Every finding on record at Brentwood Health Center by Harborview

Based on observations, staff interviews, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure soiled and clean linen carts were not stored together on three of five halls (300 Hall, 400 Hall, and 500 Hall). The deficient practice had the potential to increase the probability of the spread of infection from the soiled linen to the clean linen used while care services were being provided to residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program, dated 8/24/2022, revealed under Policy statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Under Prevention of infection: The facility will follow recommended and required guidelines to help mitigate or prevent infections as listed below: 1. Identifying possible infections or potential complications of existing infections; . 3. Educating staff and ensuring that they adhere to proper techniques and procedures; . 8. Following established general and disease-specific guidelines, such as those of the Centers for Disease Control (CDC). Observation on 6/13/2025 at 8:30 am revealed a clean linen cart stored directly next to the soiled linen cart by room [ROOM NUMBER] on the 400 Hall. Observation on 6/14/2025 at 9:12 am revealed there was a clean linen cart noted in the hall by room [ROOM NUMBER] that was touching the soiled linen cart that had visibly soiled linen in the container. Observation on 6/14/2025 at 2:30 pm revealed the clean linen cart was noted on the 300 Hall by room [ROOM NUMBER] and was touching the soiled linen cart. Observation on 6/15/2025 at 9:09 am revealed the clean linen cart and soiled linen cart were side by side and touching on the 500 Hall. Interview on 6/15/2025 at 9:10 am with the Director of Nursing (DON) confirmed that the clean linen cart was touching the soiled linen cart. During the interview, DON stated that the clean linen cart should not be that close to the cart at any time to prevent cross-contamination. The DON stated that the staff would be educated. Interview on 6/15/2025 at 9:12 am with the Infection Preventionist (ICP) revealed that the clean linen cart should not be touching the soiled linen cart at any time, and they should be at least six feet apart. The ICP nurse confirmed that the carts were touching and should not have been. During the interview, the ICP stated that the facility staff would be further educated on infection control practices. Interview on 6/15/2025 at 9:15 am with the Administrator revealed that the clean and soiled linen carts should not be stored side by side so that they are touching, due to increasing the risk for cross-contamination. Further interview also revealed that the expectation was for staff to understand how to properly store the carts and be knowledgeable of the infection control policies and practices.

Based on observations, staff interviews, record review, and review of the facility policy titled Garbage and Rubbish Disposal, the facility failed to maintain two of three facility dumpsters in a sanitary condition by ensuring the dumpsters had fitted lids and doors to prevent exposure to insects and rodents. The deficient practice created the potential to promote the harboring of pests, insects, and other organisms, and create the potential for disease transmission by pests and rodents. Findings include: Review of the facility policy titled Garbage and Rubbish Disposal, dated 2008, revealed the Policy Statement of Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. The Policy Interpretation and Implementation section included . 8. Outside dumpsters provided by garbage pick-up services must be kept closed and free of litter around the dumpster area. Concurrent observation and interviews on 6/13/2025 at 8:22 am, with Dietary Aide (DA), HH, and Maintenance Assistant GG, revealed three dumpsters with large gaps between the lids, resulting in large open spaces. Further observation revealed missing doors from the dumpsters, causing the trash not to be secure inside the dumpster and allowing exposure to insects and rodents. One dumpster door was observed sitting on the ramp, propped up against the building wall. DA HH and Maintenance Assistant GG confirmed the observations and reported that the dumpster doors had been off the dumpsters for three to four months. In an interview on 6/14/2025 at 10:17 am, the Dietary Manager (DM) reported that she reached out to the local City Hall in May 2025, but new dumpsters had not been delivered. She stated that the City Hall had informed her that the city did not have a three-door dumpster in May 2025. In an interview on 6/14/2025 at 11:54 am, Receptionist II confirmed that the problems with the dumpsters (missing doors and damaged lids) had existed since April 2025. She reported reaching out to the city for repairs and replacement of a dumpster in April 2025 and a previous follow-up after April 2025. She reported that although the dumpsters were requested, the city did not take action until 6/13/2025. She reported reaching out to the city on 6/13/2025 to request repairs after the surveyor had identified the problem with the dumpster. The receptionist reported that after making the call, a city official visited the site to attach new dumpster doors. She confirmed that the dumpster lids were not replaced.

Based on observations, staff interviews, record review, and review of the facility's policies titled Labeling and Dating Guidelines and Standard of the Week Labeling and Dating, the facility failed to ensure food items were labeled with open and/or discard dates and discarded on or before the discard dates. This had the potential to place 64 residents who received an oral diet from the kitchen at risk of food-borne illness. Findings include: Record review of the facility's undated policy titled Standard of the Week Labeling and Dating included, Upon receipt, all items should be inspected and marked with the date it was received into your facility and the date it should be discarded (if the item has a use by or discard date already on it, then you may use this date. After opening any item, the date it was opened must be clearly labeled on the front of the package, and any adjustments to the discard date should be made at this time. Review of the facility's undated policy titled Labeling and Dating Guidelines included, Upon receipt, all items should have a received date and a use by date. Upon opening, all items should have an open date and a use-by date. During the initial tour of the kitchen beginning on 6/13/2025 at 8:00 am, with Dietary Aide (DA) JJ, the following observations were made: Observations in the walk-in freezer revealed: One bag of pre-cooked biscuits, removed from the original container, labeled 6/11/2025 and missing an expiration date. One large gray pan containing two slabs of raw ribs, removed from the original container, and not labeled or dated. One large gray pan containing one slab of ribs, wrapped in plastic wrap, and not labeled or dated. One large gray pan containing chicken pieces in a clear plastic bag, removed from the original container, and not labeled or dated. One package of raw corned beef brisket, with no expiration date. One large bag of French fries, not labeled or dated Two bags of sliced squash, placed in a large brown pan, not labeled or dated One large bag of pre-cooked pepperoni, wrapped in plastic wrap, labeled with a received date of 6/18/25, with no expiration date. One coconut cream pie, not labeled or dated. Observations in the walk-in cooler revealed: Two bags of cooked noodles in a plastic bag dated 6/12/2025, and without a discard date. One bag of sliced peaches in a plastic bag dated 6/10/2025, and without a discard date. One large aluminum pan of cooked ground beef mixed with spaghetti sauce, labeled with a received date of 6/12/2025, and without a discard date. One plastic container, with a red lid, of pudding labeled with a received date of 6/10/2025, and without a discard date. One plastic container, with a green lid, of applesauce, labeled with an expiration date of 6/12/2025. One container of cooked hamburger meat, labeled with an expiration date of 6/12/2025 Observations of three plastic bins with lids revealed that one was labeled as a flour bin, one was labeled as a sugar bin, and one was labeled as a cornmeal bin. The flour, sugar, and cornmeal in the bins were removed from the original packaging. Each bin lid had a label with a date of 6/5/2025. There was no discard date. During an interview, at the time of observations, of all the above-mentioned items, with DA JJ, reported staff had received education to place the received date, opening date, used by date, and expiration date on food items. During an interview on 6/14/2025 at 11:00 am, the Dietary Manager (DM) reviewed photos of the identified food items for labeling and expired food items and confirmed all findings. The DM further stated that once staff remove any food products from their original container, staff should label the item with a discard date. She further stated that dietary staff should label all food items with a receive date, open date, and used-by/expiration date.

2. Review of R11's EHR revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation, pulmonary candidiasis, and unspecified atrial fibrillation. Review of R11's Annual MDS assessment, dated 5/21/2025, revealed Section J (Health Conditions) revealed R31 exhibited shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. Section O (Special Treatments, Procedures, and Programs) revealed R31 received O2 therapy while a resident. Review of R11's Physician's Orders included an order dated 5/17/2024 for O2 via NC at 5LPM continuous every shift. Observations on 6/13/2025 at 10:07 am and at 1:04 pm revealed R11 receiving O2 therapy by oxygen concentrator at 3.5 LPM via a NC. Observation on 6/14/2025 at 10:13 am, with LPN EE, revealed R11 receiving O2 therapy by oxygen concentrator at 7 LPM via a NC. LPN EE confirmed that the flow rate was set in error and against the physician's order of 5 liters per minute, and adjusted the flow rate. 3. Review of R122's EHR revealed an admission date of 6/9/2025, with diagnoses including, but not limited to, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and presence of an automatic (implantable) cardiac defibrillator. Review of R122's MDS assessments revealed that the admission assessment was in progress. Review of R122's Physician Orders revealed an order dated 6/9/2025 for O2 at 2 LPM via NC as needed for SOB [shortness of breath]. May remove as desired. Observations on 6/13/2025 at 10:14 am and 1:10 pm revealed R122 receiving O2 therapy by oxygen concentrator at 3.5 LPM via a NC. Observation on 6/14/2025 at 9:43 am revealed R122 receiving O2 therapy by oxygen concentrator at 4 LPM via a NC. In a concurrent observation and interview, LPN DD confirmed that the O2 was set on the wrong flow rate and not per the physician's order. In an interview on 6/14/2025 at 1:17 pm, the DON reported that her expectation was for licensed nurses to monitor the residents' O2 flow rate per shift and ensure the O2 setting was set per physician orders. Based on observations, staff interviews, record review, and review of the facility's policies titled Medication and Treatment Orders and Oxygen Administration, the facility failed to ensure oxygen (O2) was administered as ordered by the physician for three of 11 residents (R) (R31, R122, and R11) receiving O2 therapy. The deficient practice had the potential to place R31, R122, and R11 at risk of respiratory complications and unmet needs. Findings include: Review of the facility's policy titled Medication and Treatment Orders, dated 3/22/2017, revealed the Policy Statement section included, Orders for medications and treatments will be consistent with principles of safe and effective order writing. The section titled Policy Interpretation and Implementation included 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review of the facility's policy titled Oxygen Administration, dated 3/24/2017, revealed the Policy Statement section included, The purpose of this procedure is to provide guidelines for safe oxygen administration. The section titled Policy Interpretation and Implementation included, 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. The section titled Assessment included, . 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 1. Review of the electronic health record (EHR) for R31 revealed diagnoses that included, but not limited to, malignant neoplasm of endometrium, non-ischemic myocardial injury, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease with (acute) exacerbation, chronic diastolic (congestive) heart failure, transient cerebral ischemic attack, dependence on supplemental oxygen and cerebral infarction, unspecified. Review of R31's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section GG (Functional Abilities and Goals) revealed R31 required substantial/maximal assistance with mobility. Section J (Health Conditions) documented R31 exhibited shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. Section O (Special Treatments, Procedures, and Programs) revealed R31 received O2 therapy while a resident. Review of R31's Physician's Orders included an order dated 5/29/2025 for O2 at 4 liters per minute (LPM) via [by way of] a nasal cannula (NC), continuous every day and night shift, for shortness of breath. Observations on 6/13/2025 at 9:03 am, at 11:54 am, and on 6/14/2025 at 10:20 am revealed R31 receiving O2 therapy at 3.5 liters per minute via a NC. During an interview and observation on 6/14/2025 at 12:20 pm with the Director of Nursing (DON), she confirmed R31's O2 was flowing at 3.5 LPM via nasal cannula. Review of R31's orders with the DON verified that O2 was ordered at 4 LPM via NC. The DON reported that her expectations were for staff to follow the physician's orders. During an interview and observation on 6/14/2025 at 12:50 pm, Licensed Practical Nurse (LPN) AA revealed she was the nurse assigned to R31 and was responsible for making sure the O2 was administered at the correct setting per physician orders. LPN AA was shown pictures of R31 O2 setting at 3.5 LPM. She then reviewed R31's orders in the EHR and confirmed the O2 setting should have been set at 4 LPM. LPN AA revealed she had been busy passing medications and had not checked the O2 settings.

Based on observations, staff interviews, and record review, the facility failed to ensure one of 29 sampled residents (R) (R6) received care and services to avoid preventable falls. This deficient practice had the potential to place R6 at risk of injury related to avoidable falls. Findings include: Review of R6's electronic health record (EHR) revealed diagnoses including, but not limited to, epilepsy, chronic moderate intellectual disability, chronic kidney disease, age relate nuclear cataract, bilateral, anxiety disorder, and hypertension. Review of R6's Annual Minimum Data Set (MDS) assessment, dated 4/1/2025, revealed Section C (Cognitive Patterns) documented a Brief Mental Status Score (BIMS) score of 3 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required assistance with Activities of Daily Living (ADLs). Section V (Care Area Assessment [CAA] Summary) documented that falls were triggered. Review of R6's Fall Risk Assessment assessed the resident as a high risk for falls. Review of R6's Care Plan Report revealed a Focus area, revised 1/2/2025, of the resident was at risk for falls, with a history of falls documented. The Goal was for the resident to be free of fall-related injury through the next review period. Further review revealed a Focus area, dated 5/12/2023, of the resident had an Activities of Daily Living (ADL) self-care performance deficit and required assistance with all ADLs. Observation on 6/13/2025 at 9:30 am revealed R6 lying in his bed with the bed raised to a high position. Certified Nursing Assistant (CNA) CC exited the room, leaving the bed in a high position and the resident unattended by staff. In an interview on 6/13/2025 at 9:32 am, Licensed Practical Nurse (LPN) BB observed and confirmed that CNA CC had left R6 in bed and with the bed in a high position. CNA CC returned to the room and confirmed he had left the resident in the bed, with the bed in a high position, to obtain supplies for resident care. LPN BB and CNA CC stated the resident could independently move in the bed from left to right. They both confirmed the resident was at risk for falls, and the bed should be in the lowest position when left unattended to prevent injury due to falls. In an interview on 6/15/2025 at 11:51 am, the Director of Nursing (DON) her expectation that R6's bed would remain in the lowest position when left unattended. She further stated that the CNA should have called for assistance to obtain supplies or place the bed in the lowest position before exiting the room. In an interview on 6/15/2025 at 11:53 am, the Administrator stated staff would receive education on fall prevention.

