Every finding on record at Brighton Cornerstone Group, LLC

Based on interview, and facility policy review, the facility failed ensure residents had the right to be informed of, and participate in their treatment by failing to inform residents and/or their representatives in advance of the risks and benefits of psychotropic medication use prior to administration, which affected 5 (Residents 2, 20, 4, 6, and 5) of 5 residents reviewed for unnecessary medications.The findings include: Review of a facility policy titled, Antipsychotic Medication Use, revised in March 2015, indicated, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. The policy revealed that it did not address discussing the risks and benefits of antipsychotic use with residents or their representative prior to administration. 1. An admission Record indicated the facility admitted Resident #2 on 11/22/2019. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder, vascular dementia with psychotic disturbance, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #2 received antipsychotic medication during the seven-day lookback period.Resident #2's Care Plan Report included a focus area revised on 12/16/2025, that indicated the resident was at risk for adverse effects related to psychotropic medication use for dementia with psychosis. Interventions initiated 05/12/2025 directed staff to administer medications as ordered and to educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of prescribed psychoactive medication. Resident #2's Order Summary Report, with active orders as of 01/07/2026, contained an order dated 11/25/2025 for risperidone (an antipsychotic) oral tablet, 0.25 milligrams (mg) by mouth at bedtime for dementia with psychosis. Resident #2's January 2026 Medication Administration Record [MAR] revealed that staff documented that Resident #2 was receiving risperidone according to their order. Resident #2's record revealed no evidence of the resident or their representative being educated on the risk or benefits of the use of antipsychotic medication, and no evidence of consent from the resident or representatives on its use. 2. An admission Record indicated the facility admitted Resident #20 on 01/02/2026. According to the admission Record, the resident had a medical history that included a diagnosis of major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/28/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #20 received antidepressant medication during the seven-day lookback period.Resident #20's Care Plan Report included a focus area revised on 12/16/2025, that indicated the resident received antidepressant medication related to anxiety disorder, agoraphobia with panic disorder, and depression. Interventions revised on 12/16/2025 directed staff to administer antidepressant medications as ordered by the physician and to monitor side effects. Resident #20's Order Summary Report, with active orders as of 01/07/2026, contained an order dated 01/02/2026 for mirtazapine (an antidepressant) oral tablet, 7.5 milligrams (mg) by mouth for appetite/depression. Resident #20's January 2026 Medication Administration Record [MAR] revealed that staff documented that Resident #20 was receiving mirtazapine according to their orders. Resident #20's record revealed no evidence of the resident or their representative being educated on the risk or benefits of the use of antidepressant medication, and no evidence of consent from the resident or representatives on its use. 3. An admission Record indicated the facility originally admitted Resident #6 on 02/16/2024 and readmitted the resident on 12/12/2025. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder and anxiety disorder. A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Per the MDS, Resident #6 received antidepressant medication during the seven-day lookback period. Resident #6's Care Plan Report included a focus area revised on 12/12/2025, that indicated the resident received antidepressant medication related to depression and anxiety. Interventions initiated 11/05/2025 directed staff to educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of prescribed antidepressant drugs. Resident #6's Order Summary Report, with active orders as of 01/07/2026, contained an order dated 12/12/2025, for mirtazapine (an antidepressant) oral tablet, 15 milligrams (mg) by mouth at bedtime for depression/appetite. Resident #6's January 2026 Medication Administration Report [MAR] revealed that staff documented that Resident #6 was receiving mirtazapine according to their order. Resident #6's record revealed no evidence of the resident or their representative being educated on the risk or benefits of the use of antipsychotic medication, and no evidence of consent from the resident or representatives on its use. 4. An admission Record indicated the facility admitted Resident #4 on 08/11/2023. