation revealed at the time of the fall the resident had an alarm in place and sounding and was wearing pajamas and socks (not wearing non-skid socks). Interventions to prevent another fall were to "...make sure resident is wearing non-slid (skid) socks (an intervention which was to be in place from the February 13, 2012 fall)...encourage resident to use call light..." The resident was sent out to the emergency room and admitted to the hospital. Review of a hospital radiological interpretation dated February 24, 2012, revealed "...evidence of a right acetabular (hip) fracture..." Review of the Falls Prevention Program Interventions dated February 24, 2012, revealed the resident fell at 3:50 a.m., "...Resident climbed OOB (out of bed) et attempted to ambulate to RR (restroom)...transfer to ER + (positive for) hip fx - Returned to facility NWB (non-weight bearing - no weight to be placed on the leg), PT/OT. NO (new order) for soft belt due to unsteady gait et cognitive impairment." Medical record review revealed resident #37 was readmitted to the facility from the hospital on February 28, 2013, following non-surgical treatment for [REDACTED]. Medical record review of the falls risk assessment dated [DATE], revealed the resident scored a 22. Interview with the Director of Nursing (DON) on June 18, 2013, at 5:40 p.m., in the DON's office, confirmed the facility failed to ensure interventions of non-skid socks and 1:1 supervision was done as required following the fall on February 12, 2013. Medical record review of the Care Plan dated March 8, 2012, with goal and intervention dates updated June 8, 2012, September 6, 2012, November 16, 2012, February 13, 2013, and May 5, 2013, revealed, "Fracture...right displaced Acetabulum (socket of the hip joint) & (and) Fractured Ramus (pubic bone) of the right side inferior r/t (related to) fall on 2/24/12...provide 1:1 (one on one) interventions to prevent further falls or injuries...Occupational Therapy...Physical Therapy...requires assist of two staff for transfers...only to bear weight on...left leg only..." Medical record review of the Quarterly MDS dated [DATE], revealed the resident scored a 3 on the BIMS, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance of two persons for transfers and toileting, and was totally dependent on staff for locomotion. Continued review revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Medical record review of the falls risk assessment dated [DATE], revealed the resident scored a 22. Medical record review of a hospitalization and ER Visit Record revealed the resident fell and was sent to theER on [DATE]. Review of a facility investigation dated June 16, 2012, at 6:30 p.m., revealed "...resident got off toilet by...self and fell to floor...hitting head...swelling ? (one-half) dollar size felt L (left) occipital (lower back side of head) area...CNA (certified nursing assistant) had left (resident) in the bath room by...self...sent to ER returned 6-17-12..." Medical record review of the emergency room documentation dated June 16, 2012, revealed "...presented via EMS (emergency medical service) after fall at the NH (nursing home)...fell with in the bathroom, straight back and hit back of...head, unknown LOC (loss of consciousness)...recent ORIF (open reduction internal fixation) of...right hip, is supposed to be NWB (non-weight bearing) to RLE (right lower extremity)...Clinical Impression...Closed Head Injury: Minor Concussion without Loss of Consciousness...Contusion, Head, Contusion Right Hand, Contusion, Proximal Right Lower Extremity..." Medical record review of the ER radiological interpretation of a CT (Computed Tomography) of the Head dated June 16, 2012, revealed "...small left posterior parietal scalp hematoma (swelling to an area of the head from blood accumulation due to a broken blood vessel)..." Medical record review of the resident's Falls Risk assessment dated [DATE], revealed "...total score 21..." Review of the Falls Prevention Program Interventions dated June 16, 2012, revealed, "...Resident was left unattended on toilet by CNA...ER eval...Staff inservicing...CNA re-directions...PT/OT referral..." Review of the facility's fall investigation 72 Hour Follow-Up dated June 19, 2012, revealed, "...Sent to ER returned 6-17-12 @ (at) 1135 PM c Dx (with [DIAGNOSES REDACTED]. CNA redirected. Staff inserviced..." Interview with the Director of Nursing (DON) on June 18, 2013, at 5:40 p.m., in the DON's office, confirmed the facility did not follow falls interventions of no weight on the left leg and 1:1 interventions, and the resident was left alone on the toilet, resulting in the fall. Medical record review of an OT note dated June 29, 2012, revealed "...requires one person A (assist) for self-care secondary to decreased safety awareness from dementia..." Medical record review of the Quarterly MDS dated [DATE], revealed the resident #37 scored a 3 on the BIMS, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance of two persons for transfers and toileting, and was totally dependent on staff for locomotion. Continued review revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Medical record review of the hospitalization and ER Visit Record revealed the resident had a fall on September 30, 2012, with no injury. Review of a facility fall investigation dated September 30, 2012, at 5:35 a.m., revealed, "...staff alerted to room by bed alarm. Resident was lying on the floor with...feet toward...bed...head near vanity...wc (wheelchair) was turned over...contusion L (left) side of forehead..." Review of the Falls Prevention Program Interventions dated September 30, 2012, revealed, "...Fall attempting to get OOB by pulling on w/c. Obtained contusion to head...Intervention is to put w/c away p (after) res going to bed & (check) Res early in AM to see if...wants to get (up)..." Review of the fall investigation 72 Hour Follow-Up dated October 3, 2012, revealed, "X-ray (negative) for fx. Bruising to (L) side of face. CNAs instructed to put w/c away p resident goes to bed and (check) early in AM (morning) to see if...wants to get OOB (out of bed)..." Review of the Quarterly MDS dated [DATE], revealed the resident scored a 3 on the BIMS, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance of two persons for transfers and toileting, and was totally dependent on staff for locomotion. Continued review revealed the resident was frequently incontinent of bladder and occasionally incontinent of bowel. Medical record review of the Care Plan dated February 5, 2013, "Falls...Falls, at risk for, potentially related to...use of assistive device, physical restraint use, must be assisted at all times with transfers and ambulation with limited assistance of 1-2 staff, history of fracture, impaired cognition, unsteady transfer...unsteady gait...Uses pressure sensor alarm when...in bed...CNAs to use gait belt with all transfers and with ambulation, with proper technique and to always have assistance when transferring this resident...falling friends program...visual checks q1hr (every one hour) when out of bed..." Further review of the Care Plan revealed the Care Plan had continued to be updated for the Category Problem of Fracture, dated February 13, 2013, with the previously listed interventions of "...Provide 1:1 interventions to prevent further falls or injuries..." Medical record review of the hospitalization and ER Visit Record revealed the resident had a fall on March 19, 2013, without injury. Review of a fall investigation dated March 19, 2013, at 4:50 p.m., revealed "...found res (resident) in w/c lying in floor on r (right) side. W/C turned over with resident inside w/c. Soft belt intact...in front of closet...bruise to r elbow...c/o bil (bilateral) hip et leg pain...ER treatment (box checked yes)ZXXXZZ

Based on medical record review, review of facility fall investigation documentation, interview, review of manufacturer's recommendations, observations, review of facility restraint committee meeting minutes and review of the facility policy for Sunshine Room Guidelines, the facility failed to provide supervision to prevent accidents for ten residents (#134, #37, #58, #71, #95, #111, #52, #193, #2, #18) of fifty-six residents reviewed and failed to a apply soft belt restraint according to manufacturer's instructions for one resident (#13) of five soft belt restraints reviewed. The facility's failure placed four residents (#134, #37, #58, #71) in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) of eighteen residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The facility provided an acceptable Credible Allegation of Compliance on June 29, 2013. A revisit on July 9, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on June 29, 2013. Non- compliance for F-323 continues at an "E" level citation. Validation of the Credible Allegation of Complaince was accomplished through medical record review,review of facility communication books, observation and interview with front line staff and administrative staff. The facility provided evidence of new policies and procedures related to accidents and supervision, chair and bed alarms, the facility quality improvement program and evidence the Medical Director and Administrator had reviewed and approved all policies and procedures. Inservice and training records including sign-in sheets for all nursing and non-nursing staff related to the new policies and procedures were provided. Interviews with nursing staff revealed nurses and certified nursing assistants were following the new policy and procedure realted to accidents and supervision, alarms and facility quality improvement. Observations revealed assistive devices were properly applied and functioning, certified nursing assistants were conducting alarm checks, and facility communication books were being utilized. The facility will remain out of compliance at a Scope and Severity level "E"- no actual harm with potential for more than minimal harm that is not Immediate Jeopardy until it provides an acceptable plan of correction and the facility's correcive measures could be reviewed and evaluated by the Quality Assessment/ Performance Improvement Committee.