2. Review of R11's EHR revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation, pulmonary candidiasis, and unspecified atrial fibrillation. Review of R11's Care Plan Report revealed a Focus Area, created 6/5/2024, for oxygen therapy. Interventions included oxygen as ordered. Review of R11's Physician Order revealed an order dated 517/2024 for O2 at 5 LPM every shift. Observations on 6/13/2025 at 10:07 am and at 1:04 pm revealed R11 receiving O2 therapy by oxygen concentrator at 3.5 LPM via a NC. Observation on 6/14/2025 at 10:13 am, with LPN EE, revealed R11 receiving O2 therapy by oxygen concentrator at 7 LPM via a NC. LPN EE confirmed that the flow rate was set in error and against the physician's order of 5 liters per minute, and adjusted the flow rate. 3. Review of R122's EHR revealed an admission date of 6/9/2025, with diagnoses including, but not limited to, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and presence of an automatic (implantable) cardiac defibrillator. Review of R122's Care Plan Report, dated 6/10/2025, revealed a Focus Area of O2 as needed. Interventions included observing the resident for breathing problems and placing O2 as ordered by the physician. Review of R122's Physician Orders revealed an order dated 6/9/2025 for O2 at 2 LPM via NC as needed for SOB [shortness of breath]. May remove as desired. Observations on 6/13/2025 at 10:14 am and 1:10 pm revealed R122 receiving O2 therapy by oxygen concentrator at 3.5 LPM via a NC. Observation on 6/14/2025 at 9:43 am revealed R122 receiving O2 therapy by oxygen concentrator at 4 LPM via a NC. In a concurrent observation and interview, LPN DD confirmed that the O2 was set on the wrong flow rate and not per the physician's order. In an interview on 6/15/2025 at 11:38 am, the MDS Coordinator confirmed R11 and R122's care plans for oxygen therapy. She reported that her expectation was for the staff to follow the physician's orders, since the care plan interventions included administering O2 as an order. Cross-Reference F695 Based on observations, staff interviews, record review, and review of the facility policy titled Care Plans-Comprehensive, the facility failed to implement the care plan for three of 11 residents (R) (R31, R122, and R11) receiving oxygen therapy. This deficient practice had the potential to place R31, R122, and R11 at risk of not receiving treatment and/or care according to their needs. Findings include: Review of the facility policy titled Care Plans, Comprehensive, dated 4/18/2017, revealed the Policy Statement section stated, An individualized comprehensive care plan that includes measurable and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The Policy Interpretation and Implementation section included, . 5. Care Plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying sources(s) of the problem areas(s), rather than addressing only symptoms or triggers . 1. Review of R31's electronic health record (EHR) revealed diagnoses that included but not limited to malignant neoplasm of endometrium, non-ischemic myocardial injury, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease with (acute) exacerbation, chronic diastolic (congestive) heart failure, transient cerebral ischemic attack, dependence on supplemental oxygen and cerebral infarction, unspecified. Review of R31's care plan dated 6/2/2025 revealed a Focus area for O2 (oxygen) therapy r/t (related to) Ineffective gas exchange. Dx (diagnosis) of COPD (chronic obstructive pulmonary disease); Goals : R31 will have no s/sx (signs and symptoms) of poor oxygen absorption through the review date. Interventions included: Give medications as ordered by physician Oxygen Settings: O2 via NC (nasal cannula) per MD [Medical Doctor] orders . Review of R31's Physician's Orders revealed an order dated 5/29/2025 for O2 at 4 liters per minute (LPM) via a NC continuous every day and night shift for shortness of breath. Observations on 6/13/2025 at 9:03 am, at 11:54 am, and 6/14/2025 at 10:20 am revealed R31 receiving oxygen therapy at 3.5 liters per minute via nasal cannula. During an interview and observation on 6/14/2025 at 12:20 pm with the Director of Nursing (DON), she confirmed O2 setting was infusing at 3.5 LPM via nasal cannula. DON reported that her expectations were for staff to follow the care plan. During an interview on 6/14/2025 at 12:35 pm, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator revealed she was responsible for making sure each resident had a comprehensive care plan in place. She confirmed there was a care plan in place for R31 for the O2 setting to administer O2 via NC per the physician's orders.

Based on staff interview and record review, the facility failed to ensure one of five residents (R) (R28) with a qualifying diagnosis was referred to the Georgia Preadmission Screening and Resident Review (PASRR) Utilization Management for review. This deficient practice had the potential to increase the probability of R28 not having her mental and psychological care needs met. Findings include: Review of R28's admission Record revealed admission on [DATE] with the diagnoses including, but not limited to, bipolar II disorder, obsessive-compulsive behavior, major depressive disorder, anxiety disorder, and psychosis. Review of R28's Annual Minimum Data Set (MDS), dated [DATE], revealed Section A (Identification Information) revealed the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Section I (Active diagnoses) documented diagnoses including, but not limited to, anxiety disorder, depression, bipolar disorder, and psychotic disorder. Review of R28's Care Plan Report revealed a Focus of R28 was at risk for adverse effects of antipsychotic medication. R28 uses antipsychotic medications r/t bipolar disorder, obsessive-compulsive disorder, depressive disorder, and anxiety disorder. Interventions included referring to psychological/behavioral health if needed, and/or ordered by the physician. Review of R28's Physician's Orders revealed medications including, but not limited to, Zyprexa (a medication used to treat bipolar disorder) oral tablet 5 MG, diazepam (a medication used to treat anxiety disorder) oral tablet 10 MG, quetiapine fumarate (a medication used to treat bipolar disorder and depression) oral tablet 50 MG. Review of R28's clinical record revealed no PASRR Level II. In an interview on 6/14/2025 at 10:04 am, the Admissions Coordinator revealed that the PASRR Level I screening was obtained before the resident was admitted to the facility and was uploaded into the resident's electronic medical record. During the interview, the Admissions Coordinator was able to locate R28's PASRR Level I for review. In an interview on 6/14/2025 at 10:14 am, the Director of Nursing (DON) revealed that the PASRR Level I should be in the resident's record. Continued interview revealed that when a resident had a qualifying diagnosis, the PASRR Level II should be applied for, and the Social Worker was responsible for ensuring that the request was submitted. The DON confirmed R28 had qualifying diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, and psychosis. The DON also confirmed there was no PASRR Level II for R28. In an interview on 6/14/2025 at 11:30 am, the Administrator revealed that the Social Worker was responsible for ensuring the PASRR Level I and Level II assessments were submitted for residents with qualifying diagnoses. The Administrator confirmed that a PASRR Level II was not in the resident's medical record and could not provide a copy of the requested documentation for submission of the documents. Continued interview revealed that her expectation was for all residents with a qualifying diagnosis to have a PASRR Level II submitted to the appropriate agency for review.

Based on observations, staff interviews, and record review, the facility failed to ensure that one of 29 sampled residents (R) (R6) was treated in a manner that maintained or enhanced his/her dignity. Specifically, staff provided care to R6 without providing full visual privacy. This deficient practice had the potential to place R6 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of R6's electronic health record (EHR) revealed diagnoses including, but not limited to, moderate intellectual disability, epilepsy, chronic kidney disease, and anxiety disorder. Review of R6's Annual Minimum Data Set (MDS) assessment, dated 4/1/2025, revealed Section C (Cognitive Patterns) documented a Brief Mental Status Score (BIMS) score of 3 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required assistance with Activities of Daily Living (ADLs). Section H (Bladder and Bowel) documented that the resident was incontinent. Observation on 6/13/2025 at 9:30 am revealed Certified Nursing Assistant (CNA) CC providing personal hygiene care and incontinent care to R6. Further observation revealed that R6 resided in Bed A. Observation revealed the privacy curtain was not pulled, and the window blinds were opened, providing full visual observation of R6 to anyone in the hallway outside of R6's room, anyone entering the room, and the resident's roommate. R6 was observed wearing only a brief. In an interview on 6/13/2025 at 9:32 am, CNA CC reported that he was getting ready to shave the resident and provide incontinent care and confirmed he did not provide privacy by pulling the privacy curtain, and further stated that he should have. In an interview on 6/5/2025 at 11:51 am, the Administrator and Director of Nursing (DON) both stated privacy curtains should be pulled to encircle the resident's bed while staff provided ADL care.

Based on observations, staff interviews, review of facility documentation, and review of the facility policy titled Posting Direct Care Daily Staffing Numbers, the facility failed to ensure the number of nursing personnel responsible for providing direct care to residents was posted daily for staff and visitors to review while in the facility. Findings include: Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, dated 3/23/2017, revealed under policy statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Under Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of the shift, the number of Licensed Nurses (RNs [Registered Nurse], LPNs [Licensed Practical Nurse], and LVNs [Licensed Vocational Nurse]) and the number of unlicensed nursing personnel (CNAs [Certified Nurses Assistant]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Observation on 6/13/2025 at 9:22 am revealed the staffing posting was located in a clear glass case going into the main dining area, dated 5/24/2025, with a total number of 2.79. Observation on 6/14/2025 at 7:26 am revealed the staffing posting was located in a clear glass case going into the main dining area, dated 5/24/2025, with a total number of 2.79. Interview on 6/14/2025 at 7:30 am with the Director of Nursing (DON) revealed that she had recently started at the facility as the interim DON and was not sure who was responsible for ensuring that the daily Per Patient Daily Ratio (PPD) staffing was posted. During the interview, it was confirmed that the last posting was dated 5/24/2025. Interview on 6/14/2025 7:33 am with the Human Resources Director confirmed that the PPD had not been posted since 5/24/2025. Interview on 6/14/2025 at 7:34 am, interview with Administrator confirmed that the posting had not been changed since 5/24/2025. Further interview revealed that the staffing posting should be completed daily.

Based on staff interviews, record review, and a review of the facility's policy titled, MDS Completion and Submission Timeframes, the facility failed to ensure that the Minimum Data Sets (MDS) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion to ensure current and accurate data for five of 27 Residents (R) (#19, R#20, R#145, R#3, and R#17) reviewed for MDS assessments. Findings include: A review of facility policy titled MDS Completion and Submission Timeframes, last revised 4/10/2017 revealed The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to Center for Medicare and Medicaid Services (CMS) QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. It also revealed that data for assessment types; Admission, Annual, Significant Change in Status, and Significant Correction to prior MDS, were required to be transmitted within 14 days from the completion of the care plan completion. MDS assessment types, including a quarterly, significant correction to prior quarterly assessment, entry tracking record, discharge assessment, discharge assessment-return anticipated or discharge due to death, were required to be transmitted within 14 days of MDS completion date. Record review of the MDS assessment for R#19 revealed the annual MDS assessment was completed on 7/21/2023 and was marked Complete but had not been transmitted to CMS. This MDS assessment was confirmed with the Clinical Reimbursement Director. Record review of the MDS assessment for R#20 revealed that the annual assessment was due 7/24/2023 and was marked as Export Ready but had not been submitted to CMS. Interview on 8/23/2023 at 1:50 p.m. with the MDS Coordinator revealed she had been at the facility for six to seven weeks and had no prior experience with MDS assessments and submissions. She confirmed that the MDS for R#19 was completed but had not been sent. Interview on 8/23/2023 at 2:45 p.m. with the Clinical Reimbursement Director confirmed that R#19 and R#20 residents' annual MDS assessments had not been transmitted. The Clinical Reimbursement Director revealed that during the interview, she had submitted a few resident MDS assessments that were sitting ready to be submitted. She stated that when the MDS assessments are completed, they are placed in the Point Click Care system as ready to be exported, but really are not exported until they are signed off by either her or another Registered Nurse (RN) since the MDS Coordinator at the facility is an LPN. She also revealed that after the MDS is signed off by the RN, Point Click Care transmits the reports, and when they have been accepted by CMS, the facility is notified the submission has been accepted, and a final check is done to make sure all the information had been submitted correctly. She stated there may have been a glitch in the Point Click Care system and saw on R#19's MDS assessment that a flag of not transmitting the MDS assessment was in place. She stated she was able to reverse that flag and then submit the MDS. She also stated that she is responsible for several other facility MDS submissions, and sometimes it can be a few days before she is able to sign them to complete the submission process. Record review of the MDS assessment for R#145 revealed the resident entered the facility on 7/19/2023; an MDS was completed and accepted. The MDS admission assessment was dated 8/1/2023, and the status was listed as Export Ready and had not been submitted. Record review of the MDS assessment for R#3 revealed the quarterly MDS dated [DATE] was in the Export Ready status and had not been submitted. Record review of the MDS assessment for R#17 revealed an entry date of 7/31/2023 after hospitalization was in an In Progress status and had not been submitted. The initial admitted to the facility was 6/26/2023. Interview on 08/24/2023 at 1:34 p.m. with the Director of Nursing (DON) and Administrator confirmed R#19, R#20, R#145, R#3, and R#17 MDS assessments had not been transmitted within the required time frame but had since been transmitted on 8/23/2023 and accepted. The DON and Administrator confirmed they can run a report to ensure all MDS assessments have been transmitted and accepted.