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia with behavioral disturbance and agitation, anxiety disorder, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/14/2025, revealed Resident #4 had had severe impairment in cognitive skills for daily decision-making and had short-term and long-term member problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated that the resident received antipsychotic, antianxiety, and antidepressant medication during the seven-day lookback period. Resident #4's Care Plan Report included a focus area revised 07/21/2025, that indicated the resident received psychotropic medications related to anxiety/depression and dementia with behavioral disturbance. Interventions initiated 08/08/2024 directed staff to monitor for side effects such as tardive dyskinesia, extrapyramidal symptoms (EPS), frequent falls, suicidal ideation, and report to the physician as needed; consult with the pharmacy and physician to consider dosage reduction when clinically appropriate; and discuss with the physician and family regarding ongoing need for medication. Resident #4's Order Summary Report, with active orders as of 01/07/2025, included the following orders:- Citalopram hydrobromide (an antidepressant) 10 milligrams (mg) by mouth one time a day, ordered 10/06/2025.- Buspirone hydrochloride (HCl) (an antianxiety) 10 mg, two tablets by mouth three times a day, ordered 07/21/2025.- Quetiapine fumarate (an antipsychotic) 75 mg by mouth at bedtime, ordered 10/06/2025. Resident #4's January 2026 Medication Administration Record [MAR] revealed staff documented that the resident was receiving the citalopram hydrobromide, buspirone HCl, and quetiapine fumarate according to their physician orders. Resident #4's record revealed no evidence of informed consent or evidence of discussion of risks, benefits, and alternatives with the resident or their representative prior to initiation or continuation of those medications. 5. An admission Record indicated the facility admitted Resident #5 on 05/17/2019 and readmitted on [DATE]. According to the admission Record, the resident had a medical history that included a diagnosis of depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/01/2025, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received antidepressant medication during the seven-day lookback period. Resident #5's Care Plan Report included a focus area revised 06/08/2025, that indicated the resident was at risk for adverse effects related to psychotropic medication use related to diagnosis of depression. Interventions initiated 05/30/2019 directed staff to observe and report side effects and adverse reactions of psychoactive medications, such as tardive dyskinesia, extrapyramidal symptoms (EPS), suicidal ideation, and behavior changes. Resident #5's Order Summary Report, with active orders as of 01/07/2026, revealed an order for escitalopram oxalate (an antidepressant) 20 milligrams (mg) by mouth one time a day for depression, ordered 10/27/2025. Resident #5's January 2026 Medication Administration Record [MAR] revealed staff documented the resident was receiving the escitalopram oxalate according to their physician orders. Resident #5's record revealed no evidence of informed consent or evidence of discussion of risks, benefits, and alternatives with the resident or their representative prior to initiation or continuation of the antidepressant. During an interview on 01/07/2026 at 10:55 AM, the Administrator/Interim Director of Nursing (DON) stated the facility did not obtain consents for psychotropic medication use; they only obtained the resident's general consent to treat while they resided in the facility. The Administrator/Interim DON further stated that most residents who received psychotropic medications were seen by psychiatric services, and she did not know if they discussed the risks versus benefits of those medications with the resident or their representative prior to use. During an interview on 01/08/2026 at 11:16 AM, the Administrator/Interim DON stated she was not aware that the risks versus benefits of psychotropic medication use needed to be discussed with residents or their representatives prior to use. She further stated that moving forward, she planned to initiate a new assessment for psychotropic medication use, found in their electronic medical record software, to obtain consent before use. On 01/08/2026 at 9:56 AM, the Administrator/Interim DON stated that she could not find a facility policy related to the use of antidepressant or antianxiety medication.