Based on medical record review, facility policy review, review of manufacturer's instructions, observations, and interview, the facility administration failed to provide an effective system to ensure supervision and an environment free of accident hazards. The facility's failure resulted in multiple falls and placed four residents (#134, #37,#71, #58) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) of eighteen residents reviewed. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room, on June 13, 2013, at 2:40 p.m. The Immediate Jeopardy was effective June 11, 2012, and is ongoing. An extended survey was conducted on June 19, 2013. The findings included: Interview with the Administrator on June 18, 2013, at 5:00 p.m., in the Director of Nursing Office, confirmed the facility notifies the Administrator of all incident/accidents. Continued interview confirmed the Administrator was aware the facility had a high number of falls, and a high number of safety alarm usage. Continued interview confirmed the facility had no policy and procedure for monitoring the safety alarms, and had not identified a problem with implementing and monitoring interventions for falls. Refer to F 323

Based on medical record review, facility policy review, review of manufacturer's instructions, observations, and interview, the facility administration failed to provide an effective system to ensure supervision and an environment free of accident hazards. The facility's failure resulted in multiple falls and placed four residents (#134, #37,#71, #58) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) of eighteen residents reviewed. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The facility provided an acceptable Credible Allegation of Compliance on June 29, 2013. A revisit on July 8- 9, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on June 29, 2013. Non- compliance for F-490 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with front line staff and administrative staff. The facility provided evidence of new policies and procedures related to Accidents and Supervision, Chair and Bed alarms, the System Improvement Report and review of evidence the Medical Director and Administrator had reviewed and approved all policies and procedures. Inservice and training records including sign-in sheets for all nursing and non nursing staff related to the new policies and procedures were provided. Interviews with nursing staff revealed nurses and certified nursing assistants were following the new policy and procedure related to the new fall and prevention policy, and alarm policy. Interview with the Administrator revealed the Administrator met with the Governing Body members to discuss the status of the survey. Interview and documentation review with the Administrator revealed with help of an outside consultant the Administrator and the Director of Nursing developed a standardized agenda and trending reports for monitoring falls and alarms. The facility will remain out of compliance at a Scope and Severity level "E"- a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measurers could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review, facility policy review, review of manufacturer's instructions, observation, and interview, the Medical Director failed to provide oversight and participate in the development of policies and procedures to ensure an effective system for supervision of residents at risk for falls. The facility's failure placed four residents (#134, #37, #58, #71) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) of eighteen residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and Director of Nursing were informed of the Immediate Jeopardy in the Conference Room on June 13, 2013, at 2:40 p.m. The Immediate Jeopardy was effective June 11, 2012, and is ongoing. An extended survey was conducted on June 19, 2013. The findings included: Interview with the Medical Director on June 18, 2013, at 4:45 p.m., by telephone, confirmed the Medical Director was aware of the facility's reported number of incident/accidents with falls. Further interview confirmed the Medical Director had not been aware of any issues identified with falls and/or safety alarms and had not been involved in developing any policy and procedures or systems to ensure residents at risk for falls had effective interventions in place. Refer to F 323 Refer to F 490

Based on medical record review, facility policy review, review of manufacturer's instructions, observation, and interview, the Medical Director failed to provide oversight and participate in the development of policies and procedures to ensure an effective system for supervision of residents at risk for falls. The facility's failure placed four residents (#134, #37, #58, #71) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) of eighteen residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The facility provided an acceptable Credible Allegation of Compliance on June 29, 2013. A revisit on July 8- 9, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on June 29, 2013. Non- compliance for F-501 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with front line staff and administrative staff. The facility provided evidence of new policies and procedures related to Accidents and Supervision, Chair and Bed alarms, the System Improvement Report and review of evidence the Medical Director and Administrator had reviewed and approved all policies and procedures. The Medical Director reviewed treatment plans and fall interventions for each resident. Inservice and training records including sign-in sheets for all nursing and non nursing staff related to the new policies and procedures were provided. Interviews with nursing staff revealed nurses and certified nursing assistants were following the new policy and procedure related to the new fall and prevention policy, and alarm policy. The facility will remain out of compliance at a Scope and Severity level "E"-a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on review of the facility Quality Assurance (QA) Committee, facility investigation reviews, facility policy reviews, observations, and interviews, the facility failed to ensure the Quality Assurance Committee identified resident's safety, alarm use and falls as potential areas for quality improvement. The facility's failure to review data and formulate/implement improvement plans placed four resident's (#37, #58, #71, and #134), in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) of eighteen residents reviewed. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on June 13, 2013, at 2:40 p.m., in the facility conference room. The Immediate Jeopardy was effective June 11, 2012, and is ongoing. An extended survey was conducted on June 18 through 19, 2013. The findings included: Review of the facility investigations related to falls revealed the facility had not utilized the data from the investigations, to track, trend, and address resident safety concerns (both individually and globally), or to use the data in formulating strategies to ensure resident safety for all residents residing in the facility. Interview with the DON and Assistant Director of Nursing (ADON) on June 18, 2013, at 4:45 p.m., in the DON office, confirmed the ADON was over Quality Assurance (QA) and resident falls had not been recently addressed as a Quality Assurance issue. The ADON further confirmed that falls and the issue of alarm use (determined as not hooked up correctly; alarm turned off; no system to monitor functioning) had not been identified for a corrective action plan. Telephone interview with the Medical Director (MD), by telephone on June 18, 2013, at 4:45 p.m., revealed the MD is a QA Committee member and attends weekly meetings. The MD denied remembering any recent trend with falls and alarm use recently discussed. Refer to F 323 Refer to F 490 Refer to F 501

Based on review of the facility Quality Assurance (QA) Committee, facility investigation reviews, facility policy reviews, observations, and interviews, the facility failed to ensure the Quality Assurance Committee identified resident's safety, alarm use and falls as potential areas for quality improvement. The facility's failure to review data and formulate/implement improvement plans placed four resident's (#37, #58, #71, and #134), in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) of eighteen residents reviewed. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The facility provided an acceptable Credible Allegation of Compliance on June 29, 2013. A revisit on July 8- 9, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on June 29, 2013. Non- compliance for F-520 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, observation and interview with front line staff and administrative staff. The facility provided evidence of new policies and procedures related to Accidents and Supervision, Chair and Bed alarms, the System Improvement Report and review of evidence the Medical Director and Administrator had reviewed and approved all policies and procedures. Inservice and training records including sign-in sheets for all nursing and non nursing staff related to the new policies and procedures were provided. Interviews with nursing staff revealed nurses and certified nursing assistants were following the new policy and procedure related to the new fall and prevention policy and alarm policy. A Quality Assurance meeting was held on June 25, 2013 where the Administrator and Director of Nursing presented a new standardized agenda to ensure all topics and reports will be reviewed quarterly. The Administrator and Director of Nursing developed monitoring tools for falls, alarms, and care plans to ensure safety of all residents. The facility obtained an outside Healthcare Consultant and along with the Administrator conducted a Department Head meeting to review the new Quality Assurance Plan, agenda and monitoring parameters methodology for collecting and analyzing data. The facility will remain out of compliance at a Scope and Severity level "E"-a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review, facility investigation review, observation, and interview the facility failed to assess for and implement a care plan addressing behavior signs and symptoms for five residents (#12, #15, #24, #27, and #30) and the facility failed to care plan for the assessed number of assistants required for transfer for one resident (#8) of forty-nine residents reviewed. The facility's failure to assess and implement a careplan to supervise resident #15 and address the resident's unsafe behaviors in the use of the wheelchair placed the residents on Wing # I and # IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The facility provided a Credible Allegation of Compliance on November 8, 2011. A revisit conducted on November 10, 2011, revealed the corrective actions implemented on November 8, 2011, removed the Immediate Jeopardy. Non-compliance for F-280 continues at a "E" level citation (potential for more than minimal harm). Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of care plans, observation, and interview with the Licensed Counseling Social Worker, nurses, and administrative staff. The facility provided individual behavior management plans and the coinciding comprehensive care plans were reviewed for residents #12, 24, 27, and 30. Resident #15 had been dismissed from the facility. The facility will remain out of compliance at an "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, review of facility reports, observation, and interview the facility failed to provide supervision to prevent one resident (#15) with behavioral problems from harming self and others; failed to provide a safe transfer for one resident (#8) which resulted in the resident sustaining a right distal femur fracture; failed to use a mechanical lift when transferring resident (#3); failed to apply a soft belt restaint properly and use an appropriate transfer for resident (#5); failed to secure one of seven biohazard rooms; and failed to activate the personal alarm for resident (#14) of forty-nine residents reviewed. The facility's failure to supervise resident #15 and address the resident's unsafe behaviors in the use of the wheelchair placed the residents on Wing # I and # IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The facility provided a Credible Allegation of Compliance on November 8, 2011. A revisit conducted on November 10, 2011, revealed the corrective actions implemented on November 8, 2011, removed the Immediate Jeopardy. Non-compliance for F-323 continues at a "E" level citation (potential for more than minimal harm). Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of the behavior management policy and procedure, observations, and interviews with the Licensed Counseling Social Worker, nurses, and administrative staff. The facility's inservice for behavior management policy and procedures was reviewed. Resident #15 had been dismissed from the facility. The facility will remain out of compliance at an "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, review of facility reports, observation, and interview the facility failed to provide supervision to prevent one resident (#15) with behavioral problems from harming self and others; failed to provide a safe transfer for one resident (#8) which resulted in the resident sustaining a right distal femur fracture; failed to use a mechanical lift when transferring resident (#3); failed to apply a soft belt restaint properly and use an appropriate transfer for resident (#5); failed to secure one of seven biohazard rooms; and failed to activate the personal alarm for resident (#14) of forty-nine residents reviewed. The facility's failure to supervise resident #15 and address the resident's unsafe behaviors in the use of the wheelchair placed the residents on Wing # I and # IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Administrator and Assistant Director of Nursing were notified of the Immediate Jeopardy on October 21, 2011, at 12:25 p.m., in the Administrator's office. The Immediate Jeopardy constitutes substandard quality of care and was effective July 22, 2011, and is ongoing. An extended survey was conducted on October 24, 2011. The findings included: Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission nursing note of July 9, 2011, revealed the resident was admitted from an acute care hospital after previously residing at an Assisted Living facility. Review of the Nurse's Notes dated July 27, 2011 at 3:10 p.m., revealed, "Dr....(attending physician and facility Medical Director) in to see resident. Resident unable to respond to commands appropriately...Dr...then spoke with...(wife) re: (regarding) Res (resident) Advanced Dementia and having that Dx (diagnosis) for 10 yrs (years)...Dr...also stated Res (resident) is alert and oriented but unable to follow commands-that Res (resident) has the strength but not ability d/t (due to) advanced dementia... Dr... stated...didn't 'see' Res (resident) walking d/t advanced dementia..." Review of the quarterly Minimum Data Set (MDS) with a reference date of October 11, 2011, revealed the resident was assessed with [REDACTED]. The MDS recorded no physical behavioral symptoms directed toward others, but did record 'Other behavioral symptoms not directed toward others' occurred 4 to 6 days a week. Review of the facility Weekly Skin Reports, facility documentation, and Nurse's Notes revealed the following: August 12, 2011 - bruises to the bilateral upper extremities (Weekly Skin Report) August 19, 2011 - abrasion to left knee (Weekly Skin Report) August 25, 2011 - skin tear to right hand documented in Nurse's Notes August 31, 2011 - facility documentation for a skin tear top of the right hand September 3, 2011 - facility documentation for bumping right elbow/skin tear September 9, 2011 - left hand skin tear (Weekly Skin Report) September 21, 2011 - facility documentation for skin tear from chair rail September 25, 2011 - two facility documentation, one for "ran w/c into another resident's knees and ran w/c into another resident's w/c" and a second dated and timed the same as the first report "ran over another resident's feet" September 26, 2011 - facility documentation for a skin tear to the left forearm found when long-sleeve shirt removed to shower September 30, 2011 - a new bruise to the right upper extremity (Weekly Skin Report) October 2, 2011 - facility documentation, "rolled w/c into something on Wing 4 and ran into something and got a skin tear to right hand" October 4, 2011 - skin tear of the right dorsal hand documented in Nurse's Notes October 7, 2011 - facility documentation for skin tear of left hand/third finger October 9, 2011 - facility documentation, "bumped into (another resident) and (the other resident) got angry and poured water on him" October 14, 2011 - two skin tears right dorsal hand and bilateral upper extremities with small bruises (Weekly Skin Report) Review of the resident's Plan of Care (POC) revealed, "7/20/2011 - ADL (activities of daily living) Functional Deficit, potentially related to Nonambulatory...Intervention... primary mode of locomotion is the wheelchair (w/c)..." Further review of the POC revealed the Problem 'Activities' dated July 18, 2011, and did not include any interventions specific to the resident's constant motion with the w/c and moving throughout three of four wings of the facility. Review revealed all the current Problems on the POC included had a Target Date for the Goals moved forward to January 2012, but the Problems did not include the behavior displayed that had contributed to the resident being injured repeatedly with skin tears and negative interactions with fell ow residents. Review of the August 31, 2011, Nurse's Notes revealed a 5:00 p.m., "...Spoke with wife and made aware of new skin tear. Wife has concern for WC (wheelchair) safety..." Observation in the Wing I dining room from 5:45 a.m., until 6:30 a.m., on October 18, 2011, revealed resident #15 seated in a high back w/c without foot pedals or leg rest, using feet to propel around the large dining. Observation revealed seventeen residents in the dining room at 5:45 a.m., with ten of the seventeen residents asleep in their chairs. Observation of resident #15 from 5:45 a.m., until 6:30 a.m., on October 18, 2011, with the resident propelling forward and backwards at intervals, revealed the following: Bumped into a sleeping resident (#20) with the back of the w/c and resident #20 jerked their hand away from the arm of their w/c resident #15 had come into contact with and resident #20 yelled, "Get away!"; propelled w/c into the wheelchairs of residents (#25 & #30); proceeded to move from the back of the room to the front of the room, circling to the left past two tables with residents seated in their wheelchairs; then, while in a forward motion, bumped into the oxygen tank of resident #26; and bumped into the back of the w/c of resident #12 (asleep in w/c). Observation revealed there were no staff members in the dining room for the forty-five minutes when resident #15 was roaming the dining room in constant movement. Observation and interview at 6:30 a.m., on October 18, 2011, with the Licensed Practical Nurse (LPN #10) who entered the dining room upon request and observed the constant movement, bumping w/c into other residents, revealed, "He doesn't need to be in here...the Clinical Manager (CM) recently put (resident #15) on the Get Up List " Observation of Wing I Dining Room on October 18, 2011, from 11:55 a.m., until 12:35 p.m., revealed resident #15 seated with the back of w/c against the dining room wall to the left of the double door. Observation included approximately forty-five residents seated at ten tables eating with five staff members and three family members in the room assisting residents. Observation at 12:20 p.m., revealed resident #15 propelled the w/c (using the feet) forward approximately eight feet and rammed the w/c into the dining table where resident #14 was seated. Observation continued and the ramming motion was repeated three more times, then resident #15 retreated about four feet, paused for four minutes, and then rammed into the same dining table again. Observation revealed certified nursing assistant (CNA #12) came to the table of resident #14 and took resident #15 back against the dining room wall. Continued observation revealed the third food cart arrived at 12:30 p.m., and CNA #12 began to feed the resident. Interview at 8:00 a.m., on October 19, 2011, with the Director of Nurses (DON) and the Wing I Clinical Manager, at the Wing I nursing station, revealed the following: The "Get Up List" was developed by the CM and listed twenty-one residents to be gotten up prior to 7:00 a.m. and included eleven residents designated, " ...to be gotten up EVERY DAY!!!"; the List contained seven residents with behaviors; the CM was aware resident #15 was frequently in the dining room in the early morning hours unsupervised; and confirmed the first of three food tray carts were not delivered to the Wing I dining room before 8:15 a.m. Interview continued related to the observed "ramming of the dining table at lunch the prior day and the CM stated resident #15's encounters were usually not intentional and "usually in backwards motion." Interview confirmed there was no written behavior management program in place for resident #15's behaviors and the plan was to "watch out for" the resident. During interview, the CM stated a psychological consult had been ordered by the Family Nurse Practitioner (FNP/physician extender for the Medical Director), but could not confirm if it had been completed and stated "would check." Interview with the Wing I CM at 4:20 p.m., on October 20, 2011, in the conference room, verified resident #15 had been observed by the CM on October 18, 2011, at 12:20 p.m., ramming into the dining table of resident #14. During interview, the CM stated, "...I guess the CNA (#12) I asked to stay with (resident #15) was trying to help out others until (resident #15's) meal tray came...saw him ramming and told...(CNA #12) to get (resident #15) and stay with him..." Interview continued and the CM stated a "casual attempt" was made to keep the resident under "one to one" observation Tuesday, October 18, 2011, and the resident was formally "one to one" on October 19 and 20, 2011. During interview, the CM was asked why the resident was placed on "one to one" and the CM stated, "...the resident's behaviors could place others in harm's way..." Interview in the coference room, with the Assistant Director of Nurses (ADON) on October 19, 2011, at 10:00 a.m., verified resident #15 had nine skin tears, bruises, or interactions with other residents filed in formal reports and none had a complete investigation. Interview confirmed the resident had not been care planned to prevent skin tears and the unsafe use of wheelchair. Interview verified resident #15 had no behavior management program to address the unsafe behavior. Interview revealed the facility did not have a written behavior management policy or program. Interview on October 21, 2011 at 9:10 a.m., with the Nurse Practitioner (Psych Mental Health Nurse Practitioner/PMHNP) contracted for psychiatric consults on October 21, 2011, at 9:10 a.m., in the Director of Nurse's office revealed the social services staff had not formally requested a consult related to the resident and stated the primary responsibility for addressing behaviors was with the facility's Licensed Clincal Social Worker (LCSW). Interview confirmed the PMHNP had not followed up to see if the evening behaviors were being documented as was requested on October 10, 2011. Interview with the CM at 4:45 p.m., on October 20, 2011, at the Wing I nursing station, confirmed the nursing staff were not documenting the behaviors as requested on October 10, 2011, in the initial evaluation by the PMHNP. Review of the Resident Council minutes for July 2011 revealed under New Business, "Wing I resident (#22) stated, 'I keep getting bumped into all the time..." Review of a Resident Council Grievance Form initiated in response to resident #22's complaint revealed a response from the Wing I Clinical Manager, "Spoke with Res concern d/t (due to) one particular Res (#15) with dementia bumping into...asks staff to watch other res and keep ...(resident #22) away from this res. Instructed this res to call staff when...observed other res coming towards...