Based on staff interviews, record review, and a review of the facility's policy titled, Psychotropic Medication Monitoring, the facility failed to ensure that psychotropic medications, including antianxiety and antidepressant medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents (R) (R#144 and #244) reviewed for unnecessary medications. The sample size was 24 residents. Findings include: A review of the policy, Psychotropic Medication Monitoring, revised on 7/22/2022, revealed the facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include review for continued need. Pharmacy consultants will review medications monthly and review with the team. The pharmacy will provide a form for the physician to sign for reasons for having the order longer than 14 days. 1. Record Review of the most recent Admission Minimum Data Set (MDS) assessment for R#144 dated 8/9/2023 revealed primary admitting diagnoses that included but were not limited to, anxiety disorder unspecified, vascular dementia unspecified severity with psychotic disturbance, Section N-medications documented no antianxiety, antidepressant, antipsychotic, hypnotic, and opioid medications received. Record review of the Physician orders for R#144 included but was not limited to, Lorazepam 0.5 milligrams (mg) by mouth (PO) every (q) four hours (4hrs) as needed (PRN) anxiety or agitation for 14 days-order date 8/2/2023; Lorazepam 0.5mg po q4hrs PRN anxiety-order date 8/21/2023. Record review of the care plan for R#144 revealed the resident was at risk for anxiety due to a history (Hx) of anxiety disorder. Record review of the Medication Administration Record (MAR) for August 2023 revealed R#144 received Lorazepam 0.5 mg PRN for anxiety once on 8/2/2023, twice on 8/7/2023, twice on 8/12/2023, twice on 8/13/2023, once on 8/16/2023, twice on 8/22/2023, and once on 8/23/2023. Record review of the pharmacist progress note dated 8/2/2023 documented, lorazepam 0.5mg q4h PRN for anxiety/agitation for 14 days. Record review of orders revealed Lorazepam oral tablet 0.5 mg; given 0.5 mg orally every 4 hours as needed for anxiety, revision date 8/21/2023, start date 8/21/2023, end date indefinite. Record review of orders revealed Lorazepam oral tablet 0.5mg; give 0.5 mg orally every 4 hours as needed for anxiety, revision date 8/23/2023, start date 8/23/2023, pharmacy note-added stop date, end date 9/5/2023. Record review of care plan history with a copy date of 8/23/2023 documented, Nurses will give PRN meds for anxiety as needed documenting the effectiveness of medication and any adverse effects from medications given with a created date of 8/3/2023, and revision date of 8/3/2023. Record review of orders administration notes documented, Lorazepam oral tablet 0.5 mg Give one tablet by mouth every 4 hours as needed for anxiety or agitation confirmed administration of lorazepam PRN on 8/2/2023, 8/7/2023 x2 (times 2), 8/12/2023 x2, 8/13/2023 x2, 8/16/2023, 8/22/2023 x2, and 8/23/2023. Interview on 8/24/2023 at 1:30 p.m. with the Director of Nursing (DON) confirmed a PRN order that 8/2/2023, the doctor ordered the PRN medication Lorazepam 0.5 mg po q4hrs PRN anxiety for R#144. The DON revealed that she gets an e-mail with the Drug Alert with PRN psychotropic medications that are due to be either renewed or discontinued after 14 days. She prints these alerts out, gives them to the physician to complete, and then enters them into the record. She stated that there have been a few staff completing this process, and some are faxing the forms back to the pharmacy. She confirmed that if the order is greater than 14 days old, and if it is still on the MAR, the medication is still available. She confirmed the medication was past 14 days with no stop date. Her expectation was that all psychotropic medications have a stop date that is not beyond 14 days unless there is an extended stop date with a rationale by the physician. 47948 2. Record review revealed R#244 had a diagnosis of depression, anxiety disorder, and chronic pain syndrome. Record review of the Physician Orders for R#244 revealed an order for lorazepam oral concentrate 2 milligrams (mg)/milliliters (ml), give 0.5 ml by mouth every 3 hours as needed for restlessness. The stop date on the order stated indefinite. Record review of the Medication Administration Record (MAR) for R#244, dated August 2023, revealed that the resident had received a one-time dose of lorazepam upon admission, and a subsequent lorazepam PRN order had been received on 8/17/2023. The MAR indicated a start date for the lorazepam, but no end date. An interview on 08/24/2023 at 2:00 p.m. with DON confirmed that the physician order for R#244 regarding the PRN lorazepam did not have an expiration date. She stated that since the resident was on hospice, the pharmacist should automatically call within 14 days to see if the physician wanted to continue the order, even if there was not a designated stop date on the order. A phone interview on 8/23/2023 at 3:10 p.m. with Registered Pharmacist (RPh) AA employed at the pharmacy the facility utilizes, revealed that if there are any psychotropic medications ordered PRN, regardless if there is a 14 day limited order or indefinite order, the pharmacy will fax a Drug Alert to the corresponding facility to inform them the order needed to be evaluated by the physician to determine if the order needed to be continued another 14-30 days or discontinued. The fax sent indicates the date the fax was sent, who the fax is in reference to, and the specific medication. She stated that if the medication was to be continued or for a longer period than 14 days, the provider had to document on the form the rationale for continuing the medication. After this form is completed by the provider, the facility is to fax it to the pharmacy for their records. She stated that when there is a PRN psychotropic medication order written, a 14-day supply is delivered to the resident for use regardless of whether it is a 14-day limited order or an indefinite stop order. She confirmed if all available doses were not utilized during the 14-day period, the medication would still be available for administration in the resident's medication bin and available for administration. The medication would not be discontinued on the MAR if this form is not returned, or a new physician order written. She also revealed that sometimes it was difficult to get the facilities to return the completed Drug Alert form for them to place a stop date in the MAR.

Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, and Job Title: Administrator, and staff interview, it was determined that the facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls, and provided adequate supervision to prevent falls for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines revised 5/1/17 revealed the following: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Director of Nursing (DON)/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Review of the facility's Job Title: Administrator job description with a revised date of 10/2014 revealed: Job Description: Directs the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional Vice President, to provide appropriate care for our patients. Essential Regulatory Functions: 8. Enforces the Nursing Center guidelines. 14. Assumes responsibility with department supervisor to provide adequate staffing. During interview with the Administrator on 6/22/18 at 8:50 p.m., she stated that falls were discussed in morning meetings, interventions discussed and the care plan updated. She further stated that falls for individual residents may not be taken to QA for discussion as they handled falls as they occurred. She stated during further interview that she did not feel there was a trend in falls, as the residents had different co-morbidities and the falls occurred on different units. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/18/18 through 6/22/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F 657. The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for four residents (R) (R#85, R#96, R#70, R#71). Cross reference to F 689. The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or skilled services meetings per facility policy so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R#85, R#96, R#70, R#71). Cross reference to F 725. The facility failed to have sufficient staff to provide supervision to prevent falls for four residents with multiple falls (R#85, R#96, R#70, R#71). Cross reference to F 867. The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, implemented, and analyzed the effectiveness of corrective action plans for residents that sustained multiple falls (R#85, R#96, R#70, R#71).

Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, and staff interview, it was determined that the facility failed to provide consistent evidence of interdisciplinary team (IDT) input into development and revision of interventions for falls, and for evaluation of the effectiveness of current interventions to prevent falls for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated [DATE] revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. 1. IJ was determined to exist as of [DATE], when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated [DATE] revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and [DATE], which included falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. In addition, the fall on [DATE] resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on [DATE]. Further review of the clinical record revealed that she had falls on [DATE], [DATE], [DATE], and [DATE]. Further record review revealed the fall on [DATE] resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on [DATE] resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on [DATE], [DATE], and [DATE], and she sustained a nasal fracture after the fall from her wheelchair on [DATE]. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on [DATE], an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revision date of [DATE] revealed: Overview: Each patient's risk for falls is evaluated by the interdisciplinary team. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. Clarification: When a patient is found on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Assessment: 2. Upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified. When a Fall Occurs: 3. Implement intervention/s to prevent recurrence and maintain patient safety. 1. Review of R#85's clinical record revealed an original admission date of [DATE] and that he had [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R#85 had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment); had two or more falls with injury, and one fall with major injury, since the prior assessment. Further review of this MDS revealed that falls triggered as an area of concern with the decision to care plan. Review of his Quarterly MDS dated [DATE] revealed that he had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and one fall with non-major injury since the prior assessment. Review of a Fall Risk assessment dated [DATE] revealed that he was assessed with [REDACTED]. Further review of this assessment revealed that the section Care plan Indicated/updated was answered No. Review of Interdisciplinary Progress Notes (IPN) dated [DATE] at 9:00 p.m. revealed that R#85 was observed on the floor in his room at 8:20 p.m., and the resident alleged that his roommate had knocked him down, and had a skin tear to right elbow. Review of an IPN dated [DATE] at 7:00 a.m. revealed R#85 was observed laying on his back on the floor behind the door to his room around 6:05 a.m., resident could not tell how or what happened, laceration to left forehead and also observed a small laceration to the bridge of resident's nose, and a bruise coming up around his left eye. Transported to ER (emergency room ) around 6:30 a.m. Review of a radiology report dated [DATE] revealed an impression of comminuted [MEDICAL CONDITION] proximal humerus. Review of a CT (computerized axial tomography) of the head dated [DATE] revealed mild nasal bone deformity suggesting fracture of indeterminate age, this could also be chronic. Review of a CT cervical spine dated [DATE] revealed findings suspicious for a tiny, nondisplaced [MEDICAL CONDITION] of the odontoid (a projection from the second cervical vertebra). Review of R#85's risk for injury related to falls comprehensive care plan with an original date of [DATE] and an effective date of [DATE] revealed the following interventions: [DATE]: Move recliner closer to bed. [DATE]: Bed in lowest position. [DATE]: Call light within reach and educate on use-consider cognition. Undated interventions to this care plan included night light on due to [MEDICAL CONDITION] and visual impairment (which was discontinued on an unknown date as the resident was immobile); electric bed in place; fall mat; bolsters in place; and chair alarm in place. Review of the [DATE] falls documentation revealed there was no documentation of the height of the bed at the time of the fall to determine if an intervention for bed in lowest position was an appropriate intervention, and no investigation as to how the fall occurred to determine what additional interventions may have been appropriate. Review of an undated QA (Quality Assurance) fall audit for R#85 revealed that the only intervention for the fall on [DATE] was for bed in lowest position. Review of a Falls Report from [DATE] to [DATE] revealed that R#85 had a witnessed fall in his room on [DATE]. Review of an undated QA (Quality Assurance) fall audit revealed that no interventions were placed on the falls care plan. Review of a PAR (Patients at Risk) Review form dated [DATE] revealed that R#85 had a fall on [DATE] with injuries/fracture and on [DATE] resident was attempting to ambulate unassisted and had a fall. Resident encouraged to call for assistance but due to cognitive impairments we will have to monitor ambulation. Review of the section on this PAR Review form Review patients plan of care revealed that the No boxes were checked for were care plan revisions indicated ? and care plan updated by PAR team ? Further review of the team members signatures in attendance revealed that there were only nurses in attendance, and it did not reflect an interdisciplinary approach. Review of an IPN dated [DATE] at 10:40 p.m. revealed that R#85 was observed sitting on the floor in front of a chair in his room by staff around 10:15 p.m., resident was trying to go to the bathroom without assistance from staff. Resident stated that his right hip was hurting. No chair alarm was in use, bed alarm working and in place. Review of a right hip X-Ray dated [DATE] revealed an acute [MEDICAL CONDITION] right femur. No documentation was found of an investigation conducted for the root cause of the fall on [DATE], nor interdisciplinary discussion of possible interventions to try to prevent future falls. Review of R#85's risk for falls care plan with an effective date of [DATE] and a risk for falls care plan developed on [DATE] and revised on [DATE] revealed there were no interventions listed for a bed alarm as noted in the IPN note on [DATE], and the intervention on the [DATE] care plan for a chair alarm was undated, so it was not known when it was implemented. Review of a Nurse's Note created by the Director of Nursing (DON) dated [DATE] at 12:23 p.m. revealed that R#85 was no longer trying to get out of bed, so the bed alarm was discontinued. Review of an Occupational Therapy Certification with service dates from [DATE] to [DATE] noted R#85 was currently on low-high bed with B (bilateral) bed bolsters and sensor alarm. Review of R#85's risk for falls and other injuries related to falls comprehensive care plan with an onset date of [DATE] and updated date of [DATE] revealed the following interventions were all dated [DATE]: Administer first aid as needed; anticipate patient's needs-check frequently; assess contributing factors related to fall history; assess medications for contributing factors; bed bolsters; bed wheels in locked position; call light in reach-consider his cognition; low bed; mat at bedside: left; notify physician and family/responsible person of fall; obtain x-ray as ordered; provide ADL (activity of daily living) care, transfer with mechanical lift. Further review of additional interventions for this care plan dated [DATE] (during the survey) revealed moved to room closer to nurse's station on [DATE]; and encourage to spend time in day room for better observation/social stimulation. An Event-Initial Note dated [DATE] at 12:05 a.m. revealed the resident scooted to foot (of bed) past bed bolster and got up unassisted. Resident fell to floor and received a skin tear to rt (right) elbow. Resident noted with plain socks on. New intervention added after the fall included to provide non-skid socks, and mat at bedside on left. Review of the falls care plan with a developed date of [DATE] revealed there were no interventions added for use of non-skid socks after the fall on [DATE]. A PAR (Patients at Risk) Review dated [DATE] revealed: the patient had a recent fall, he scooted to foot of bed past bolster and got up unassisted. He fell to floor and received a skin tear to rt (right) elbow. Resident was in plain socks no skid protection. Previous interventions implemented included bed in low locked position, bed against wall, patient closer to day room bed bolsters, etc. See care plan. Interventions work for most part. Changes made to the plan of care bed mat added to left side, make sure patient has on no skid socks. Further review of this PAR Review revealed that an interdisciplinary team was in the meeting. However, there was no evidence for a discussion of the safety for continued use of the bed bolsters. Observation on [DATE] at 12:41 p.m. revealed that R#85 was in bed with a fall mat to one side, with a winged mattress and bed bolsters attached to the bedframe bilaterally in the middle of the bed between the winged portions of the mattress. During interview with the Director of Nursing (DON) on [DATE] at 3:28 p.m., she stated that either herself or the ADON (Assistant DON) reviewed the notes after a fall, and they talked about it in their weekly PAR meeting and the day after a fall during morning meetings, and ensured that appropriate interventions were in place. During interview with the DON on [DATE] at 5:02 p.m., she stated that either she or MDS staff updated the care plan after every fall, after the fall was discussed in morning meetings. During interview with the DON on [DATE] at 9:08 a.m., she stated that in morning meetings, which was attended by an interdisciplinary team, they reviewed the 24-hour report from the previous day for any falls, and decided if a therapy screen should be done. She stated during further interview that there was no discussion of review of the current interventions to see if they were appropriate. She stated that after the morning meeting, the ADON and herself discussed any falls, and if any new interventions should be put in place. She further stated that most of the interventions, on the electronic care plan, were dated [DATE], as that was when the facility implemented their new electronic documentation system. During further interview with the DON at this time, she stated that an intervention of a night light and for the bed to be in low position were added after the fall on [DATE], that she did not know the height of the bed at the time of this fall, and did not know why these were the interventions were added other than the resident liked for his room to be dark. 2. Review of the closed clinical record for R#96's revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted on hospice on [DATE] and expired on [DATE]. Review of R#96's Admission MDS dated [DATE] revealed that he had short and long term memory problems with inattention and disorganized thinking, needed limited assistance for ambulation, had a fall with fracture in the six months prior to admission, and one fall with no injury and one fall with a non-major injury since admission. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 5, he did not walk in his room or corridor over the seven days of the assessment period, and had one fall with a major injury since the last assessment. Review of R#96's clinical record revealed a baseline care plan was not found. Review of a comprehensive care plan for risk for falls related to a history of falls with injuries and unsteadiness was developed on [DATE]. Further review of this falls care plan revealed that it was revised on [DATE] and [DATE] (due to falls since admission-although it was not put into place due to lack room availability) for a room change closer to the nurse's station; on [DATE] to toilet after breakfast; on [DATE] to re-educate to use call light for assistance; on [DATE] to keep wheelchair nearby during toileting; on [DATE] for a therapy screen; on [DATE] for non-skid shoes when out of bed and gripper socks; and an undated intervention for a leg bag for catheter when out of bed when able. Review of a falls care plan with a developed date of [DATE] revealed the following interventions and dates: [DATE]: Assess medications for contributing factors [DATE]: Assess contributing factors related to fall history [DATE]: Wheelchair [DATE]: Bed in low position [DATE]: Call light in reach: consider resident's cognition and re-educate as needed [DATE]: Activity referral [DATE]: Assist patient with ADLs (activities of daily living) as needed [DATE]: Keep call light and most frequently used personal items within reach [DATE]: Transfer to acute care setting for evaluation [DATE]: Administer first aid as needed [DATE]: Notify physician and family/responsible person of fall [DATE]: Observe X 72 hours for possible injury related to a fall [DATE]: Bed alarm sensor [DATE]: Needed and desired items in reach/easy access [DATE]: Place patient in open area for maximum observation opportunities [DATE]: Notify hospice nurse as needed Review of a Falls Report from [DATE] to [DATE], and a Records List (of falls) from [DATE] to [DATE] revealed that R#96 had 10 falls between admission on [DATE] and [DATE]. In addition, there was one fall on [DATE] that was not captured on the falls reports. Review of clinical record documentation related to falls for R#96 revealed the following: An IPN dated [DATE] (the day of admission) at 10:00 p.m. revealed that upon med rounds found this resident lying on the floor between his bed and his roommate's bed. Review of an IPN dated [DATE] at 7:55 p.m. revealed the resident was on the floor in bathroom with feet pointing out of bathroom, on buttock/back, naked, catheter on floor. S/T (skin tear) noted X 2 to left elbow. Resident educated on call light use importance of assistance. Non skid socks placed on feet, bed moved against wall and a bedside commode at bedside. Call light clipped to gown. Staff keeps reminding resident to use call light. Review of a Skilled Services Review Notes completed [DATE] revealed that patient found on floor in restroom on his buttock/back [DATE]. On [DATE] patient noted on floor between bed and roommate's bed attempting to move pillow from between his legs. Further review of this note revealed it was signed by a nurse and therapist, but no evidence that an evaluation of interventions were done. An IPN dated [DATE] at 10:00 a.m. revealed that R#96 was noted on the floor near his bed in his room. No documentation was found as to the height of the bed, use of non-skid footwear, where he was prior to the fall, to be able to determine what new interventions should be tried. An IPN dated [DATE] at 1:30 p.m. noted resident sitting on floor in his room next to his bed, stated he was getting into bed. Was re-educated to use call light when he needs assistance. (No mention of any new falls interventions other than re-educated on call light use). An IPN dated [DATE] at 7:15 p.m. noted resident found on bathroom floor by CNA (Certified Nursing Assistant). Educated resident on call light use for bathroom assistance. Review of the intervention on the care plan dated [DATE] was to keep wheelchair nearby when toileting, but no notation found of why this intervention was appropriate. An SBAR (Situation-Background-Appearance-Review) Communication Form dated [DATE] revealed resident noted lying side lateral on floor by dresser, trying to get up. Resident noted wearing plain socks and feet kept slipping with attempts to get himself up. Non-skid socks were placed on and resident educated to use call light (an intervention after a fall on [DATE] was to place non-skid socks on feet). Review of the intervention on the falls care plan for this fall was for a therapy screen. However, review of a Comprehensive Rehabilitation Screen dated [DATE] noted that R #96 was already on PT caseload. An untimed IPN dated [DATE] (sic) noted found resident lying on floor. Had been to bathroom. Encouraged to use call light. No intervention was found on the care plan for this fall, and no notation found of what interventions were in place at the time of the fall. An IPN dated [DATE] at 1:24 p.m. noted patient assisted to the floor with the assistance of the CNA. Patient encouraged to use the call light when help is needed. No intervention was found on the care plan for this fall. An SBAR Communication Form dated [DATE] noted patient assisted to floor with assistance of CNA. No notation was found of any new or existing interventions discussed. A Nurse's Note dated [DATE] at 3:24 a.m. revealed that R#96 was found lying on the floor on back in doorway of bathroom. Reminded to use call light when he needs to get up to go to bathroom. Call light is within reach. Review of the risk for falls care plan revealed that interventions dated [DATE] were for call light in reach, but the Nurse's Note noted the call light was in reach. Further review of this care plan revealed an intervention dated [DATE] for bed in low position, but there was no notation in any of the falls documentation that the bed was not in lowest position. An Event-Initial Note dated [DATE] revealed R#96 was found lying in the doorway of bathroom and room on back. Is forgetful and does not use call light for assistance. New intervention added after the fall included bed in low position, call light in reach. Rationale for selecting above intervention(s) listed as effective and efficient. Review of an Observation Data report dated [DATE] at 10:52 a.m. for follow-up fall revealed new orders/interventions not effective. A PAR (Patient at Risk) Review Note dated [DATE] revealed that the resident has had several falls within the last month with the most recent falls on [DATE] and [DATE] (it does not mention the fall on [DATE]). On both occasions resident attempted to use the bathroom unassisted. He has periods of confusion with disorganized thought process and considered to have impaired judgement and safety awareness. Previous interventions implemented: Resident's room change closer to nurses station (resident resided in room C-12 at the time of this note, which was the last room on the C-hall, furthest away from the nurse's station), staff to assist with toileting after breakfast, re-direct and reinforced to use call light for assistance, keep wheelchair nearby during toileting, therapy screen-assisted by staff with dressing, non-skid socks, bed against the wall, and leg bag for catheter when out of bed. No documentation was found of a discussion of the effectiveness of these interventions. A Nurse's Note dated [DATE], late entry for fall that occurred on [DATE] at 12:20 a.m. revealed that R#96 was observed by staff lying halfway in the hall and halfway in his room on the floor. Resident had discoloration to bridge of nose, and active bleeding from both nostrils. Resident stated I was getting up to go the bathroom and fell . Encouraged resident to call staff for assistance if he wants to use the bathroom. Resident left the facility via stretcher accompanied by EMS at 12:40 a.m. in route to hospital. Review of a hospital Discharge Summary dated [DATE] revealed R#96 stated he tripped and fell . Review of the Discharge [DIAGNOSES REDACTED]. Review of an Event-Initial Note dated [DATE]: Resident was observed lying in between the doorway of his room and hallway. Per resident attempting to ambulate unassisted to the bathroom. New intervention added after the fall: Call light in reach. Toileting: encourage patient to call for assistance. A Nurse's Note dated [DATE] at 12:39 p.m.: Writer (the DON) told daughter that we would also look at a possible room change to move this resident closer to the nurses station (pending), resident will also be evaluated by therapy upon return to facility, other fall interventions include placement of bed and chair alarm, bed in lowest position and fall mat. Will await residents (sic) return to facility and then further evaluate needs. Review of the falls care plan revealed that a room change closer to the nurse's station was also an intervention dated [DATE]. Nurse's Notes dated [DATE] at 10:06 a.m. revealed that R#96 was observed on his knees kneeling on his bed, attempting to transfer from his wheelchair to his bed unassisted. Patient educated on the importance of using his call light for assistance. Bed alarm in place and working. Review of an Event-Initial Note dated [DATE] revealed that a bed alarm was in place call light in reach educated on importance of using call light for assistance. New intervention added after the fall: Bed alarm: sensor; call light in reach; needed and desired items in reach/easy access; place patient in open area for maximum observation opportunities. Review of a Skilled Services Review dated [DATE] revealed patient continues to have falls the plan is to move him closer to nurse station as room becomes available. Fall on [DATE] had small laceration to nose other fall no injury. Patient has bed alarm and we are going to add chair alarm. We will continue to remind patient to ask for assistance. Encourage and assist him to activity lobby for better observation and socialization. Review of interventions mentioned in the clinical record immediately after a fall or later discussion of the fall revealed that encouraging the resident to ask for assistance to get up and/or use of call light encouraged was mentioned for nine of the 11 falls ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]), despite the resident's cognitive impairment. During interview with the DON on [DATE] at 1:29 p.m., she stated that R#96's care plan had interventions for bed in low position and call light in reach on [DATE], and assumed that the bed was not in low position and call light not in reach if that was what the new interventions were. She stated that the intervention on [DATE] was to move R#96 closer to the nursing station, and that he was not assessed for a toileting plan as he had a suprapubic catheter. The DON stated during continued interview that they did not evaluate to see if R#96 was falling at a certain time of day, or review his meds as possibly contributing to the falls. 3. Review of R#70 clinical record revealed the resident was admitted to the facility on [DATE] at around 11:30 a.m. and she arrived in a wheelchair accompanied by family. The resident was admitted from an area acute hospital due to [DIAGNOSES REDACTED], volume depletion, urinary infection, general decline, dementia. Review of the Face Sheet for R#70 revealed the following admission Diagnoses: [REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Health Status (BIMS) of 3, indicating that she was cognitively impaired. She required extensive assistance of one person in bed mobility, transfer, walk in room, wall in corridor, locomotion off unit, dressing, eating, toileting, personal hygiene, and had occasional episodes of being incontinent of bowel and bladder. She required physical assistance of one person to help partially with her bathing needs. She had no impairments of upper and lower body range of motion and used a cane for mobility. Her medication used for the past seven days consisted of an antibiotic for a urinary tract infection. The resident was assessed as having no falls or fractures in the last month and the last six months, prior to admission. Further review of this MDS revealed that fall triggered as an area of concern with a decision to care plan. Review of the MDS dated [DATE] revealed R#70 had a (BIMS) of 99. She was totally dependent on two persons for assistance in bed mobility, dressing, eating, toileting, personal hygiene, and was incontinent of bowel and bladder. She had no impairment of her upper body range of motion and impairment of one side of her lower body range of motion. The resident was assessed as having no falls since admission although the resident had several falls in the facility, including a major fall with fracture. R#70 medications used in the past seven days included antibiotics for pneumonia and an opioid for pain management for a fall that has occurred during this past quarters review period. Review of the Fall Risk Form dated, [DATE] at 7:09 p.m., revealed the resident was assessed with [REDACTED]. The assessment revealed R#70 high risk for falls was due to wearing glasses, cognitive impairment, being restless, needing assistance with behaviors, needing assistance with mobility, being independent with supervision for transfers, non- weight bearing, has a wheelchair, was incontinent, receives one high risk medication, has anxiety and was care planned for falls. Review of R#70's care plan revealed a baseline care plan that was to be completed within 48 hours of admission to the facility was absent from the resident record. An interview on [DATE] at 3:35 p.m. with Registered Nurse (RN) DD revealed a confirmation that a baseline care plan was not completed on R#70. Review of the Data Collection, Skilled Services Nursing Assessment document dated [DATE] revealed the resident's cognition varies throughout the day, was pleasant, wanders, had difficulty walking used a wheelchair and walker. Although the Admission MDS dated [DATE] assessed the resident as using a cane. Review of the Nurse Note documentation dated [DATE] 12:50 p.m. revealed the R#70 was a new admit and had to be redirected to sit down this shift several times and has an unsteady gait. R#70 was sitting in the dining area of unit and was continued to be monitored. Review of Nurse Note documentation dated [DATE] at 2:39 p.m. revealed that the resident had a fall in the hallway of B- unit. No injuries from that fall were noted with assessing the resident after the fall. A rash was noted on her lower back. Medical was made aware of both issues and no treatment for [REDACTED]. Family was notified of the fall and back rash. Non-skid socks were given to this resident to prevent future falls. Non-skid socks were not added to the care plan. Review of the Observation Data documentation dated [DATE], [DATE], [DATE], revealed that on follow up for the fall there had been no change in condition. Review of the Nurse Note Documentation dated [DATE] at 2:33 p.m. revealed that the resident was working with therapy and was up dancing the Cha-Cha with the therapist. Night shift reported that the resident was up all-night wandering around the special care unit. The resident has slept most of the day shift except during meals, which consumption was poor, and she requested to go home several times. The resident also slides her bottom out from under her in the wheelchair. Therapy aware of resident sliding down. Non-skid socks also on resident feet. Review of the Nurse Note Documentation dated, [DATE] at 9:53 a.m. revealed that the Physician examined the resident for routine visit. No new orders. Review of the Nurse Note Documentation dated [DATE] at 10:08 a.m. revealed the resident was complaining of right leg pain, Physician notified, and new order received for [MEDICATION NAME] 325 milligrams (mg) two tablets, by mouth, four times per day for pain/fever. [MEDICATION NAME] 325 milligrams (mg) two tablets given, by mouth, to the resident with effective results. Review of the Nurse Note Documentation dated [DATE] at 4:18 p.m. revealed family visited the resident and right leg pain was better, but the resident complained of abdominal pain. The family requested a urinalysis due to the resident's past history of urinary tract infections and the nurse obtained an order from the physician. Review of the Event Initial Note [DATE] at 8:30 p.m. revealed the resident was found lying on the floor on her right side near the foot of her bed. The document further revealed that the resident was ambulating around her room without assistance using her cane at the time of the fall. The resident stated she did not hit her head and she was still hurting in (TRUNCATED)

Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, and staff interview, it was determined that the facility failed to have sufficient staff to provide supervision to prevent accidents for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revised date of 5/1/17 revealed the following: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Review of R#85's clinical record revealed an original admission date of [DATE] and that he resided on the MCU, and had falls in his room on 11/30/17 (he alleged that his roommate pushed him down), 12/1/17, 12/11/17, 12/29/17, and 4/10/18. Further record review revealed that he was diagnosed with [REDACTED]. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18.Review of the clinical records for R#85, R#96, R#70, R#71 revealed that there was no documentation that any of the falls noted above were witnessed by staff, except for the fall on 2/19/18 for R#96, and the fall on 12/11/17 for R#85. During interview with the Administrator on 6/22/18 at 8:30 p.m., she stated that there was nothing formally in QA (Quality Assurance) related to deploying staff to meet the residents' needs, and that staffing was deployed based on acuity of the residents. During an interview on 6/22/18 at 11:10 a.m. with the Director of Nursing (DON), she stated that she and a Certified Nursing Assistant (CNA) were responsible for creating the schedule for the nursing staff. During further interview with the DON, she stated that on the 7:00 a.m. to 7:00 p.m. shift, there was one nurse and three CNAs scheduled to provide care for the residents on the MCU, and on the 7:00 p.m. to 7:00 a.m. shift there was one nurse and three CNAs that were scheduled to provide care for the residents on both MCU and A-Hall. Continued interview revealed that when the MCU and A-Hall were at full capacity, it housed 50 residents. During an interview on 6/22/18 at 7:25 p.m., Licensed Practical Nurse (LPN) EE stated that she was the charge nurse from 7:00 p.m. to 7:00 a.m., and her assignment included the A-Hall, B-Hall (MCU), and private rooms P-1, P-2, P-3, and P-4. She stated that from 7:00 p.m. until 11:00 p.m. there was a total of four to five CNAs that worked the assignment with her, and that at 11:00 p.m., there were three CNAs total for the assignment. LPN EE stated during continued interview that it could be difficult for her to monitor the residents for behaviors and falls, because she was split between the three halls. During an interview on 6/22/18 at 7:40 p.m. with CNA FF, she stated that there were usually two CNAs scheduled on the 3:00 p.m. to 11:00 p.m. shift on the MCU. She stated during further interview that she didn't feel that there was enough staff to take care of the residents, and that she and the other CNA took turns making rounds so one CNA could change residents, and the other CNA could watch the residents who were up in the common area. Cross refer F689

Based on review of Quality Assurance (QA) information related to falls, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines and Quality Assurance-Performance Improvement (QAPI) policy, and staff and physician interview, the facility failed to have a Quality Assessment and Assurance (QAA) committee that effectively identified, developed, implemented, and monitored corrective action plans for four residents (R) that sustained multiple falls (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revised date of 5/1/17 revealed that each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Review of the facility's Quality Assurance-Performance Improvement (QAPI) policy (undated) revealed the following: Guiding Principles: The QAPI Process will be used within daily operations to guide decision making and improving care and services to meet the current and future needs of patients, customers, and the community. Governance and Leadership: The implementation of the QAPI Process is the responsibility of the Administrator. The Administrator may delegate aspects of this process to the QAPI Committee and/or key associates but retains the responsibility for oversight of the process, including ensuring that: 1. An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. 4. The QAPI program identifies and prioritizes problems and opportunities that reflect organization process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. 5. Corrective actions address gaps in systems, and are evaluated for effectiveness. Performance Improvement Projects (PIPs): PIPs will be chartered and implemented through the QAPI Committee based on priority as aligned with key customer expectations, center strategic objectives and resource availability. At least annually a PIP that focuses on high risk or problem-prone areas should be chartered. Concurrent PIPs should be limited to the number that the center is able to support within available resources for success. PIP team members should include representatives from various departments/units/shifts as affected and associates who work with the system/process on daily basis. During the course of PIP team charter, each PIP facilitator will be charged with leading the team in root cause analysis to determine underlying causes of issues, rather than applying quick fixes that address symptoms only. Reporting to the QAPI Committee should include root cause analysis findings. Systematic Analysis and Systemic Action: At the direction of the QAPI, changes in systems and processes should be monitored for a defined period after the change to identify these consequences which may be either positive or negative. QA Event (Just Do It) reports will be reviewed by QAPI Committee to ensure this tool is used for QA events in absence of system/process problems. The QA Event tool (Just Do It form) should not be used in place of the PIPs. During interview with the Director of Nursing (DON) on 6/22/18 at 3:01 p.m., she stated that they did not analyze falls immediately after the fall, except for what was discussed in morning meetings. She further stated that she took falls data to the QA monthly meetings and falls were discussed there. She stated during continued interview that they did not document drill downs (to determine the root cause of falls) during the monthly QA meeting. During interview with the Administrator on 6/22/18 at 3:18 p.m., she stated that falls were currently in QA but was not sure for how long, and that they had not made leaps and bounds progress, just small progress with it. During review of the facility's QA data related to falls and interview with the Administrator and DON on 6/22/18 at 4:10 p.m., the following was noted: 2/10/17 (2017): audits revealed that interventions not updated for falls. 3/17/17 (2017): audits revealed that some fall incident reports were not entered in the computer. During interview with the DON at this time, she verified that this affected the ability to accurately track the number of falls. The DON stated during further interview at this time that a PIP was developed to decrease the number of falls, falls with injury, and decrease recurrent falls for the same resident. She stated during continued interview that she did not know when this PIP was developed as there was no date on the form, but that it had a target date of 5/18/17. The DON stated at this time during interview and review of the facility's QA data that an audit was done on 5/15/17 (2017) of not filling out incident reports completely. During continued interview with the DON at this time, she stated that on 5/20/18, they did a Just Do It audit, which was part of of their QA, that included that some weeks of PAR were missed, and that some falls and pertinent information related to a fall was not listed on the PAR and/or skilled notes. The DON further stated that she had not done anything yet to address the concerns found with this audit, and did not respond when asked if she had to wait for a QA meeting to address identified concerns. During interview with the Administrator at this time, she stated that the Records List report (for falls) noted that there were falls on all of the halls, and occurred at different times of the day, so she did not see a pattern of falls. During interview with the DON at this time, she verified that other than printing this report off, that there was no documentation that the falls data was analyzed, such as identifying residents with frequent falls and/or falls with injuries, and time of day of the falls. The DON stated during continued interview that the Regional Nurse Consultant came out and identified where some of their weaknesses were, and it included adding interventions to care plans after a fall. She stated that there were glitches in their recently-implemented electronic health records (EHR) system that they were still working out, and that sometimes things entered didn't come over. She further stated that her investigation of a fall was only as good as the nurse's documentation after the fall, and that the incident report information was not always complete. During interview with the facility's Medical Director on 6/22/18 at 6:19 p.m., he stated that he attended QA meetings at least every two or three months, and that the Administrator went over any issues she needed for him to know about when he made rounds at the facility every two or three weeks. He further stated that they had discussed falls, but nothing specific as far as increased numbers of falls or not addressing falls. He further stated that he was called about every fall that happened in the facility so that he was aware of individual falls, but not necessarily anything specific related to problems with falls management. During interview with the Administrator on 6/22/18 at 8:30 p.m., she stated that there was nothing formally in QA related to deploying staff to meet the residents' needs, but that staffing was deployed based on acuity of the residents. Review of QA documents revealed the following: A Performance Improvement Project (PIP) with a chartered date by QAPI Committee and Date of Study on 2/5/18 revealed: The Key Performance Indicators and Desired Outcome was to decrease falls and falls with major injury over the next 30 days. The Summary of Root Cause Analysis (RCA) Findings revealed: Appropriate interventions placed upon admission. Communicate with staff daily aware of changes in condition change in inventions (sic). Daily rounding and communicating to staff. Weekly review-IDT (interdisciplinary team) rounds for changes, thoroughly investigating immediate at time of falls. Completion of incident report. Review of the Action Plan for this PIP revealed to retrain staff on fall prevention; review resident admission hx (history); rounding with IDT on each fall; complete thorough invest. (investigation); CP (care plan) imitated on admit; CNA (Certified Nursing Assistant) communication of fall risk; medication review/therapy consult; rethink use of alarms. Review of a Regional Nurse Center Visit Report dated 1/12/18: Opportunities for Improvement: 1. Fall documentation with detail description of fall, immediate intervention. 7. Care plan review, revise, update with appropriate interventions timely. Review of an untitled and undated QA document related to falls revealed: Target Date 5/18/17 ongoing: Review each fall in morning meeting. Bring charts, review the whole patient. Review why fall occurred. Documentation of detail description of the fall, assessment documented, and immediate interventions documented . Target Date 6/30/17: Review each resident's current fall care plan. Review, revise plan of care. Care plan should be thoroughly reviewed for appropriate interventions and goals. Add current fall and interventions place. An undated Performance Improvement Project (PIP) (Follow-up Date of 7/4/17) noted an opportunity to decrease number of falls, decrease falls with injury, decrease in number of residents with multiple falls. The Desired Outcome was to decrease number of falls by 20%, and decrease number of repeat falls by 20% over the next 60 days. Summary of Root Cause Analysis (RCA) Findings: Investigation of falls thoroughly to determine cause. Communicate cause, F/U (follow-up) to evaluate effectiveness of interventions. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/18/18 through 6/22/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F 657. The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for four residents (R) (R#85, R#96, R#70, R#71). Cross reference to F 689. The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or skilled services meetings per facility policy so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R#85, R#96, R#70, R#71). Cross reference to F 725. The facility failed to have sufficient staff to provide supervision to prevent falls for four residents with multiple falls (R#85, R#96, R#70, R#71). Cross reference to F 835. The facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls, and provided adequate supervision to prevent falls for four residents (R#85, R#96, R#70, R#71). Cross reference to F 837. The facility's Governing Body failed to ensure that there was an effective falls program including consistently determining the root cause of falls, and ensure the Quality Assurance (QA) program was effective in developing, implementing, and analyzing falls data to address falls for four residents (R) (R#85, R#96, R#70, R#71). During an interview with the Administrator, DON and Regional Nurse Consultant, conducted on 6/22/18 at 8:30 p.m., the Administrator was unable to provide any feedback regarding what type of model or system the facility's QAPI Committee utilizes to analyze data collected, develop their PIPs for problem areas identified and study the results of their actions to determine what, if any further action was required. She stated that the members of the QA Committee, if they identify something that isn't working in their department, have an option of doing a Performance Improvement Plan or PIP, introduce it into QA and then start working their plan; or they may complete a Just Do It plan which is used if they think they can resolve the problem quickly. Information (from the PIP and/or Just Do It) is brought back to the QA Committee for review. The Committee also use audits the management team (corporate) completes. She also stated the Consulting Pharmacist's monthly audits of each resident's drug regimen and audits of trends within the facility which are used to compare the facility's performance to their internal organizational data as well as state and national standards. The Administrator stated that sufficient staffing is always in QA. She discussed interventions utilized to reach their goal of being agency free which was met in April.