Based on observation, interview, record review, review of facility policy and manufacturer instructions, the facility failed to ensure a medication error rate of less than 5 percent (%). There were six errors out of 26 opportunities, which yielded a medication error rate of 23.08%, which affected 2 (Resident 36 and Resident 15) of 8 residents observed during medication administration.The findings include: A facility policy titled, Administering Medications, revised December 2012, indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The policy specified, 3. Medications must be administered in accordance with the orders, including any required time frame. Further review revealed, 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. An admission Record indicated the facility admitted Resident #36 on 04/12/2022. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, essential hypertension, and irritable bowel syndrome. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/07/2025, revealed Resident 36 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. Resident 36's Order Summary Report, with active orders as of 01/07/2026, included the following orders:- Polyethylene glycol powder (a laxative)17 grams (gm) by mouth one time a day for constipation, dated 01/30/2025.- Symbicort Inhalation Aerosol (a bronchodilator combination) inhaler, 160-4.5 micrograms (mcg) per actuation, two puffs inhaled orally two times a day for COPD, with orders to rinse their mouth with water after use and do not swallow, dated 01/30/2025. The manufacturer's instructions for the Symbicort inhaler, dated 12/2017, revealed, Rinse your mouth with water and spit the water out after each dose (2 puffs) of Symbicort. Do not swallow the water. This will help to lessen the chance of getting a fungus infection (thrush) in the mouth and throat. During an observation on 01/09/2026 at 7:28 AM, Certified Medication Technician (CMT) 1 administered medications to Resident 36. The CMT mixed the polyethylene glycol powder with 4 to 5 ounces (oz) of water and administered the medication to the resident but did not ensure the resident consumed the entire amount, discarding approximately 2 oz. The CMT administered two puffs of the Symbicort inhaler and did not have the resident rinse and spit afterward as ordered. 2. An admission Record indicated the facility admitted Resident 15 on 10/27/2023. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, hepatic encephalopathy (a brain dysfunction due to liver disfunction), and cicatricial lagophthalmos of the left eye (an inability to fully close the eye lid). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/08/2025, revealed Resident 15 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident 15's Order Summary Report, with active orders as of 01/07/2026, included the following orders:-Breo Ellipta Inhalation Aerosol Powder (a bronchodilator combination) Breath Activated 100-25 micrograms (mcg) per actuation, one puff inhaled orally one time a day for COPD, with orders to rinse mouth with water after each use and spit, ordered 01/31/2025.-Polyethylene glycol-propylene glycol ophthalmic gel (an ophthalmic lubricant) 0.4-0.3% instill one application in the left eye two times a day for lagophthalmos, ordered 01/31/2025.- Polyethylene glycol powder (a laxative)17 grams (gm) by mouth one time a day for constipation, ordered 12/11/2025.-Lactulose oral solution 10 gm/ 15 milliliters (ml), 45 ml by mouth four times a day for hepatic encephalopathy, ordered 03/31/2025. The manufacturer's instructions for the Breo Ellipta inhaler, revised May 2023, revealed, 2.3 Administration Information included, After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. An observation on 01/09/2026 at 7:41 AM revealed Certified Medication Technician (CMT) 1 prepared and administered medications to Resident #15. The CMT mixed the polyethylene glycol powder with approximately 4 ounces (oz) of water and administered only approximately 2 oz of the medication. CMT 1 administered the inhaler and did not have the resident rinse and spit afterward, applied polyethylene glycol-propylene glycol ophthalmic gel to both eyes instead of only the left eye as ordered, and administered 30 milliliters of the lactulose instead of the 45 ml ordered. During an interview on 01/07/2026 at 12:32 PM, CMT 1 stated that she was supposed to have the resident rinse and spit after using inhalers and confirmed that she did not do that for Resident 36 or Resident 15 but should have in order to prevent thrush. CMT 1 stated that she put Resident 15's eye gel in both eyes and stated that she did not realize it was only ordered for the left eye. CMT #1 confirmed that she gave 30 ml of lactulose and stated that she knew the resident was supposed to get 45 ml, but she was nervous. She stated that she should have read the whole order and double checked prior to administering