(resident #22)" During the Group Interview, conducted with seven residents, on October 19, 2011, at 10:10 a.m., in the Wing II dining room, the resident council interim president (resident #27) stated resident #15 continued to be an issue for the residents due to bumping fell ow residents with...w/c, During the Group interview, resident #22 stated, "...my sister had to get ___ (resident #15) off (another unnamed resident)...mashing with w/c." Continued interview revealed several residents in the group interview referred to resident #15 as, 'the rammer." Interview on October 20, 2011, at 9:30 a.m., with resident #22 in the resident's room revealed, "...a couple of weeks ago" resident #15 had bumped into resident #22's walker causing the walker to hit their legs, while seated in the dining room. Review of the facility's documentation confirmed the incident had occured on September 25, 2011, and the resident had sustained no injury. Interview on October 20, 2011, at 3:30 p.m., with resident #27, in the resident's room, revealed resident #15 was named the Wild Man by resident #27. Interview continued and resident #27 stated, "The Wild Man backs into people, rams people, and hits the glass wall in the dining room...tired of (resident #15) coming into my room and them not doing anything about it...I doused him with my water pitcher and he shivered..." Interview on October 20, 2011, at 4:00 p.m., with resident #19, in the resident's room, revealed, "(Resident #15) goes so fast (resident #15) could hurt someone." Continued interview with resident #19 revealed resident #15 was "dangerous" and the resident was afraid of resident #15. Continued interview revealed the resident used a walker for ambulation and couldn't get out of resident #15's way if was too close. Interview on October 20, 2011, at 4:30 p.m., with residents' #36, #37, and #38, in the dining room, confirmed resident #15 "was confused and was always rolling the wheelchair in the dining room bumping into residents." Interview further revealed they, "knew to watch for him and keep out of his way." Interview on October 20, 2011, at 4:25 p.m., with resident #40, in the resident's room, revealed resident #15 had bumped into resident #40's wheelchair from behind last week while seated at a dining room table. Continued interview revealed resident #40 had been pushed into the edge of the table, but was not injured. Continued interview revealed resident #40 was afraid of resident #15 and "watched out" to see the whereabouts of resident #15. During an extended interview with the Administrator on October 21, 2011, at 9:10 a.m., in the conference room, related to injuries of unknown origin and resident behaviors, the administrator verified signing six of the reports filed for resident #15 and stated, "I can't possibly know about all the behaviors...I knew about 2 or 3...I wasn't aware of what (resident #15) was doing with...wheelchair." During the interview, the administator verified the facility did not have a behavior management program and stated, We are working on it right now..." Resident #8 was transferred to the facility from a Hospice in another state on July 20, 2010, with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated April 26, 2011, revealed the resident was ninety-four years old, non-ambulatory, with functional limitations of both lower extremities. Review of the physician orders [REDACTED]." Review of the mobile x-rays obtained on June 2, 2011, revealed, "Conclusions: 1. Acute comminuted fracture of distal femoral metaphysis...3. Moderate diffuse osteopenia... " Review of the Physical Therapy Screening Tool dated July 21, 2010, revealed, "...has B (bilateral) plantar flexion contractures (foot drop)...Recommend lifting pt (patient) for transfers... " Interview in the conference room on October 20, 2011, at 8:30 a.m., with the Physical Therapist (PT) responsible for the July 21, 2010, screening and recommendation verified resident #8 remained a full lift from admission and the PT stated they did not know why the CNA care plan called for, "Wt. Bearing-limited," with two persons at the time the resident sustained [REDACTED]. Review of the resident's Plan of Care, last updated April 31, 2011, revealed, "Problem - FALLS 07/28/2010 - At risk...Nonambulatory, Requires full staff assistance with all transfers...Problem-ADL (activities of daily living)...Requires total assistance with transfers... Intervention-...Assist with transfers with assist of 1-2 at all times... " Review of the Care Plan (not dated) provided by the Wing I Clinical Nurse Manager and identified as the care plan provided for the certified nursing aides (CNA) prior to June 1, 2011, revealed under the heading 'Assistance-Transfer' the boxes for two (persons) and Wt. (weight) Bearing were checked with "limited" penciled in next to Wt. Bearing. Review of the facility's Investigation/Witness Accounts Form (written statement) of one of the two CNAs (certified nursing assistant #1) performing the transfer at the time resident #8 was injured revealed, "Another CNA asked me to come into the room to assist with transferring a resident into the shower chair. As we were transferring resident into the chair we had to place resident on the floor due to slipping. Resident set with one leg under bottom and one out in front with her back resting on my legs. We called for assistance and while waiting for assistance we got resident's leg out from under her. Resident complained of pain once back in bed after shower. I advised other CNA to inform nurse to make sure resident was okay." Review of the second CNA's statement (CNA #2) revealed the resident was placed into the shower chair after a third CNA arrived to help and was put back into the bed after the shower was completed with a weight-bearing transfer performed by CNAs #1 and #2. Review of the Investigation/Witness Accounts Form completed by the CNA (#11) assisting the resident the following morning, June 2, 2011, revealed, "...This morning at breakfast when I pulled...up...complaining terribly in pain with...leg...pulled the cover up and noticed...knee very swollen...ankle area bruised...went and got...nurse on duty." Interview with LPN #1 by telephone on October 19, 2011, at 2:50 p.m., revealed LPN #1 first learned of the incident involving resident #8 after 4:00 p.m., on June 1, 2011, when one of the CNAs, "...came and told me they had to...set on the floor...(resident) wasn't complaining of pain and I didn't assess any injury...I wasn't told what really happened...When I came to work the next day, I learned about the fracture...began questioning everyone and got a different story from each one. " Review of a facility investigation follow-up, completed by the Assistant Director of Nursing (ADON) on June 4, 2011, revealed, "Sent to ER (emergency room ) on 6-2 c/o (complaint) RLE (right lower extremity) pain. Acute Femoral fx (fracture) noted. Redirection to CNA to have assistance when transfers..." During interview at 3:10 p.m., with the ADON on October 19, 2011, in the conference room, the ADON stated, "CNAs transferred and didn't do a good transfer...They were doing a transfer and the resident started slipping and was lowered to the ground..." Interview verified the ADON had not addressed the resident having "leg pulled out from under (him/her)" as one of the CNA's written statements revealed and had not addressed the resident being moved prior to the nurse in charge assessing the resident. Interview continued and confirmed the CNAs are instructed and repeatedly educated to have a nurse assess the resident after falls. Interview at 10:50 a.m., on October 21, 2011, by telephone with CNA #2 verified, when oriented to the facility upon hire, they were instructed not to move a resident after a fall or if the resident was lowered to the floor to have the nurse assess the resident prior to moving the resident. Interview continued and confirmed on June 1, 2011, the CNAs "partly picked (the resident) up and got leg out from under..." then put into shower chair, showered and returned to bed with a partial weight-bearing transfer and did not request a nurse to assess . Review of the investigation which included a basal cause dated June 10, 2011, completed by the Wing 1 Clinical Manager revealed, "CNA's were attempting to transfer res (resident) from bed to shower chair-had to lower res to floor, during which time res right leg twisted underneath...resulting in distal femur fracture." Review of the investigation revealed Basal Cause, "improper transfer tech (technique). No use of gait belt. " Interview in the Director of Nurse's office on October 21, 2011, at 10:00 a.m., with the Wing 1 Clinical Manager and the ADON, verified the resident's Plan of Care stated one to two persons were to assist with transfers, the CNA care plan stated two persons to assist with transfers. Interview verified the care plans were not in agreement with the amount of assistance necessary to transfer and confirmed both care plans were in conflict with the recommendation from the Rehab staff for a full lift of the resident for transfers. Interview confirmed, at the time the resident sustained [REDACTED]. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was total dependence for transfers, independent for decision making, and other behavioral symptoms occurred four to six days a week. Medical record review of the Falls Prevention Program Interventions dated March 1, 2010, and updated March 12, 2011, revealed "...one to two person transfer with mechanical lift..." Medical record review of the Interdisciplinary Plan of Care dated September 19, 2011, revealed "...At risk for Falls R/T (related to) impaired physical mobility, neurogenic disorder, and medication use...assist with transfer, assisting at level of: Total with mechanical lift and 2 or more persons...use mechanical lift for all transfers with assist of 2 or more persons..." Observation on October 20, 2011, at 8:18 a.m., in the resident's room, revealed CNA #9 and CNA #10 transferred the resident from the wheelchair to the bed with a gait belt. Interview with Registered Nurse (RN) #4 on October 20, 2011, at 9:05 a.m., in the Wing Two Nurses' Station, confirmed the resident was to be transferred with the mechanical lift and the facility failed to provide a safe transfer. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had short and long term memory problems, required limited assistance and one person physical assist for transfers, dressing, and bathing. Medical record review of the Interdisciplinary Plan of Care dated July 26, 2011, revealed "...Restraint Use: Soft Belt, potentially related to Unsteady gait...Risk Factors...falls, injury..." Medical record review of the physician's orders [REDACTED]. Review of the manufacturer's application instruction sheet for the lap belt revealed, "...lay the belt across the patient's lap...bring the strap ends with loops down over the thighs between the seat and the wheelchair skirt guard...go around the back post and cross the straps behind the patient...secure the loops on the wheelchair tilt levers...belt should be over the patient's hips at a 45-degree angle holding the hips against the back of the chair..." Further review revealed "...adverse reactions: The patient may become restless or agitated if the device is uncomfortable...severe emotional, psychological problems may occur if a patient's movement is severely limited..." Observation and interview on October 18, 2011, at 6:45 a.m., in the Wing IV dining room, with Licensed Practical Nurse (LPN) #4 revealed the resident seated in a wheelchair with a soft belt yelling loudly. Continued observation and interview revealed the right strap of the belt was between the wheelchair seat and the wheelchair skirt and the left strap of the belt was placed over the wheelchair skirt. Continued interview confirmed the soft belt restraint was not applied correctly according to the manufacturer's instructions. Medical record review of the Interdisciplinary Plan of Care dated July 26, 2011, revealed, "...assist in transfer...limited assist of one person..." Medical record review of the Physical Restraint Elimination assessment dated [DATE], revealed, "...non-ambulatory... chairbound...partial weight bearing/assist of one for transfer..." Observation on October 18, 2011, at 9:50 a.m., in the resident's room, revealed Certified Nurse Aide (CNA) #6 and CNA #7 transferred the resident from the wheelchair to the toilet, by lifting the resident under the arms. Interview with CNA #6 on October 18, 2011, at 10:00 a.m., in the resident's bathroom, confirmed a gait belt was to be used when transferring residents and the CNA's had failed to use a gait belt. Interview with Occupational Therapist Registered (OTR) #1 on October 18, 2011, at 12:10 p.m., in the Wing Two Nurses' Station, confirmed a gait belt was required for all transfers but there was no written policy. Continued interview confirmed all staff were educated upon hire and periodically during employment to "always" use a gait belt during transfers. Continued interview revealed it was not appropriate to lift a resident under the arms due to the potential for injury such as shoulder/arm fracture and the facility failed to provide a safe transfer. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident had severely impaired cognitive skills, was totally dependent with transfers, and did not walk. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls. Medical record review of the Interdisciplinary Plan of Care, reviewed on July 20, 2011, revealed "...Falls, at risk for...Use personal or pressure sensor alarms when...is in chair or bed..." Observation on October 18, 2011, at 8:50 a.m., revealed the resident seated in a wheelchair, in the dining room, with a clip alarm attached to the back of the resident's shirt. Continued observation revealed the clip alarm was connected to an alarm box attached to the back of the resident's wheelchair, and there was no indication the alarm box was activated. Observation and interview on October 18, 2011, at 8:55 a.m., with LPN #1, in the dining room, revealed LPN #1 removed the alarm box from the back of the resident's wheelchair, and confirmed the alarm box was not turned on/activated. C/O # Observation on the one-hundred hall on October 18, 2011, at 5: 50 a.m., revealed a biohazard room with a key visibly inside the lock to the door. Continued observation at this time revealed the one-hundred hall dining room directly adjacent to the biohazard room with seventeen residents up waiting for breakfast. Observation and interview on October 18, 2011, at 5:55 a.m., with Licensed Practical Nurse (LPN) # 5 of the biohazard room revealed a laboratory refrigerator containing three vacutainers of blood. Further observation revealed a centrifuge machine (used to spin blood for laboratory findings) with one vacutainer of blood. Interview with the Director of Nursing (DON) on October 18, 2011, at 1:16 p.m., in the DON's office, confirmed the biohazard room is to be kept locked.