Based on review of the facility's Quality Assurance-Performance Improvement policy, Board of Directors procedural guidelines, and staff interview, it was determined that the facility's Governing Body failed to ensure that there was an effective falls program including consistently determining the root cause of falls, and ensure the Quality Assurance (QA) program was effective in developing, implementing, and analyzing falls data to address falls for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Quality Assurance-Performance Improvement (QAPI) policy (undated) revealed: Governance and Leadership: Elements of the QAPI Process will be reported to the Board of Directors periodically. QAPI Communications: The QAPI Committee will communicate findings to the appropriate personnel for reporting to the governing body. Review of the facility's Board of Directors procedural guidelines with a reviewed date of (MONTH) (YEAR) revealed: Board of Directors: Utilizes market analysis and market research for community needs and develops strategies for our Centers. Plans for long range and prioritizes demands through our strategic planning and goal setting process. Our leaders implement the goals through integrated services in the markets we serve. Services are provided for management and clinical support. Alignment of services for staff and function with allocation of resources, professional staff, based on service provided while systematically assessing performance and implementing priority driven improvement management. Maintain improvement. During interview with the Regional Nurse Consultant GG on 6/22/18 at 8:20 p.m., she stated that the way the corporation was structured, that each building operated as an LLC (Limited Liability Company). She further stated that the Administrator was considered the governing body for their building, and all department heads reported to her. During interview with the Regional Nurse Consultant GG on 6/22/18 at 9:19 p.m., she stated that Regional Vice President HH was part of the Governing Body, and he appointed the Administrator at each facility. She stated during further interview that the facilities had weekly calls with him on Mondays and Fridays, so the Administrator stayed in touch with him a lot. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/18/18 through 6/22/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F 657. The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for four residents (R) (R#85, R#96, R#70, R#71). Cross reference to F 689. The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or skilled services meetings per facility policy so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R#85, R#96, R#70, R#71). Cross reference to F 725. The facility failed to have sufficient staff to provide supervision to prevent falls for four residents with multiple falls (R#85, R#96, R#70, R#71). Cross reference to F 835. The facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls, and provided adequate supervision to prevent falls for four residents (R#85, R#96, R#70, R#71). Cross reference to F 867. The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, implemented, and analyzed corrective action plans for residents that sustained multiple falls (R#85, R#96, R#70, R#71).

Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, corporate, physician, and staff interview, it was determined that the facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or Skilled Services meetings per facility guidelines so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R) ( R#85, R#96, R#70, R#71). In addition, the facility failed to reassess for the continued use of bed bolsters after one resident (R#85) climbed past them and fell out of bed, and failed to reassess for the continued use of a motorized wheelchair after two accidents involving use of the chair for one resident (R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revision date of 5/1/17 revealed: Overview: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Each center will take a proactive approach for new patients admitted and will consider all patients to be at risk for falls until reviewed by the IDT. A care plan for falls will be initiated upon admission for each patient identified as a fall risk. Clarification: When a patient is found on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Assessment: 2. Upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified. 5. Patients should be reviewed in the Patient at Risk (PAR) or UR (Utilization Review) meeting as indicated. When a Fall Occurs: 1. Conduct a head to toe assessment to identify any injuries or changes in condition. 2. Observe and interview the patient or witnesses to determine possible cause of the fall. 3. Implement intervention/s to prevent recurrence and maintain patient safety. 4. Complete the Event Management Report to capture the investigation of the fall and assessment of the patient. This information should be entered into event management database for tracking and trending. 10. Review falls with the IDT in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete (including Event Management Report). 11. Review the event and patient status at the next scheduled PAR and/or UR meeting as indicated. 1. Review of R#85's clinical record revealed an original admission date of [DATE] and that he had [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed that R#85 had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment); needed extensive assistance for walking in his room; had two or more falls with injury, and one fall with major injury, since the prior assessment. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 99 (unable to complete one or more questions of the interview), had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making, and fluctuating inattention. Further review of this MDS revealed that walking in his room did not occur during the 7-day assessment period. Review of R#85's risk for injury related to falls comprehensive care plan with an original date of 6/4/14 and an effective date of 12/13/17 noted he had a recent fall resulting in laceration to forehead and fracture to right arm and fracture of odontoid (neck). Further review of this care plan revealed that it was updated to reflect a fall on 11/30/17 where he was observed on floor sitting next to sink; on 12/11/17 for ambulating unassisted; and on 12/29/17 observed sitting on floor in front of recliner. Review of the interventions to this care plan revealed: 6/30/17: Move recliner closer to bed. 12/1/17: Bed in lowest position. 12/13/17: Call light within reach and educate on use-consider cognition. Undated interventions to this care plan included night light on due to [MEDICAL CONDITION] and visual impairment (which was discontinued on an unknown date as the resident was immobile); electric bed in place; fall mat; bolsters in place; chair alarm in place. Review of R#85's risk for falls and other injuries related to falls comprehensive care plan with an onset date of 2/20/18 and updated date of 6/21/18 revealed the following Care Area/Problem statement: Fall risk was related to a history of wandering, unsteady gait, drags his feet when he ambulates, and history of prior falls with fractures. Recent falls with injuries of fractures to cervical spine, humerus and femur. He has a [DIAGNOSES REDACTED]. He is at risk for functional decline related to falls. He has history of ambulating without assistance prior to fracture of femur. He is confined to bed/chair most of time since his injury. He receives medications for diabetes which increases his risk for hypo/hyperglycemic episodes which increases his risk for falls and other injuries. Review of the Interventions for this care plan included the following dated 2/20/18: Administer first aid as needed; anticipate patient's needs-check frequently; assess contributing factors related to fall history; assess medications for contributing factors; bed bolsters; bed wheels in locked position; call light in reach-consider his cognition; low bed; mat at bedside: left; notify physician and family/responsible person of fall; obtain x-ray as ordered; provide ADL (activity of daily living) care, transfer with mechanical lift. Further review of additional interventions for this care plan dated 6/21/18 (during the survey) revealed moved to room closer to nurse's station on 12/1/17; and encourage to spend time in day room for better observation/social stimulation. Further review revealed the resident requires assistance with daily care, care plan reviewed on 6/4/18 revealed the assistance was due to several factors such as recent fractures to humerus, cervical (sic) and femur; he has had a significant decline in ADL care since his hospitalization requiring total assistance with daily care; and he resides in Memory Care Unit (MCU) due to [DIAGNOSES REDACTED]. Review of a Fall Risk assessment dated [DATE] revealed that R#85 was assessed with [REDACTED]. Further review of this assessment revealed that the section Care plan Indicated/updated was answered No. Review of R#85's Bed Rail/Assist Bar assessment dated [DATE] noted no equipment was currently attached to his bed. Review of a Falls Report from 6/3/17 until 2/20/18 (at which time the facility went to an electronic health record (EHR) and a different procedure for collecting falls data) revealed that R#85 had unwitnessed falls in his room on 6/30/17 at 10:30 a.m.; 11/30/17 at 8:20 p.m.; 12/1/17 at 6:05 a.m.; 12/11/17 at 7:05 p.m. (marked as witnessed); and 12/29/17 at 10:15 p.m. Review of a Records List report for falls dated 2/21/18 to 6/19/18 (after the facility transitioned to an EHR) revealed that R #85 had a fall on 4/10/18. Review of clinical record documentation related to falls for R#85 revealed the following: -Falls on 11/30/17 and 12/1/17: Interdisciplinary Progress Notes (IPN) dated 11/30/17 at 9:00 p.m. revealed that R#85 was observed on the floor in his room at 8:20 p.m., and the resident alleged that his roommate had knocked him down. Skin tear to right elbow noted. R#85 stated that his right arm and shoulder hurt. Doctor notified of event and new order given to have x-ray of right arm and shoulder in a.m. (NOTE: This fall was unwitnessed, and the facility did a self-report to the State Survey Agency with their investigation for an allegation of resident to resident abuse, #GA 680). IPN dated 12/1/17 at 7:00 a.m. revealed R#85 was observed laying on his back on the floor behind the door to his room around 6:05 a.m., resident could not tell how or what happened, writer observed blood coming from the left side of his forehead, writer applied gauze to laceration to left forehead and applied pressure to stop bleeding. Writer also observed a small laceration to the bridge of resident's nose, and a bruise coming up around his left eye, he had a skin tear from fall last night. R#85 stated that his neck hurt while writer was wrapping his head. Transported to ER (emergency room ) around 6:30 a.m. Review of a hospital History of Present Illness dated 12/1/17 revealed a final impression of laceration to left side of forehead, and closed comminuted fracture of right proximal humerus. Review of a radiology report dated 12/1/17 revealed an impression of comminuted [MEDICAL CONDITION] proximal humerus. Review of a CT (computerized axial tomography) of the head dated 12/1/17 revealed mild nasal bone deformity suggesting fracture of indeterminate age, this could also be chronic. Review of a CT cervical spine dated 12/1/17 revealed findings suspicious for a tiny, nondisplaced [MEDICAL CONDITION] of the odontoid (a projection from the second cervical vertebra). IPN dated 12/1/17 at 6:25 p.m. revealed R#85 returned to facility at 4:00 p.m. with right arm in sling. Resident has bruising around and under left eye with bandage on forehead. Review of an FNP (Family Nurse Practitioner) Progress Note dated 12/6/17 revealed that resident had falls that occurred on 11/30/17 and 12/1/17. On 12/1/17 he was observed on the floor by nursing staff. He had bruising and laceration to the left side of the forehead and complained of neck pain. Hospital imaging revealed comminuted right humerus fracture. Transferred to another hospital for further evaluation by Ortho (orthopedics). Sling placed to RUE (right upper extremity). Suture closure performed to laceration site to forehead. No surgical intervention performed. Review of the Plan of this Progress Note included fall precautions to be implemented. Review of a PAR (Patients at Risk) Review form dated 12/17/17 revealed that R#85 had two falls. On (MONTH) 1st (2017) he had a fall with injuries/fracture and on (MONTH) 11th (2017) resident was attempting to ambulate unassisted and had a fall. Resident encouraged to call for assistance but due to cognitive impairments we will have to monitor ambulation. The section on this PAR Review form Review patients plan of care revealed that the No boxes were checked for were care plan revisions indicated? and care plan updated by PAR team? Further review of the team members signatures in attendance revealed that there were only nurses in attendance and it did not reflect an interdisciplinary approach, and there was no notation of an investigation of the root cause of the fall, such as footwear on at the time of the fall, bed in low position, etc. Fall on 12/29/17: Review of an IPN dated 12/29/17 at 10:40 p.m revealed that the resident was observed sitting on the floor in front of his rocking chair in his room by staff around 10:15 p.m., resident was trying to go to the bathroom without assistance from staff. Skin tear to right arm below elbow noted, resident stated that his right hip was hurting and felt like he couldn't stand on it. No chair alarm was in use, bed alarm working and in place. An IPN dated 12/30/17 7A-7P noted the resident was seen by FNP F/U (follow-up) fall. Dislocation of some sort noted to right leg. N.O. (new order) to send to hospital. An FNP Progress Note dated 12/30/17 noted resident is status [REDACTED]. He is a poor historian and uncertain of how he fell . Resident is complaining of right hip pain. Xray ordered and reveals acute [MEDICAL CONDITION] right femur. He currently has neck and right humerus fractures from previous falls in-facility. Review of a right hip X-Ray dated 12/30/17 revealed an acute [MEDICAL CONDITION] right femur. A Hospital Course summary with date of admission of 12/30/17 and date of discharge 1/4/18 noted nh (nursing home) resident with cervical (C2) and right humeral fx (fracture) (from recent fall) managed nonop (non-operatively) due to advanced medical conditions. Apparently fell again on 12/30/17 suffering right intertrochanteric femur fx. S/P (status [REDACTED]. An Occupational Therapy Daily Note with service dates from 1/5/18 to 2/3/18 noted R#85 was currently on low-high bed with B (bilateral) bed bolsters and sensor alarm. Review of a Nurse's Note created by the Director of Nursing (DON) dated 3/27/18 at 12:23 p.m. revealed that R#85 was no longer trying to get out of bed. Since recent falls in the past few months resulting in hip and shoulder fractures he is no longer ambulatory and less active. Will discontinue bed alarm at this time and continue with other fall interventions. No documentation was found of an investigation conducted for the root cause of the fall on 12/29/17, including where the resident was prior to the fall, the footwear he had on, etc. -Fall on 4/10/18: An Event-Initial Note dated 4/10/18 at 12:05 a.m. revealed the resident scooted to foot of the bed, past the bed bolster and got up unassisted. Resident fell to floor and received a skin tear to rt (right) elbow. Resident noted with plain socks on. New intervention added after the fall included to provide non-skid socks, and mat at bedside on left. An Initial C[NAME] (Change of Condition) Report to MD (Medical Doctor) dated 4/10/18 revealed the resident had a fall in room at 12:05 a.m. Writer noted resident on floor at foot of bed. Resident scooted to foot of bed pass (sic) bed bolsters and was able to get out of bed unassisted. Roommate in room stated resident fell trying to walk. Resident noted with plain socks on and received a skin tear with flap to rt elbow. Resident voiced pain to rt elbow. Non skid socks placed on resident and fall mat placed on left side of bed. A PAR (Patients at Risk) Review dated 4/10/18 revealed the patient had a recent fall, he scooted to the foot of bed past bolster and got up unassisted. He fell to floor and received a skin tear to rt (right) elbow. Resident was in plain socks no skid protection. Previous interventions implemented included bed in low locked position, bed against wall, patient closer to day room, bed bolsters, etc. See care plan. Interventions work for most part. Changes made to the plan of care bed mat added to left side, make sure patient has on no skid socks. Further review of the falls documentation revealed that there was no notation of the height of the bed at the time of the fall, why he was attempting to get up, or what other interventions were in place. A Therapy Referral dated 4/11/18, completed by the Director of Nursing (DON) revealed that the resident was previously able to walk prior to fractures. Review of the Noted change of condition section on the form revealed a fall on 4/10/18 out of bed scooted past the bolster and fell to floor. An Observation Data form dated 4/11/18 and 4/13/18 noted reason for observation was fall, no injuries. Review of the question on this form Are new orders/new interventions effective? revealed the response was NA (not applicable). An IPN dated 1/29/18 at 2:22 p.m. revealed that R#85 was pulling at bolsters and trying to unclip them off of bed. Review of all of the above documentation related to the fall on 4/10/18 revealed that the facility did not assess for continued use of the bed bolsters after this fall. Other than the documentation above that PAR Reviews were conducted on 12/17/17 and 4/10/18, there was no evidence found in the paper or EHR that PAR meetings and/or Skilled Services reviews were held to discuss R#85's falls. Review of a PAR Review dated 3/6/18 noted R#85 had a fall in (MONTH) with a [MEDICAL CONDITION], but the discussion in the review was for his weight loss only. Review of a PAR Review dated 4/18/18 revealed that R#85's weight change only was discussed. Review of a PAR Review dated 5/8/18 revealed that R#85's weight change and wound only were discussed. Observation on 6/18/18 at 3:44 p.m. revealed that there were bolsters attached to the bedframe of R#85's bed on each side in the middle of the mattress. Observation on 6/20/18 at 9:18 a.m. revealed that R#85 was in a reclining gerichair in the activity room. Observation in his room at this time revealed that he had a winged mattress with elevated sides on the top and bottom thirds on each side of the mattress. Further observation revealed that the bolsters were laying on top of the bed at this time and not attached to the bedframe, and there was a fall mat on one side of the bed. Observation on 6/21/18 at 12:41 p.m. revealed that R#85 was in bed with a fall mat to one side, with a winged mattress and bed bolsters attached to the bedframe bilaterally in the middle of the bed between the winged portions of the mattress. Further observation revealed that the winged portions of the mattress were raised approximately three inches from the surface of the mattress as measured with the surveyor's tape measure, and the height of the bed bolsters was measured at eight inches above the level of the mattress. During interview with Certified Nursing Assistant (CNA) CC on 6/21/18 at 1:00 p.m., she stated R#85 had bolsters on his bed because he didn't have bedrails, and the bolsters helped him to turn and kept him from falling out of the bed. She further stated she was not aware of him ever trying to climb over or past the bolsters. During interview with the Director of Nursing (DON) on 6/21/18 at 3:28 p.m., she stated that incident reports were not kept after entering the information in the falls tracking system, and that Corporate organization no longer had a falls management program. She stated during further interview that herself or the ADON (Assistant DON) reviewed the notes after a fall, and they talked about it in their weekly PAR meeting and the day after a fall during morning meetings, and ensured that appropriate interventions were in place. During interview with the DON on 6/21/18 at 5:02 p.m., she stated that either she or MDS staff updated the care plan after every fall, after the fall was discussed in morning meetings. During interview with the Administrator at this time, she stated that there was no formal documentation of what was discussed in the morning meetings. During interview with the DON on 6/22/18 at 9:08 a.m., she stated that they did not have a formal Falls Committee or Falls Management Program. She further stated that in morning meetings, which was attended by the DON, ADON, Administrator, Treatment Nurse, Therapy, Care Plans, Social Services, Admissions, and Medical Records staff, they reviewed the 24-hour report from the previous day for any falls, and decided if a therapy screen should be done. She stated during further interview that they read the accident report completed by the nurse on duty so that everyone in the morning meeting was aware of the fall, but that there was no discussion of review of the current interventions to see if they were appropriate, and no documentation of what was discussed in the meeting. The DON stated that the morning meeting only lasted 10 to 15 minutes, and concerns other than falls were discussed, so there was not an in-depth discussion of the fall. She stated that after the morning meeting, the ADON and herself discussed any falls, and if any new interventions should be put in place, but that there was no documentation of this. The DON stated during continued interview that the dates of care plan interventions in the electronic care plan may be the date the facility went to the electronic system, and not necessarily the date the intervention was initially put in place. During further interview with the DON at this time, she stated that she didn't know if R#85 broke his arm after the fall on 11/30/17 when his roommate allegedly pushed him down, or if it happened when he fell behind the door in his room on 12/1/17. The DON stated that interventions of a night light and for the bed to be in low position were added after these two falls, and did not know why these interventions were chosen other than the resident liked for his room to be dark. The DON further stated she did not know if the bed bolsters were in place at the time of the fall on 12/1/17, and confirmed there was no investigation of where the resident was prior to the fall, if the bed was in low position, if he had non-skid socks on, or any other interventions that were in place at the time of the fall, so she didn't really know how the fall occurred. During continued interview with the DON at this time, she stated that it appeared R#85 was getting up from the chair in his room on 12/29/17, as the nurse's notes say that no chair alarm was in use, and he was found on the floor by the chair. She further stated that there was an intervention for a chair alarm on the care plan, but it was not dated so she didn't know if it was implemented before or after the fall on 12/29/17. During further interview with the DON at this time, she stated that Therapy must have been consulted for the bed bolster use, because they had to order them. She verified there was no date on the care plan as to when the bolsters were added, but thought it may have been after the fall on 12/29/17. She verified that there was no mention of bed bolsters in the PAR meetings except after the fall past the bolsters on 4/10/18. She further stated that they thought the bed bolsters would be a good intervention to keep him from falling out of bed, and that the bolsters were not a restraint because he could get around them. She stated during continued interview that she didn't recall discussing continued bolster use after the fall on 4/10/18, and verified that there was no documentation of an assessment done for continued use after this fall. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Skilled Services Admission/Readmission Review dated 12/5/17 revealed that R#96 was admitted to the hospital after [MEDICAL CONDITION] in bathroom at home, resulting in left [MEDICAL CONDITION]. Further review revealed the Patient/Family Goals and Expectations was to return to prior level of function prior to fall, and anticipated length of stay in skilled care was short term, with a plan to discharge home with caregiver. Review of R#96's Admission assessment dated [DATE] revealed that he had a history of [REDACTED]. Review of R#96's Admission MDS dated [DATE] revealed that he had a BIMS score of 99 (indicates that interview could not be conducted due to cognitive impairmemt), needed limited assistance for ambulation, had a fall with fracture in the six months prior to admission, and one fall with no injury and one fall with a non-major injury since admission. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 5 (a score of 0 to 7 indicates severe cognitive impairment), he did not walk in his room or corridor over the seven days of the assessment period, and had one fall with a major injury since the last assessment. Review of R#96's clinical record revealed a baseline care plan was not found. Review of a comprehensive care plan for risk for falls related to a history of falls with injuries and unsteadiness was developed on 12/14/17. Further review of this falls care plan revealed that it was revised on 12/4/17 for a room change closer to the nurse's station; on 12/22/17 to toilet after breakfast; on 12/29/17 to re-educate to use call light for assistance; on 1/7/18 to keep wheelchair nearby during toileting; on 1/9/18 for a therapy screen; on 3/6/18 for non-skid shoes when out of bed and gripper socks; and an undated intervention for a leg bag for catheter when out of bed when able. Review of a falls care plan with a developed date of 5/3/18 revealed the following interventions and dates: 3/1/18: Assess medications for contributing factors 3/1/18: Assess contributing factors related to fall history 3/1/18: Wheelchair 3/2/18: Bed in low position 3/2/18: Call light in reach: consider resident's cognition and re-educate as needed 3/4/18: Activity referral 3/4/18: Assist patient with ADLs (activities of daily living) as needed 3/4/18: Keep call light and most frequently used personal items within reach 3/25/18: Transfer to acute care setting for evaluation 3/30/18: Administer first aid as needed 3/30/18: Notify physician and family/responsible person of fall 3/30/18: Observe X 72 hours for possible injury related to a fall 4/2/18: Bed alarm sensor 4/2/18: Needed and desired items in reach/easy access 4/2/18: Place patient in open area for maximum observation opportunities 5/3/18: Notify hospice nurse as needed Review of R#96's Comprehensive Falls assessment dated [DATE] revealed that he was a new admission with history of fall at home (multiple falls). Review of a Comprehensive Falls assessment dated [DATE] revealed that he was a readmit from the hospital, and that he had not had a fall since the last assessment. Review of a Falls Report revealed that R#96 had falls on 12/4/17; 12/5/17; 12/22/17; 12/29/17; and 1/7/18. Review of a Fall Risk assessment dated [DATE] revealed that he had a score of 7 (score of 7 to 18 indicates high risk). Review of a Falls Report from 6/1/17 to 2/28/18, and a Records List (of falls) from 2/21/18 to 6/19/18 revealed that R#96 had 10 falls between admission on 12/4/17 and 4/2/18. In addition, there was one fall on 2/19/18 that was not captured on the falls reports. Review of clinical record documentation related to falls for R#96 revealed the following: -Fall on 12/4/17: An IPN dated 12/4/17 revealed that R #96 was admitted from the hospital on this date from home at 7:20 p.m. after fall at home with left [MEDICAL CONDITION] and hemiarthroplasty (surgical repair of the [MEDICAL CONDITION]). An IPN dated 12/4/17 at 10:00 p.m. revealed that upon med rounds found this resident lying on the floor between his bed and his roommate's bed. Resident was taking off his abduction pillow. No visible signs of injuries. -Fall on 12/5/17: Review of an IPN dated 12/5/17 at 7:55 p.m. revealed the resident was on the floor in bathroom with feet pointing out of bathroom, on buttock/back, naked, catheter on floor. S/T (skin tear) noted X 2 to left elbow. Stated he needed to have a bowel movement and fell . Resident educated on call light use importance of assistance. Non skid socks placed on feet, bed moved against wall and a bedside commode at bedside. Call light clipped to gown. Staff keeps reminding resident to use call light. An IPN dated 12/6/17 at 2:50 p.m. noted that at approximately 1:00 p.m. R#96 was gotten OOB (out of bed) by therapy and sat in W/C (wheelchair) to eat lunch. At 1:20 p.m. therapy went back to check and resident was in bathroom and catheter was attached to W/C with bag. Catheter was separate (sic) below tube and Y-port. FNP examined and ordered to sent to ER (emergency room ) to evaluate catheter and to check left hip placement related to previous falls. An IPN dated 12/6/17 at 6:30 p.m. revealed that R#96 being moved from D-12-D to A-1-W. It is closer to bathroom and nurses station. Resident to return (from hospital) with new catheter. Review of a Skilled Services Review Notes completed 12/19/17 revealed that patient found on floor in restroom on his buttock/back 12/5/17, no injuries. On 12/4/17 patient noted on floor between bed and roommate's bed attempting to move pillow