the medications to ensure she was giving medications according to physician orders. During an interview on 01/07/2026 at 3:25 PM, CMT 2 stated that she would have a resident rinse and spit after using inhalers in order to prevent thrush. She stated that when passing medications, she compared the label of the medication card with the MAR and checked for the five rights, right resident, medication, dose, time, and route and checked three times. During an interview on 01/07/2026 at 3:17 PM, Licensed Practical Nurse (LPN) 3 stated that after a resident was administered an inhaler, staff should have the resident rinse their mouth and spit. She stated that in order to ensure medications were administered according to physician orders, the staff should read the medication administration record (MAR), and check it three times with the five rights, right resident, medication, dose, route, and time. During an interview on 01/08/2026 at 11:33 AM, LPN 4 stated that when administering medications, the staff should follow the five rights and check it three times. She stated that polyethylene glycol powder should be mixed in 8 oz of water, and if the resident did not take the whole thing, then it should be documented. She stated the resident should rinse their mouth and spit after the use of an inhaler to prevent oral problems. During an interview on 01/08/2026 at 11:16 AM, the Administrator/Interim Director of Nursing (DON) stated that when medications were being administered, the CMT/Nurse should look at the order, look at the MAR, and check it three times for the right dosage, resident, route, medication, and time. She stated polyethylene glycol powder should be mixed in 4 to 8 oz of fluid, and if the resident did not consume the full amount of a mixed medication, staff should document and notify the physician. She stated that when a resident used an inhaler, they should rinse their mouth and spit after use to prevent coating in their mouth.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 of 2 sampled residents (R14) reviewed for beneficiary notifications was provided a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) prior to the end of covered Medicare Part A services.The findings include: An undated document provided by facility staff titled, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC), indicated, A Medicare provider or health plan (Medicare Advantage plans and cost plans collectively referred to as 'plans') must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The policy continued, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Resident 14's admission Record indicated the facility admitted the resident on 07/22/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia, depression, and diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2025, revealed Resident 14 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A list of residents discharged from a Medicare covered Part A stay with benefit days remaining during the six months prior to the survey revealed Resident 14 was discharged from a Medicare covered Part A stay on 12/05/2025 but remained in the facility. Resident 14's SNF Beneficiary Notice Scenarios for Surveyors form, completed by the facility staff, revealed the facility initiated Resident 14's discharge from Medicare Part A services when the resident's benefit days were not exhausted. During an interview on 01/07/2026 at 11:21 AM, the Administrator/Interim Director of Nursing (DON) stated the Corporate [NAME] Specialist told her that she accidentally missed the email notifying her that Resident 14's payor source was changing, so she did not issue a NOMNC or SNF ABN notifying the resident or their representative of the change. During an interview on 01/08/2026 at 10:31 AM, the Corporate [NAME] Specialist stated the facility staff notified her when a resident was discharging from Medicare several days in advance, and she then prepared the paperwork to notify the resident and their family of their billing options. The Corporate [NAME] Specialist further stated she was notified of Resident 14's payor change in a timely manner, but she did not issue a NOMNC or SNF ABN due to an oversight on her part. During an interview on 01/08/2026 at 11:16 AM, the Administrator/Interim DON stated that if a resident received skilled nursing services and was scheduled to discharge from those services, they were notified several days in advance. Per the Administrator/Interim DON, the MDS Coordinator then emailed the Corporate [NAME] Specialist of the payor changes, then issued a NOMNC or SNF ABN notifying the family and their representative of their billing options moving forward. She further stated that she expected NOMNCs and SNF ABNs to be completed prior to a resident's last day of coverage so the resident and their family could prepare for their next payor source or get started on a Medicaid application.