Based on observation, medical record review, facility policy review, and interview, the facility failed to be administered in a manner to ensure an effective system was in place to investigate injuries of unknown origin were thoroughly investigated, resulting in an injury of unknown origin not being thoroughly investigated for one (#12) resident, failed to ensure the supervision and safe use of a wheelchair for one (#15) resident in order to prevent the resident from harming self and others, and failed to ensure social services were provided for residents (#12, #15, #27, #30) with behaviors for forty-nine residents reviewed which placed resident #12, #15, #27, & #30 in Immediate Jeopardy (a situation in which a provider's non-compliance has caused, or is likely to cause serious harm, injury, impairment, or death). The Administrator and Assistant Director of Nursing were notified of the Immediate Jeopardy on October 21, 2011, at 12:25 p.m., in the Administrator's office. The Immediate Jeopardy was effective July 22, 2011, and is ongoing. An extended survey was conducted on October 24, 2011. The findings included: An extended interview with the Administrator on October 21, 2011, at 9:10 a.m., in the conference room, revealed the following: The Administrator stated injuries of unknown origin, including injury around the genital area, would require a thorough investigation with the Medical Director, nursing, social services, and the Abuse Coordinator involved. The Administrator stated the Licensed Clinical Social Worker (LCSW) was the Abuse Coordinator and upon further questioning (specific to the LCSW's interview of October 20, 2011, when the LCSW stated, I am not the designated Abuse Coordinator) the Administrator stated, "...maybe she isn't the Coordinator, ..I'm not sure it is in writing...maybe that is a weak area." The Administrator verified the nursing staff members involved in assessing the injury of unknown origin for resident #12 did not have the education and training necessary to determine if assult could be ruled out. During the interview, the Administrator stated, "I'm not the guy to tell you we were 100%..." The Administrator verified there were no questions or discussions related to the injury of unknown origin for resident #12 with the Administrator prior to October 20, 2011, "Yesterday (October 20, 2011) I talked to the wound care nurses...people did check her ...documentation is not 100%..." The Administrator confirmed the Medical Director was not informed of the injury of unknown origin for resident #12. When the Administrator was asked about resident #15's unsafe behaviors with wheelchair and whether aware resident #27 had an altercation with resident #15 and resident #30 had hit resident #12 in the face, the Administrator responded, "I can't possibly know about all the behaviors...I knew about 2 or 3...I wasn't aware of what (resident #15) was doing with...wheelchair." Continued interview confirmed the facility did not have a behavior management program and stated, "we are working on it right now..." Refer to F225J Refer to F250K Refer to F280K Refer to F323K

Based on medical record review, facility investigation review, observation, and interview the facility failed to assess for and implement a care plan addressing behavior signs and symptoms for five residents (#12, #15, #24, #27, and #30) and the facility failed to care plan for the assessed number of assistants required for transfer for one resident (#8) of forty-nine residents reviewed. The facility's failure to assess and implement a careplan to supervise resident #15 and address the resident's unsafe behaviors in the use of the wheelchair placed the residents on Wing # I and # IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Administrator and the Assistant Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office on October 21, 2011, at 12:25 p.m. The Immediate Jeopardy was effective July 22, 2011, and is ongoing. An extended survey was conducted on October 24, 2011. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 00, indicating the resident was severely cognitively impaired and unable to participate in the mental status assessment. Medical record review of an Interdisciplinary Plan of Care, dated December 9, 2010, and updated September 9, 2011, revealed the resident had [DIAGNOSES REDACTED]. Medical record review of a Social Service Progress Note dated March 8, 2011, revealed, "...very confused...alert & (and) active...history of resisting care...altercations with other residents...staff to observe for further prob (problems) and intervene." Review of a facility investigation dated January 3, 2011, revealed an altercation with another resident, resulting in resident #12 being "...slapped across the face...seperated (separated) residents." Review of a facility investigation dated January 17, 2011, revealed another resident, "...slapped (resident #12) scratching the nose, a small amount of bleeding occurred...seperated (separated) residents...assessed for injuries." Review of a facility investigation dated March 28, 2011, revealed, "...resident became agitated and began clawing at CNA (Certified Nursing Assistant)." Review of a facility investigation dated May 16, 2011, revealed an altercation with another resident and witnessed by Activity Department staff, in Wing One dining room, resulted in resident #12 being sent to the emergency room due to multiple scratches on the face and a cut to the left eye. Review of a facility investigation dated August 23, 2011, revealed, "...resident was propelling self in wheelchair...when another resident began hitting resident (#12) in the face with fists...hematoma (bruise) above left eye...seperated (separated) residents." Review of a facility investigation dated October 15, 2011, revealed, "(resident #12)...grabbed res (resident #30) by the arm and would not release...then res (#30) started hitting res (#12) on the R (right) lower jaw." Interview with the Wing One Clinical Manager, verified resident #12 frequently exhibited behaviors, the resident's behaviors had resulted in resident to resident altercations, and confirmed behavior management/modification was not addressed in the resident's plan of care. Interview with Licensed Clinical Social Worker and the Social Worker Assistant, on October 20, 2011, at 11:15 a.m., in the conference room, confirmed resident #12 frequently exhibited "intrusive" behaviors, these behaviors had resulted in resident to resident altercations, and a behavioral care plan had not been established for the resident. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with a reference date of October 11, 2011, revealed the resident was unable to be assessed by the staff for Mental Status. The MDS recorded no physical behavioral symptoms directed toward others, but did record 'Other behavioral symptoms not directed toward others' ocurred 4 to 6 days a week. Observation of the resident at 6:00 a.m., on October 18, 2011, revealed a lap belt restraint worn around waist. Review of the resident's Plan of Care (POC) revealed, "7/20/2011 - ADL (activities of daily living) Functional Deficit, potentially related to Nonambulatory...Intervention... primary mode of locomotion is the wheelchair (w/c)..." The resident self propells their own wheelchair. Review of the complete POC revealed the Problem 'Activities' was dated from July 18, 2011 and did not include any interventions specific to the resident's constant motion with the wheelchair and moving throughout two of four wings of the facility. Review revealed all the current Problems included had a Target Date for the Goals moved forward to January 2012, but the Problems did not include the behaviors that had contributed to the resident being injured repeatedly with skin tears and negative interactions with fell ow residents. Review of the August 31, 2011, Nurse's Notes revealed a 5:00 p.m., entry, "...Spoke with wife and made aware of new skin tear. Wife has concern for WC (wheelchair) safety..." Interview and review of restraint records with the resident's Clinical Manager at 10:00 a.m., on October 19, 2011, in the conference room verified the resident's restraint was pre-assessed, continued to be assessed quarterly, and had not been added to the Interdisciplinary Plan of Care. Interview with the Assistant Director of Nurses (ADON) on October 19, 2011, at 10:00 a.m., in the conference room, verified resident #15 had nine skin tears, bruises, or interactions with other residents, filed in formal reports, and confirmed the resident had not had the skin tears or the unsafe use of wheelchair care planned. Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 2 on the Brief Interview of Mental Status (BIMS) which indicated the resident had severe cognitive impairment. Medical record review of the Nurse's notes dated June 8, 2011, at 7:35 p.m., revealed "...aide told me to come look at pt. (patient) and aide found a bruise on... left side of... breast and...no fall has occurred." Further review of the Nurse's notes dated June 8, 2011, at 8 p.m., revealed"...pt. told me that the bruise on...left breast has always been there and was from...wheel chair." Review of facility investigation, dated June 8, 2011, revealed "...while giving care tonight...turned...while putting...to bed. Resident has lg (large) bruise on... (left side of)... breast did not see yesterday...". Further review of facility investigation, dated June 8, 2011, at 7:35 p.m., revealed "bruise to left side of breast...pt stated no fall...looks like gait belt might have bruised left side of...breast. Pt. stated that the bruise has always been there and it's from...wc (wheel chair)..." Interview with the resident on October 20, 2011, at 4:40 p.m., in the resident's room, revealed the resident needed assistance with transfers and staff used a lift for transfers into the wheel chair. Resident stated "...it hurts when they get me up...bruise on left breast has always been there and it is from the wheel chair..." Medical record review of the Interdisciplinary Plan of Care, dated July 19, 2011, revealed the care plan had not been updated to reflect bruising of the left breast. Review of facility investigation , dated June 8, 2011, revealed "...bruising continues,...requires assistance with bed mobility and extensive assistance with transfers, and unable to determine exact cause and time...". Interview with Clinical Manager (CM) on Wing 1, on October 20, 2011, at 9:15 a.m., in the nurse's station, confirmed bruising was found on the resident's left breast and the care plan was not updated. Interview with the Assistant Director of Nursing (ADON), on October 24, 2011, at 8:15 a.m., in the Director of Nursing's office, confirmed the Interdisciplinary Plan of Care was not updated to reflect any interventions to prevent future occurrences. Resident # 27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 13 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively intact and had no mood or behavior indicators. Medical record review of the Psychiatric Note dated September 29, 2011, revealed "...complex behaviors...fixed [MEDICAL CONDITION] staff to monitor resident's behaviors..." Medical record review of the Nurse's Notes dated October 9, 2011, revealed "...Res (resident #27) was in...room et (and) res (#15)...came in and...(resident #27) yelled...to get out then took...water pitcher et threw water in...