Based on observation, record review, resident and staff interviews, the facility failed to develop a comprehensive, individualized care plan with appropriate interventions for the care of a [MEDICAL CONDITION] and [MEDICAL CONDITION] bag for one of one resident (R) (R#3) that had a [MEDICAL CONDITION]. The sample was three residents. Refer F328 Findings include: Record review for R#3 revealed an original admitted to the facility of 10/23/15 with a [MEDICAL CONDITION]. The resident was re-admitted to the facility on [DATE], [DIAGNOSES REDACTED]. Review of the care plan for R#3 with a start date of 11/6/15 identified that the resident requires a suprapubic catheter and a [MEDICAL CONDITION]. The Goal documents that the resident will be free of infection and associated complications. The interventions indicated only [MEDICAL CONDITION] care and Observe for signs and symptoms of infection, which did not specify if this was related to catheter care or [MEDICAL CONDITION] care. The care plan did not address how often [MEDICAL CONDITION] care was to be provided, what is included in [MEDICAL CONDITION] care, how often the [MEDICAL CONDITION] bag should be monitored and no individualized interventions Interview with R#3 on 4/1/17 at 11:20 a.m. revealed that the resident had [MEDICAL CONDITION] bag under his shirt on the left side of his stomach. The [MEDICAL CONDITION] bag could be seen bulging from under the shirt. When the shirt was lifted, it was observed that the [MEDICAL CONDITION] bag was filled with gas/air and stool was present. R#3 stated the [MEDICAL CONDITION] bag began blowing up around 5:30 a.m. and that no one had checked it yet today. R#3 stated in a further interview at 1:40 p.m., that he does not like the [MEDICAL CONDITION] bag to have stool in it and stated I don't want that stuff on me. Subsequent observations were conducted at 12:30 p.m., 1:40 p.m. and 2:15 p.m. on 4/1/17 of the [MEDICAL CONDITION] bag filled with gas/air and stool The resident stated during both subsequent observations that the Certified Nursing Assistant (CNA) had still not checked the bag. An interview with the Director of Nursing (DON) on 4/1/17 at 3:42 p.m. revealed the staff should be checking the [MEDICAL CONDITION] bag in the same manner as check and change every two hours and the CNA should report any abnormalities to the nurse. The DON further stated that R#3 is very funny about his bag being full of stool and that he did not like any stool on himself. He likes his [MEDICAL CONDITION] bag clean and empty. A telephone Interview on 4/1/17 at 4:23 p.m. with the Licensed Practical Nurse (LPN) RAI Coordinator revealed that the software program used for developing care plans is called Keane. In this program, a care area, such as [MEDICAL CONDITION], is selected. Once selected, the library has pre-selected interventions. Whoever is developing the care plan will de-select the interventions that do not apply and has the capability of entering individualized interventions. The RAI Coordinator stated that typically the interventions for a [MEDICAL CONDITION] would include things such as the frequency of [MEDICAL CONDITION] care, changing the bag, [MEDICAL CONDITION] cleaning instructions of the stoma site, re-applying a new wafer, check and changes every two hours and any individual interventions needed. The RAI Coordinator stated that since she was not in the facility, she could not say who developed the care plan or why the care plan for R#3's [MEDICAL CONDITION] was so vague. The RAI Coordinator further stated that several other people had been helping with assessments and care plans.

Based on observation, record review, review of the undated General Care Guidelines- Ostomy Care, resident and staff interviews, the facility failed to monitor and empty the [MEDICAL CONDITION] bag that was full of gas and stool in a timely manner for one resident (R) (R#3) with a [MEDICAL CONDITION]. The sample was three residents. Findings include: Review of the facility's undated General Care Guidelines- Ostomy Care documented: Intent- Provide guidelines for proper application and maintenance of bag system maintaining intact [MEDICATION NAME] skin and patient comfort. [MEDICAL CONDITION] bags are designed to be emptied prn (as needed) and changed every 2-5 days when odor or discoloration is noted. During an interview with R#3 on 4/1/17 at 11:20 a.m., it was observed that the resident had a [MEDICAL CONDITION] bag under his shirt on the left side of his stomach. The [MEDICAL CONDITION] bag could be seen bulging from under the resident's shirt. When the shirt was lifted, it was apparent that the [MEDICAL CONDITION] bag was filled with gas/air and bowel movement was present. R#3 stated the [MEDICAL CONDITION] bag began blowing up around 5:30 a.m. and that no one had checked the bag yet today. He stated that the night CAN was in his room and emptied his catheter and thought she was going to check his [MEDICAL CONDITION] bag too but she turned and walked out of the room. R#3 stated that when he has his regular male Certified Nursing Assistant (CNA), he checks his bag every two hours and changes his bag, but when other CNA's take care of him, this does not happen. They come in and take care of his roommate and walk right out of the room. Record review for R#3 revealed an initial admission to the facility on [DATE] with a [MEDICAL CONDITION]. The resident was re-admitted to the facility on [DATE]. R#3 has multiple [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating the resident had no cognitive impairment. The resident does not exhibit moods or behaviors and the resident requires extensive assistance with toileting. Section H- Bowel and Bladder indicated the resident had a [MEDICAL CONDITION] and indwelling catheter. Review of the Quarterly MDS assessment dated [DATE] indicated admission to the facility on [DATE]. Although in Section C- Cognitive Patterns checked that a BIMS should be conducted , there is no BIMS summary score. Review of the Quarterly MDS assessment dated [DATE] revealed in Section C- Cognitive Patterns that a BIMS should be conducted but no BIMS summary score indicated. Review of the care plan for R#3, with a start date of 11/6/15, identified a [MEDICAL CONDITION] with diagnosis (Dx) of [MEDICAL CONDITION]. The Goal documents the resident will be free of infection and associated complications. The interventions indicated only [MEDICAL CONDITION] care and Observe for signs and symptoms of infection. No other interventions in place. Review of the Physician order [REDACTED]. [MEDICAL CONDITION] care daily and as needed. An observation conducted on 4/1/17 at 12:30 p.m. of R#3 revealed the [MEDICAL CONDITION] bag could still be seen bulging from under the resident's shirt. Interview with R#3 stated that no one has checked his bag. The resident stated that CAN would probably come to check and change his bag after lunch. An observation conducted on 4/1/17 at 1:40 p.m. of R#3 revealed the [MEDICAL CONDITION] bag could still be seen bulging from under the resident's shirt. R#3 stated that the CNA had still not checked his bag. R#3 stated that he does not like his bag to be full and stated I don't want that stuff on me. R#3 further stated that he does not want his visitors to see the bag or smell anything. R#3 stated that he could call the staff to check his [MEDICAL CONDITION] bag but that he should not have to do that. R#3 stated that he cannot open his fingers or lift his shirt to check his own bag and they are supposed to check on him every two hours, or at least that's what they say. R#3 stated that he has voiced his concerns to the Director of Nursing (DON) and he was told that he needs to follow the chain of command and report this concern to his nurses. A subsequent observation at 2:15 p.m. revealed the [MEDICAL CONDITION] bag remained filled with gas/air and stool. An interview was conducted on 4/1/17 at 2:20 p.m. with CNA caring for R#3 (CNA AA) to ask when she would be conducting [MEDICAL CONDITION] care and that this care needed to be observed by the surveyor. CNA AA stated that she would finish with the resident she was working with and let the surveyor know when she was ready to provide [MEDICAL CONDITION] care for R#3. Observation on 4/1/2017 at 2:45 p.m. of [MEDICAL CONDITION] care for R#3 with CNA AA and CNA BB revealed the staff knocked on the resident's door, explained they were going to provide [MEDICAL CONDITION] care and requested permission from the resident for the surveyor to observe the care. R#3 stated that it would be acceptable. Observation of the [MEDICAL CONDITION] bag revealed it was filled tight with gas/air and with a small amount of stool. During the treatment ostomy care was provided utilizing clean technique and the ostomy appliance was changed. Observation of the ostomy sight revealed a pink opening with no evidence of broken skin or infection. The resident tolerated the procedure well and the care was appropriately performed by the staff. During an interview on 4/1/17 at 3:25 p.m. with CNA AA, she revealed that R#3 does not like to be bothered much but that he will call to have his [MEDICAL CONDITION] bag burped at times. CNA AA stated that the [MEDICAL CONDITION] bag is supposed to be checked every two hours just like a check and Change' and that she had been busy today trying to complete the Saturday baths. Interview conducted on 4/1/17 at 3:42 p.m. with the Director of Nursing (DON) revealed ultimately the CNAs are responsible for [MEDICAL CONDITION] care and will report any abnormalities to the nurse. The CNAs are expected to check on the [MEDICAL CONDITION] bag every two hours the same as a check and change for bowel movement (BM) or release of gas. The DON further stated that R#3 is real funny about his [MEDICAL CONDITION] bag. He does not like see BM and does not want BM on him. R#3 has been known to refuse treatment of [REDACTED]. The Don stated that the only documentation of [MEDICAL CONDITION] care is on the Medication Administration Record [REDACTED]. The only other documentation is a BM Report which document when the resident had a BM. There is no documentation of [MEDICAL CONDITION] checks every two hours or findings during these checks. Review of the MAR for March 1 through March 31, 2017 revealed [MEDICAL CONDITION] Care Daily and As Needed. Each day had a signature at 7:00 a.m. and 7:00 p.m. The April 2017 MAR indicated [REDACTED].

Based on observation and interview, the facility failed to ensure that the nurse staffing data sheet was posted daily for public review. The facility census was Findings include: During initial tour of the facility with the Administrator on 4/1/17 at 10:55 a.m., it was noted, in the glass case outside of the dining room, that the last day the nurse staffing data was posted was on Monday, 3/27/17. An interview with the Administrator at the time of the observation revealed the Director of Nursing is responsible for posting the nursing hours each day by noon. The Administrator stated that there is no facility policy but that this was her expectation. The Administrator did not know why the nurse staffing data had not been posted since Monday and stated when the DON arrives to the facility we could ask her. Interview conducted on 4/1/17 at 1:06 p.m. with the DON revealed she had completed the daily nurse staffing forms for 3/28/17 (Tuesday), 3/29/17 (Wednesday), 3/30/17 (Thursday) and 3/31/17 (Friday) but they were in a folder and she had not posted them in the glass case for public view. The DON stated that she knows the nurse staffing hours should be posted everyday but she had a busy week and was doing the best she can. The DON said she usually has the form posted in the glass case by noon. The DON further stated that weekend supervisor is responsible for posting the nursing hours on the weekends. Interview conducted on 4/1/17 at 1:20 p.m. with the weekend Registered Nurse (RN) Supervisor revealed in the morning, she checks the schedule, verifies that everyone on the schedule is in the building, assigns the nurse's and CNAs on the Map Out (assignment sheet), fills out the nursing hours form and places it in the glass case, usually by 9:00 a.m. The RN Supervisor stated that she was late getting the nurse staffing hours posted because they facility had two late admits the day before and she was verifying the new admissions medications.