Based on observation, interview, and record review, the facility failed to provide necessary activity of daily living (ADL) care for 1 of 1 sampled resident's (Resident 12) reviewed for ADL care. Specifically, the facility failed to offer to shave Resident 12's facial hair. The findings include: An admission Record indicated the facility originally admitted Resident 12 on 03/03/2025 and readmitted the resident on 06/03/2025. According to the admission Record, the resident had a medical history that included diagnoses of left humerus fracture, chronic obstructive pulmonary disease (COPD), asthma, diabetes mellitus, peripheral vascular disease, hypertension, gastroesophageal reflux disease (GERD), chronic pain, major depressive disorder, morbid obesity, anxiety disorder, dysphagia, and diverticulosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/01/2025, revealed Resident 12 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated that the resident required set-up or clean-up assistance for eating, and supervision or touching assistance for showering/bathing. Resident 12's Care Plan Report included a focus area revised 12/1/2025, that indicated the resident had a self-care deficit related to general weakness and requiring assistance with ADLs. Interventions initiated 06/10/2025 directed staff to assist the resident with bathing needs daily per bath schedule and resident's preference, shampoo hair with showers, keep nails clean daily and trim weekly as needed, and explain procedures prior to beginning and provide privacy. Resident 12's December 2025 and January 2026 bath/shower indicated that staff documented that Resident 12 received showers at least twice a week; however, there was no documentation that shaving was offered or completed. On 01/05/2026 at 12:38 PM, Resident 12 was observed sitting in the dining room with long facial hair on their chin. During an interview at that time, Resident 12 stated that they disliked the length of the facial hair and stated that they received a shower that morning but did not get shaven. Resident 12 stated they did not ask to be shaved but stated that they should not have to. On 01/06/2026 at 9:40 AM, Resident 12 was observed sitting at a dining room table visiting with other residents. Resident #12 continued to have long facial hair on their chin. On 01/07/2026 at 10:36 AM, Resident #12 was observed sitting at a dining room table playing a game with other residents. The resident had long facial hair on their chin and increased hair growth on their upper lip. On 01/07/2026 at 3:20 PM, Resident #12 was observed to continue to have long facial hair on the chin and increased growth on the upper lip. During an interview on 01/07/2026 at 3:25 PM, Certified Nursing Assistant (CNA) #5 stated all residents should be shaved every shower day, and it should always be offered. She stated she was not usually in that hall, and CNA #6 was the shower aide for the resident. During an interview on 01/08/2026 at 9:16 AM, CNA #6 stated she gave Resident #12 a shower on Monday (01/05/2026) but did not shave them because the resident did not ask and she did not think about it. She stated she should have offered. During an interview on 01/07/2026 at 3:17 PM, Licensed Practical Nurse (LPN) #3 stated that all residents should be shaved on their shower days if needed. She stated a resident should not have to ask to have it done, and it should be offered when needed. During an interview on 01/08/2026 at 11:16 AM, the Administrator/Director of Nursing (DON) stated residents should be shaved upon request and, if visible, shaving should be offered and completed during showers. She stated that it applied to all residents, and that if facial hair was seen, shaving should be offered. The Administrator/Interim DON stated the CNAs sometimes worried about offending residents, but shaving should still be offered. She stated that Resident #12 should have been shaved with the shower on Monday. On 01/08/2026 at 11:16 AM, the Administrator/Interim DON stated she was unable to locate a policy for ADLs, showers, or shaving.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) and followed infection prevention and control practices for 1 (Resident 29) of 1 resident's reviewed for tube feeding. The findings include:A facility policy titled, Enhanced Barrier Precautions, updated 04/05/2024 revealed, It is the policy of this facility that Enhanced Barrier Precautions in conjunction with standard precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO, or residents with '[sic] infection or colonization with a CDC [Centers for Disease Control and Prevention]-targeted MDRO when Contact Precautions do not otherwise apply. The policy revealed, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy revealed, EBP should be used for any residents who meet the definitions/criteria below, wherever they reside in the facility, which included, Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. The policy revealed, High-contact Resident Care activities included, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. An admission Record indicated the facility admitted Resident 29 on 12/05/2025. According to the admission Record, the resident had a medical history that included diagnoses of traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue that covers it) with loss of consciousness, non-traumatic subarachnoid hemorrhage from anterior (towards the front) communicating artery, hypertension, vitamin B deficiency, anemia, anxiety disorder, seizures, and muscle spasms. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/2025, revealed Resident 29 had severe impairment in cognitive skills for daily decision-making and had no short-term or long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident required a feeding tube and received 51% or more of their total calories and 501 cubic centimeters (cc) or more of fluid via tube feeding each day. Resident 29's Care Plan Report, revealed a focus area initiated 12/17/2025, that indicated the resident had a potential for nutritional problems related to their NPO [nothing by mouth] status and indicated that resident had a feeding tube. Interventions initiated 12/17/2025 directed staff to administer medications as ordered and provide tube feeding as ordered. An observation on 01/07/2026 at 3:10 PM revealed Licensed Practical Nurse (LPN) 3 entered Resident 29's room without putting on the proper personal protective equipment (PPE), wearing only gloves, and administered medication to the resident through the resident's feeding tube. There was no signage on the door indicating that the resident was on Enhanced Barrier Precautions, and there were no PPE supplies in the room or in the hallway outside the door. During an interview on 01/07/2026 at 3:17 PM, LPN 3 stated that the facility had two residents on EBP because of MDRO, but she did not know she was supposed to wear a gown when providing care for the feeding tube. She stated that she did not know it was required for wounds, indwelling catheters, or other conditions besides MDROs and thought it was at the discretion of the physician. During an interview on 01/07/2026 at 3:29 PM, the Administrator/Interim Director of Nursing (DON) stated that the facility only implemented EBP for MDROs based on consultant guidance. After reviewing the policy, the Administrator/Interim Administrator acknowledged that EBP should have been implemented for residents with wounds, catheters, and feeding tubes. She stated that she was not aware of this requirement until it was brought to her attention and stated that the consultant did not provide that information.

Based on observation, interview, record review, and facility policy review, the facility failed to cover, store and serve food in accordance with professional standards for food service safety which had the potential to affect 36 of the facility's 36 residents who consumed food from the kitchen. Observation of the kitchen revealed food items stored in the refrigerator and freezers that were not covered and exposed to air, and which were outdated and not rotated to ensure older items were used first. Further observation of the dry pantry storage revealed two large bins, one filled with cornmeal and a second filled with flour which were undated to indicate when they were opened or when the items should be discarded. The findings include: Review of the facility policy titled, Food Receiving and Storage, revised ,d+[DATE], revealed foods were to be received and stored in a manner that complied with safe food handling practices. Continued review revealed dry foods in storage bins were to be removed from original packaging, labeled and dated with the use by date, and be rotated using the first in-first out (FIFO) system. Further review revealed all foods stored in the refrigerator or freezer were to be covered, labeled, and dated with a use by date. Observation of the kitchen, on [DATE] at 11:42 AM, revealed refrigerator 1 had an opened box of cream cheese that was not covered and was exposed to air. Per observation, two unopened bags of broccoli and one opened bag of broccoli with expiration dates of [DATE], and the opened bag of broccoli was unsealed and exposed to air. Continued observation revealed a large package of salad lettuce with an expiration date of [DATE], located behind another package of salad lettuce with a newer used by date which indicated the products had not been rotated. Observation of freezer 1 revealed one box of ground beef patties that were uncovered and exposed to the air. Observation of refrigerator 2 revealed a box of sausage patties not covered and exposed to air. Continued observation of freezer 2 revealed a box of oatmeal raisin frozen cookie dough uncovered and exposed to air. Observation of the dry pantry storage area revealed two large bins, one filled with cornmeal and a second filled with flour, which were both undated. In interview with [NAME] 2 on [DATE] at 11:25 AM, he stated he was aware of how to store foods items. He said new products were dated with a received date and stored; however, if a product was opened then an opened date was to be marked on the product package. [NAME] 2 stated most food items were discarded after three days. He reported if the package had an expiration date that preceded the facility's use by date, then staff used the product expiration date and discarded it. The [NAME] said all food items should be rotated to ensure older food items were used first and should be covered to prevent exposure to air contaminants. He stated it was the responsibility of all staff to ensure those guidelines were being followed as in the facility policy. Additionally, he