(resident #15) face...left message for Social Services..." Medical record review of the Social Service Progress Notes revealed the last entry was dated September 27, 2011. Medical record review of the Psychiatric Note dated October 14, 2011, revealed "[MEDICATION NAME] (antipsychotic)[MEDICATION NAME] (medication for [MEDICAL CONDITION]) for behaviors...continues to have fixed [MEDICAL CONDITION] staff to monitor behaviors..." Medical record review of the Interdisciplinary Plan of Care dated March 8, 2011, revealed the care plan had not been revised to reflect the resident's behaviors. Interview with the Social Worker Assistant on October 24, 2011, at 8:15 a.m., on Wing One Nurses' Station, confirmed Social Services had not completed a follow up for the resident's behavior on October 9, 2011 and had not addressed the resident's behaviors in the care plan. Resident # 30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for decision making and behaviors occurred four to six days a week. Medical record review of the facility investigation dated June 27, 2011, revealed, "...resident verbally arguing...slapped resident (#12) across face..." Medical record review of the facility investigation dated October 15, 2011, revealed, "...heard altercation...resident started hitting resident (#12) on right lower jaw..." Medical record review of the Nurse's Notes dated October 15, 2011, revealed "...resident (#30) got into an altercation...separated residents (#12 and #30)...placed in N.P. (Nurse Practitioner) book..." Medical record review of the Interdisciplinary Plan of Care dated October 7, 2011, revealed the care plan had not been revised to reflect the resident's behaviors. Interview with the Clinical Nurse Manager on October 20, 2011, at 10:00 a.m., in the Wing One Nurses' Station, confirmed the resident had a history of [REDACTED]. Resident #8 was transferred to the facility from a Hospice in another state on July 20, 2010, with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated April 26, 2011, revealed the resident was ninety-four years old, non-ambulatory, with functional limitations of both lower extremities. Review of the physician orders [REDACTED]." Review of the mobile x-rays obtained on June 2, 2011, revealed, "Conclusions: 1. Acute comminuted fracture of distal femoral metaphysis...3. Moderate diffuse osteopenia... " Review of the Physical Therapy Screening Tool dated July 21, 2010, revealed, "...has B (bilateral) plantar flexion contractures (foot drop)...Recommend lifting pt (patient) for transfers... " Interview in the conference room on October 20, 2011, at 8:30 a.m., with the Physical Therapist (PT) responsible for the July 21, 2010, screening and recommendation verified resident #8 remained a full lift from admission and the PT stated they did not know why the CNA care plan called for, "Wt. Bearing-limited," with two persons at the time the resident sustained [REDACTED]. Review of the resident's Plan of Care, last updated April 31, 2011, revealed, "Problem - FALLS 07/28/2010 - At risk...Nonambulatory, Requires full staff assistance with all transfers...Problem-ADL (activities of daily living)...Requires total assistance with transfers... Intervention-...Assist with transfers with assist of 1-2 at all times... " Review of the Care Plan (not dated) provided by the Wing I Clinical Nurse Manager and identified as the care plan provided for the certified nursing aides (CNA) prior to June 1, 2011, revealed under the heading 'Assistance-Transfer' the boxes for two (persons) and Wt. (weight) Bearing were checked with "limited" penciled in next to Wt. Bearing. Review of the facility's Investigation/Witness Accounts Form (written statement) of one of the two CNAs (certified nursing assistant #1) performing the transfer at the time resident #8 was injured revealed, "Another CNA asked me to come into the room to assist with transferring a resident into the shower chair. As we were transferring resident into the chair we had to place resident on the floor due to slipping. Resident set with one leg under bottom and one out in front with her back resting on my legs. We called for assistance and while waiting for assistance we got resident's leg out from under her. Resident complained of pain once back in bed after shower. I advised other CNA to inform nurse to make sure resident was okay." Review of the second CNA's statement (CNA #2) revealed the resident was placed into the shower chair after a third CNA arrived to help and was put back into the bed after the shower was completed with a weight-bearing transfer performed by CNAs #1 and #2. Review of the Investigation/Witness Accounts Form completed by the CNA (#11) assisting the resident the following morning, June 2, 2011, revealed, "...This morning at breakfast when I pulled...up...complaining terribly in pain with...leg...pulled the cover up and noticed...knee very swollen...ankle area bruised...went and got...nurse on duty." Interview with LPN #1 by telephone on October 19, 2011, at 2:50 p.m., revealed LPN #1 first learned of the incident involving resident #8 after 4:00 p.m., on June 1, 2011, when one of the CNAs, "...came and told me they had to...set on the floor...(resident) wasn't complaining of pain and I didn't assess any injury...I wasn't told what really happened...When I came to work the next day, I learned about the fracture...began questioning everyone and got a different story from each one. " Review of a facility investigation follow-up, completed by the Assistant Director of Nursing (ADON) on June 4, 2011, revealed, "Sent to ER (emergency room ) on 6-2 c/o (complaint) RLE (right lower extremity) pain. Acute Femoral fx (fracture) noted. Redirection to CNA to have assistance when transfers..." During interview at 3:10 p.m., with the ADON on October 19, 2011, in the conference room, the ADON stated, "CNAs transferred and didn't do a good transfer...They were doing a transfer and the resident started slipping and was lowered to the ground..." Interview verified the ADON had not addressed the resident having "leg pulled out from under (him/her)" as one of the CNA's written statements revealed and had not addressed the resident being moved prior to the nurse in charge assessing the resident. Interview continued and confirmed the CNAs are instructed and repeatedly educated to have a nurse assess the resident after falls. Interview at 10:50 a.m., on October 21, 2011, by telephone with CNA #2 verified, when oriented to the facility upon hire, they were instructed not to move a resident after a fall or if the resident was lowered to the floor to have the nurse assess the resident prior to moving the resident. Interview continued and confirmed on June 1, 2011, the CNAs "partly picked (the resident) up and got leg out from under..." then put into shower chair, showered and returned to bed with a partial weight-bearing transfer and did not request a nurse to assess . Review of the investigation which included a basal cause dated June 10, 2011, completed by the Wing 1 Clinical Manager revealed, "CNA's were attempting to transfer res (resident) from bed to shower chair-had to lower res to floor, during which time res right leg twisted underneath...resulting in distal femur fracture." Review of the investigation revealed Basal Cause, "improper transfer tech (technique). No use of gait belt. " Interview in the Director of Nurse's office on October 21, 2011, at 10:00 a.m., with the Wing 1 Clinical Manager and the ADON, verified the resident's Plan of Care stated one to two persons were to assist with transfers, the CNA care plan stated two persons to assist with transfers. Interview verified the care plans were not in agreement with the amount of assistance necessary to transfer and confirmed both care plans were in conflict with the recommendation from the Rehab staff for a full lift of the resident for transfers. Interview confirmed, at the time the resident sustained [REDACTED].

Based on medical record review, observation, and interview, the facility failed to provide social services adequate to meet the needs of four residents (#12, #15, #27, & #30) of four residents reviewed with behaviors affecting other residents. The facility's failure to provide social services adequate to address the resident to resident behaviors placed the residents on Wing I and IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The facility provided a Credible Allegation of Compliance on November 8, 2011. A revisit conducted on November 10, 2011, revealed the corrective actions implemented on November 8, 2011, removed the Immediate Jeopardy. Non-compliance for F-250 continues at a "E" level citation (potential for more than minimal harm). Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observation, and interview with the Licensed Counseling Social Worker, nurses, and administrative staff. The facility provided new policies/procedures including a policy for Behavior Management. The facility provided evidence of in-service education for all staff for the adopted behavior management policy and for specific resident behavior management plans, The individual behavior management plans and the coinciding comprehensive care plans were reviewed for residents #12, 27, and 30. Resident #15 had been dismissed from the facility. In addition, the behavior management plan for the single resident presenting with a new behavior on November 8, 2011, was reviewed. The behavior management plan to address this resident's new behavior was inserviced for the staff caring for the resident on November 9, 2011. Observation confirmed each of these residents also had the behavior management plans filed at each nursing station with an accompanyiing grid to facilitate recording behaviors. The facility will remain out of compliance at an "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, observation, and interview, the facility failed to provide social services adequate to meet the needs of four residents (#12, #15, #27, & #30) of four residents reviewed with behaviors affecting other residents. The facility's failure to provide social services adequate to address the resident to resident behaviors placed the residents on Wing I and IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Administrator and the Assistant Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office on October 21, 2011, at 12:25 p.m. The Immediate Jeopardy constitutes substandard quality of care and was effective July 22, 2011, and is ongoing. An extended survey was conducted on October 24, 2011. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident with a Brief Interview for Mental Status (BIMS ) score of 00, indicating the resident had severe cognitive impairment and was unable to participate in this mental status assessment. Continued review of the MDS revealed the resident required extensive staff assistance for transfers, mobility, and some activities of daily living. Medical record review of an Interdisciplinary Plan of Care, dated December 9, 2010, and updated September 9, 2011, revealed a [DIAGNOSES REDACTED]. Continued review revealed behavior signs or symptoms had not been addressed in the resident's care plan. Review of a facility investigation dated January 3, 2011, revealed an altercation with another resident, resulting in resident #12 being "...slapped across the face...seperated (separated) residents." Review of a facility investigation dated January 17, 2011, revealed another resident, "...slapped (resident #12) scratching the nose, a small amount of bleeding occurred...seperated (separated) residents...assessed for injuries." Review of a facility investigation dated March 28, 2011, revealed "...resident became agitated and began clawing at CNA (Certified Nursing Assistant)." Review of a facility investigation dated May 16, 2011, revealed an altercation with another resident and witnessed by Activity Department staff, in Wing One dining room, resulted in resident #12 being sent to the emergency room (ER) due to multiple scratches on the face and a cut to the left eye. Review of a facility investigation dated August 23, 2011, revealed, "...resident was propelling self in wheelchair...when another resident began hitting resident (#12) in the face with fists...hematoma (bruise) above left eye...separated residents." Review of a facility investigation dated October 15, 2011, revealed, "...(resident #12) grabbed res (resident #30) by the arm and would not release...then res (#30) started hitting res (#12) on the R (right) lower jaw." Interview with the Wing One Clinical Manager (CM) confirmed resident #12 had frequently exhibited behaviors resulting in resident to resident altercations. Interview continued and the CM verified the social services staff were responsible to assess and address behaviors and confirmed behaviors were not addressed in the resident's Interdisciplinary Plan of Care. Interview with Licensed Clinical Social Worker and Social Service Assistant, on October 20, 2011, at 11:15 a.m., in the conference room, verified resident #12 was known to exhibit "intrusive" behaviors and this frequently lead to resident to resident altercations resulting in harm to resident #12. Interview continued and confirmed the resident's known behaviors had not been care planned and a behavior management program had not been established for resident #12. Interview with Psychiatric Mental Health Nurse Practitioner (PMHNP) on October 21, 2011, at 9:22 a.m., in the Director of Nurse's office, confirmed resident #12 was diagnosed with [REDACTED]. Interview with the PMHNP confirmed the resident had frequently exhibited behaviors resulting in resident to resident altercations and no formal behavior modification/behavior management care plan had been established for resident #12, by the Interdisciplinary Team including nursing, social services, and the PMHNP. Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with a reference date of October 11, 2011, revealed the resident was assessed with [REDACTED]. The MDS recorded no physical behavioral symptoms directed toward others, but did record 'Other behavioral symptoms not directed toward others' occurred 4 to 6 days a week. Review of the August 31, 2011, Nurse's Notes revealed a 5:00 p.m., entry, "...Spoke with wife and made aware of new skin tear. Wife has concern for WC (wheelchair) safety..." Observation in the Wing I dining room from 5:45 a.m., until 6:30 a.m., on October 18, 2011, revealed the resident in a high back wheelchair (w/c) without foot pedals or leg rest using feet to propel around the large dining. Observation revealed seventeen residents in the dining room at 5:45 a.m., with ten of the seventeen residents asleep in their wheelchairs. Observation of resident #15 from 5:45 a.m., until 6:30 a.m., on October 18, 2011, with the resident propelling forward and backwards at intervals, revealed the following: Bumped into a sleeping resident (#20) with the back of the w/c and resident #20 jerked their hand away from the arm of their w/c resident #15 had come into contact with and resident #20 yelled, "Get away!"; propelled w/c into the wheelchairs of residents (#25 & #30); proceeded to move from the back of the room to the front of the room, circling to the left past two tables with residents seated in their wheelchairs; then, while in a forward motion, bumped into the oxygen tank of resident #26; and bumped into the back of the w/c of resident #12 (asleep in w/c). Observation revealed there were no staff members in the dining room for the forty-five minutes resident #15 was roaming the dining roam in constant movement. Observation of Wing I Dining Room on October 18, 2011, from 11:55 a.m., until 12:35 p.m., revealed resident #15 seated with the back of w/c against the dining room wall to the left of the double door. Observation at 12:20 p.m., revealed resident #15 propelled the w/c (using the feet) forward approximately eight feet and rammed the w/c into the dining table where resident #14 was seated. Observation continued and the ramming motion was repeated three more times, then resident #15 retreated about four feet, paused for four minutes, and then rammed into the same dining table again. Observation revealed certified nursing assistant (CNA #12) came to the table of resident #14 and took resident #15 back against the dining room wall. Continued observation revealed the third food cart arrived at 12:30 p.m., and CNA #12 began to feed the resident. Review of the resident's Plan of Care (POC) revealed the resident's "problems" did not include the behaviors contributing to the resident being injured repeatedly with skin tears and negative interactions with fell ow residents. Interview with the Assistant Director of Nurses (ADON) on October 19, 2011, at 10:00 a.m., in the conference room, verified the facility had formal reports of the resident's interactions with other residents and confirmed the resident did not have the unsafe use of the wheelchair care planned. During interview, the ADON stated social services were responsible to assess behaviors and verified the resident's unsafe behavior with the wheelchair affecting other residents was not correctly assessed on the October 2011 MDS and had not been care planned to develop interventions for the behavior. Interview on October 21, 2011 at 9:10 a.m., with the Nurse Practitioner (Psych Mental Health Nurse Practitioner/PMHNP) contracted for psychiatric consults, in the Director of Nurse's office revealed the social services staff had not formally requested a consult related to the resident and stated the primary responsibility for addressing behaviors was with the facility's Licensed Clincal Social Worker (LCSW). Interview in the conference room with the LCSW at 11:15 a.m., on October 20, 2011, revealed the LCSW stated, "assistant responsible for that resident (referrring to resident #15). Interview verified the LCSW had not been consulted related to the resident's behaviors with the wheelchair. Interview continued, the social services assistant joined the interview and verified after assessing the resident with behaviors in October 2011, the social services staff did not work in conjunction with the Interdisciplinary Team to develop interventions in an effort to maintain the safety of the resident and the other residents on Wing I & IV, where resident #15 had been documented to frequently wander. Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 13 on the Brief Interview of Mental Status (BIMS) which indicated the resident was cognitively intact and had no mood or behavior indicators. Medical record review of the Psychiatric Note dated September 29, 2011, revealed, "...complex behaviors...fixed delusions...nursing staff to monitor resident's behaviors..." Medical record review of the Nurse's Notes dated October 9, 2011, revealed, "...Res (resident #27) was in...room et (and) res (#15)...came in and...(resident #27) yelled...to get out then took...water pitcher et threw water in...(resident #15) face...left message for Social Services..." Medical record review of the Social Service Progress Notes revealed the last entry was dated September 27, 2011. Medical record review of the Psychiatric Note dated October 14, 2011, revealed, "...risperdal (antipsychotic)...depakote (medication for Schizophrenia) for behaviors...continues to have fixed delusions...nursing staff to monitor behaviors..." Medical record review of the Interdisciplinary Plan of Care dated March 8, 2011, revealed the care plan had not been revised to reflect the resident's behaviors. Interview with the Social Worker Assistant on October 24, 2011, at 8:15 a.m., on Wing One Nurses' Station, confirmed Social Services had not completed a follow up for the resident's behavior on October 9, 2011. Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was moderately impaired for decision making and behaviors occurred four to six days a week. Medical record review of the facility documentation dated June 27, 2011, revealed, "...residents (#12 and #30) verbally arguing...(resident #30) slapped resident (#12) across face..." Medical record review of the facility documentation dated October 15, 2011, revealed, "...heard altercation...resident started hitting resident on right lower jaw..." Medical record review of the Nurse's Notes dated October 15, 2011, revealed, "...resident got into an altercation...separated residents...placed in N.P. (Nurse Practitioner) book..." Medical record review of the Interdisciplinary Plan of Care dated October 7, 2011, revealed the care plan had not been revised to reflect the resident's behaviors. Medical record review of the resident's chart revealed no social service notes, no nurse practitioner notes, or behavior monitor form addressing behaviors, and the facility had not referred the resident for psychiatric examination. Interview with the Wing One Clinical Manager (CM), on October 20, 2011, at 10:00 a.m., in the Wing One Nurses' Station, confirmed the resident had a history of [REDACTED]. Interview with the Director of Nurses on October 24, 2011, at 8:10 a.m., in the DON's office verified the social service assistants did not have the training and expertise of the LCSW. During the interview, the DON confirmed the social services department had not developed interventions and did not have a behavior management program in place to to address resident #12's intrusive behaviors, resident #15's unsafe behaviors with the wheelchair, and residents #27 and #30's aggressive behaviors towards other residents.

Based on observation, medical record review, facility policy review, and interview, the facility failed to be administered in a manner to ensure an effective system was in place to investigate injuries of unknown origin were thoroughly investigated, resulting in an injury of unknown origin not being thoroughly investigated for one (#12) resident, failed to ensure the supervision and safe use of a wheelchair for one (#15) resident in order to prevent the resident from harming self and others, and failed to ensure social services were provided for residents (#12, #15, #27, #30) with behaviors for forty-nine residents reviewed which placed resident #12, #15, #27, & #30 in Immediate Jeopardy (a situation in which a provider's non-compliance has caused, or is likely to cause serious harm, injury, impairment, or death). The facility provided a Credible Allegation of Compliance on November 8, 2011. A revisit conducted on November 10, 2011, revealed the corrective actions implemented on November 8, 2011, removed the Immediate Jeopardy. Non-compliance for F-490 continues at a "E" level citation (potential for more than minimal harm). Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observations, and interviews with the Licensed Counseling Social Worker, nurses, and administrative staff. The facility provided evidence of a completed investigation of the bruising of unknown origin of resident #12. In addition, the Assistant Director of Nursing (ADON) provided the findings and conclusions from the investigations of forty-four additional injuries of unknown origin. The ADON provided the methods adopted to facilitate the identification of all injuries of unknown origin, communication to all responsible parties, investigation of the injuries to a conclusion, and the system to track and trend the injuries. The facility provided new policies/procedures including a policy for investigation of injuries of unknown origin adopted as part of the abuse policy, The facility provided evidence of in-service education for all staff. The facility provided new policies/procedures including a policy for Behavior Management. The facility provided evidence of in-service education for all staff for the adopted behavior management policy and for specific resident behavior management plans, The individual behavior management plans and the coinciding comprehensive care plans were reviewed for residents #12, 27, and 30. Resident #15 had been dismissed from the facility. The facility will remain out of compliance at an "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on review of the Quality Assurance Committee meeting minutes; Weekly Skin Reports; reports filed for residents' skin tears and bruising; and resident to resident altercations; observation; and interview, the facility failed to ensure the Quality Assurance Committee identified potential areas of concern and implemented a plan to address the areas of concern. The facility's failure to address residents' safety by reviewing and developing data in the aggregate to assist in formulating improvement plans (for individual residents and for specific populations of residents) placed residents on Wing I and IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Administrator and Assistant Director of Nursing were notified of the Immediate Jeopardy on October 21, 2011, at 12:25 p.m., in the Administrator's office. The Immediate Jeopardy was effective July 22, 2011, and is ongoing. An extended survey was conducted on October 24, 2011. The findings included: Review of the Weekly Skin Report dated October 11, 2011, revealed twenty-one of the Wing I residents had current bruises of the upper or lower extremeties compared to ten residents with similiar bruising on Wing II and eleven residents with similiar bruising on Wing IV. Interview with the Assistant Director of Nurses (ADON) on October 19, 2011, at 4:00 p.m., verified the ADON was a member of the Quality Assurance Committee and primarily responsible for review of the Weekly Skin Reports. Interview confirmed the ADON had reviewed the Weekly Skin Reports for cumlative information for individual residents, but had not assimilated total facility data related to bruising and had not recognized the twenty-one residents with bruises on Wing I as being twice as many as on the other two wings with similiar populations. Interview with the Assistant Director of Nursing (ADON), on October 21, 2011, at 10:50 a.m., in the Director of Nurse's office, revealed the ADON reviewed occurrence reports for the facility to determine if investigation outcomes, care planning, and corrections were in place for specific events. The ADON confirmed performance data was not trended to track specific outcomes related to injuries, resident to resident behaviors, and for the specific area of occurrence. Further interview with the ADON, confirmed the facility had not used investigation data in an effort to track specific events such as: residents running into other residents with wheel chairs; injuries; specific times; location; and staff intervention. During an extended interview with the Administrator on October 21, 2011, at 9:10 a.m., in the conference room, related to injuries of unknown origin and also related to resident behaviors, the administrator verified the Quaility Assurance Committee had not utilized data from adverse event reports in an effort to identified potential areas of improvement and implemented a plan to address the areas of concern. Refer to F225J Refer to F250K Refer to F280K Refer to F323K Refer to F490K

Based on review of the Quality Assurance Committee meeting minutes; Weekly Skin Reports; reports filed for residents' skin tears and bruising; and resident to resident altercations; observation; and interview, the facility failed to ensure the Quality Assurance Committee identified potential areas of concern and implemented a plan to address the areas of concern. The facility's failure to address residents' safety by reviewing and developing data in the aggregate to assist in formulating improvement plans (for individual residents and for specific populations of residents) placed residents on Wing I and IV in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The facility provided a Credible Allegation of Compliance on November 8, 2011. A revisit conducted on November 10, 2011, revealed the corrective actions implemented on November 8, 2011, removed the Immediate Jeopardy. Non-compliance for F-520 continues at a "E" level citation (potential for more than minimal harm). Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observations, and interviews with the Licensed Counseling Social Worker, nurses, and administrative staff. The Assistant Director of Nursing provided the methods adopted to facilitate the identification of all injuries of unknown origin, communication to all responsible parties, investigation of the injuries to a conclusion, and the system to track and trend the injuries. The facility will remain out of compliance at an "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, facility investigation review, policy review, and interview, the facility failed to thoroughly investigate and report an injury of unknown origin for one (#12) of forty-nine residents reviewed. The facility's failure to thoroughly investigate and report an injury of unknown origin placed resident #12 in immediate jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation, has caused or is likely to cause, serious harm, injury, impairment or death. The Administrator and the Assistant Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office on October 21, 2011, at 12:25 p.m. The Immediate Jeopardy constitutes substandard quality of care and was effective July 22, 2011, and is ongoing. An extended survey was conducted on October 24, 2011. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment and was unable to participate in the interview/assessment. Review of the MDS revealed the resident required extensive staff assistance for transfers, mobility, and some activities of daily living. Medical record review of a nurse's note dated July 22, 2011, by Licensed Practical Nurse (LPN) #6 revealed, "10:40 p.m. My aide came to me and told me Certified Nursing Assistant (CNA) #8 found a bruise...I went to look at it...bruise to L (left) leg to the inside." Review of the facility investigation and a signed statement by CNA #8, dated July 22, 2011, revealed, "I can see on resident's (res) face (res) in pain...I saw a huge bruise on left leg inside...I notice before the bruise near the pelvic area is swollen, so I reported to my charge nurse (LPN #6)." Continued review of facility investigation and a signed statement by LPN #6 dated July 22, 2011, revealed, "My aide (CNA #8) came and told me the resident had a bruise on (res) leg at 10:30 p.m., Friday, 7-22-11. I went and pt (patient) was in bed on R (right) side and aide pulled pt leg apart and I saw a bruise on L (left) leg to inside and red in color." Review of the facility investigation dated July 22, 2011 revealed the physician was notified. Review of the Weekly Skin Assessment form dated July 22, 2011, revealed a body diagram with the right leg shaded in, from the knee to the pelvis. The diagram was labeled "lg (large) bruise with [MEDICAL CONDITION]." Medical record review of a nurse's note dated July 23, 2011, revealed,"CNA called nurse to res (resident) room after assisting res to bed. This nurse noted purple bruising and swelling from the inner R (right) thigh extending down to the calf. Also, redness warmth and swelling to the R (upper) thigh...resident will holler out and grab leg with range of motion...T/O (telephone order)/ Dr (named physician): Venous Doppler (ultrasound diagnostic test) in a.m. to R leg to R/O (rule out) [MEDICAL CONDITIONS]. Notify MD (Medical Doctor) of results for possible X-ray order..." Review of the facility investigation and a signed statement by CNA #13, dated July 23, 2011, at 9:15 p.m., revealed, "...while getting resident ready for bed noticed lg (large) bruise to rt (right) leg, went and got nurse to come look..." Continued review of facility documentation dated July 23, 2011, revealed LPN #9's statement, "...bruising & (and) swelling R (right) inner thigh, extending down to R calf. Redness, swelling and warmth noted to R upper thigh." Review of the facility policy entitled "Bradley Healthcare & Rehab Center: Resident Injuries/Accidents of Unknown Origin" (revised 4-21-08) revealed, "The facility will provide a means to monitor injuries of unknown origin as part of an on-going quality assurance program. This procedure will assist the facility to identify injuries that may be related to mistreatment, abuse or neglect, and assist in prevention of injuries reoccurring...3. The investigation consists of an assessment of the resident's condition to determine the cause of the injury by other means than abuse or neglect...6. The Administrator and the Director of Nursing must be notified immediately when there are injuries present where suspicion of abuse or neglect, or allegations of abuse exist. The Administrator/Director of Nursing will be responsible to notify appropriate regulatory and enforcement officials as required by State and Federal Law." Review of the facility's "72 Hour Follow-Up" document by the Assistant Director of Nursing (ADON) dated July 26, 2011, revealed, "Bruising continues @ (at) this time. Bruising not noted on prior shift/rounds. Resident requires assistance with bed mobility and transfers." Continued review revealed no other examination, follow-up, or interventions had been implemented. Interview with CNA #8, by telephone, on October 21, 2011, at 11:10 a.m., confirmed CNA #8 discovered bruising and swelling to resident #12's "left thigh and pelvic area." CNA #8 stated the bruising and swelling had not been noticed earlier in the shift and was causing the resident pain. CNA #8 stated the bruising was reported to the charge nurse (LPN #6) when discovered. CNA #8 clarified the "pelvic area" as "vaginal area" to identify the specific anatomical location of the "swelling." Interview with LPN #6, by telephone, on October 21, 2011, at 1:15 p.m., related to the July 22, 2011 incident, revealed LPN #6 stated, "I kinda remember a bruise on the thigh ...pinkish-purple kinda...not huge...kinda difficult to see...left the resident's room and returned to nurses' station to complete incident report." Interview with Treatment Nurse #2, one of two treatment and skin care nurses (licensed practical nurses), on October 21, 2011, at 8:45 a.m., in the conference room, revealed the treatment nurses routinely did treatments and skin assessments together, frequently on the evening shift, during the hours of 7:00 p.m. to midnight. Treatment Nurse #2 stated, "I remember looking at and documenting the bruising (on resident #12) on July 22nd." Interview revealed Treatment Nurse #2 was unsure of the exact time of the assessment. Review of Treatment Nurse #2's time card, provided by the facility's Pay Roll Clerk, revealed Treatment Nurse #2 had not clocked in after clocking out at 2:06 p.m. on July 22, 2011, (The bruises and swelling were discovered and reported at 10:30 p.m. by CNA #8, eight hours and twenty-four minutes after Treatment Nurse #2 had clocked out for the day). Review of the Weekly Skin assessment dated [DATE], revealed the skin assessment for resident #12 had been initialed and completed by Treatment Nurse #1 on July 22, 2011. Interview with Treatment Nurse #1, on October 21, 2011 at 8:58 a.m., in the conference room, revealed, "I don't remember...if that's what I wrote, I guess that's right. I don't remember specifics..." Interview with Nurse Practitioner #1 (NP) by telephone, on October 20, 2011, at 5:48 p.m., revealed NP #1 had not been made aware of the extent of the bruising to the resident. During interview, NP #1 stated, "...had I known the bruising was that large and/or involved the pelvic area then I would have examined the resident personally, as well as insisted on a complete investigation to determine the cause of the injuries and to rule out any inappropriate contact." Continued interview revealed NP #1 was in the facility on July 26, 2011 but did not examine resident #12 or write a progress note. The NP reviewed the results of the Venous Doppler test and ordered X-rays of the leg. Interview with the Medical Director, by telephone, on October 21, 2011, at 2:25 p.m., revealed the Medical Director was not aware of resident #12's bruises discovered on July 22, 2011, and July 23, 2011. The Medical Director stated, "The facility needed to find out exactly what happened...due to the obvious implication of possible sexual misbehavior." Interview with the ADON, in the conference room, on October 20, 2011, at 12:20 p.m., confirmed bruising of unknown origin had been identified on the resident and no cause for the bruising had been determined. The ADON confirmed no follow-up examination or documentation had been completed, nor had any intervention been identified to prevent this type of injury from reoccurring. The ADON further confirmed the bruising had not been investigated or reported as an injury of unknown origin, and the facility's policy related to "Resident Injuries/ Accidents of Unknown Origin" had not been implemented. Interview with the Nursing Home Administrator (NHA), on October 21, 2011, at 8:12 a.m., in the conference room, revealed, "...was not necessarily advised of all incident reports...I don't review all incident reports...but always involved with serious injuries or abuse allegations." The Administrator confirmed the injury had not been thoroughly investigated, and a cause for the bruises had never been determined. The Administrator further confirmed the facility policy related to injuries of unknown origin had not been implemented.

Based on medical record review, facility investigation review, policy review, and interview, the facility failed to thoroughly investigate and report an injury of unknown origin for one (#12) of forty-nine residents reviewed. The facility's failure to thoroughly investigate and report an injury of unknown origin placed resident #12 in immediate jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation, has caused or is likely to cause, serious harm, injury, impairment or death. The facility provided a Credible Allegation of Compliance on November 8, 2011. A revisit conducted on November 10, 2011, revealed the corrective actions implemented on November 8, 2011, removed the Immediate Jeopardy. Non-compliance for F-225 continues at a "D" level citation (potential for more than minimal harm). Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observation, and interview with the Licensed Counseling Social Worker, nurses, and administrative staff. The facility provided evidence of a completed investigation of the bruising of unknown origin of resident #12. In addition, the Assistant Director of Nursing (ADON) provided the findings and conclusions from the investigations of forty-four additional injuries of unknown origin. The ADON provided the methods adopted to facilitate the identification of all injuries of unknown origin, communication to all responsible parties, investigation of the injuries to a conclusion, and the system to track and trend the injuries. The facility provided new policies/procedures including a policy for investigation of injuries of unknown origin adopted as part of the abuse policy, The facility provided evidence of in-service education for all staff. The facility will remain out of compliance at a "D" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.