reported if staff did not follow those guidelines residents could be exposed to E.coli (Escherichia coli) or salmonella (common bacteria that can cause food poisoning). [NAME] 2 further stated if the residents were served food that was contaminated, they could become very sick. In interview with [NAME] 1 on [DATE] at 11:25 AM, she stated food items were to be dated, covered properly, and stored. She stated new food items were marked with the received date. The [NAME] reported when opened foods were to be covered, either in the original container or placed into a sealed container. She said opened food items were to be dated with an opened date for staff to know when to discard those items. [NAME] 1 stated all staff had the responsibility to follow the facility's policy and procedures regarding food safety to ensure residents were not being served contaminated or freezer burned foods that might cause sickness. She further stated she believed the facility should be serving residents good quality food. In interview with the Dietary Manager (DM) on [DATE] at 11:35 AM, she stated her expectations for all dietary staff was for them to ensure they were following policies and procedures regarding food safety. She stated if there were concerns with staff not following those guidelines an in-service would be provided. The DM reported food safety was to include covering food items when stored and ensuring the items were dated. She said food safety also included checking the use by or expiration dates to ensure staff were rotating the old and new food items and discarding those that had expired. The DM explained residents could experience sickness, food poisoning, and it was the facility's responsibility to serve food that was nutritious and palatable. Additionally, she further stated the facility was the resident's home and they should be provided quality care. In interview with the Administrator on [DATE] at 5:20 PM, she stated her expectations for the dietary staff was for them to follow the facility's policies and guidelines related to food safety. She stated she expected staff to ensure food items were being stored per safe food practices. The Administrator said safe food practices included covering and dating opened food items before they were stored in the refrigerator or freezers. She reported she would expect the staff to have knowledge of expiration dates and how to rotate old and new products before opening new products as that was part of their job duties. She further stated she would never want to serve residents foods that were unsafe or unacceptable per safety guidelines.

Based on interview, record review, and review of the facility staffing schedules, it was determined the facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least 8 consecutive hours a day, 7 days a week as required. Review of the facility's staffing schedules revealed the facility failed to provide eight consecutive hours of RN coverage for 15 days between 07/27/2024 and 09/29/2024. This failure affected all persons residing in the facility during those 15 days. The findings include: Review of the facility's, Facility Assessment Tool: Staffing Plan dated 11/01/2022, revealed the facility should have one Registered Nurse (RN) as the Director of Nursing (DON) full-time days, and at least one RN or Licensed Practical Nurse (LPN) for each shift. Continued review revealed the Facility Assessment Tool further noted if more than one new (resident) admit or readmit occurred on a shift, then the facility should consider bringing in another licensed nurse for at least four hours of a shift to assist. Review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, dated 07/01/2024 through 09/30/2024, revealed there was no RN coverage documented for eight consecutive hours for the following 15 dates: 07/27/2024, 07/28/2024, 08/03/2024, 08/04/2024, 08/11/2024, 08/18/2024, 08/24/2024, 08/25/2024, 08/31/2024, 09/01/2024, 09/07/2024, 09/08/2024, 09/15/2024, 09/28/2024, and 09/29/2024. In interview with the Director of Nursing (DON) on 03/06/2025 at 4:30 PM, she stated she came in and worked for the eight hour RN coverage. She said she was not aware of what the facility's PBJ Report noted and would have to find out who was responsible for submitting the information for the report. The DON reported she was aware of the Federal Regulations and to the best of her knowledge the facility had a RN working eight hours a day, seven days a week. She said she did not know why the facility's PBJ Report was not reflecting that. She further stated she worked the past weekend both Saturday (03/01/2025), and Sunday (03/02/2025) for eight hours each day. In interview with the Cooperate Account Specialist (CAS) on 03/06/2025 at 5:02 PM, she stated at that time, she was the person responsible for submitting the facility's PBJ Report data. She stated she obtained the data from the facility's payroll system which kept up with the employee's time. The CAS said the data came across downloaded into a text file, and she did have access to the reports. She explained she would have to go back to the employee timecards and look at those specific dates to verify whether they had RN's working on those days. The CAS reported there might have been something she had missed that should have come over to tell her that information. She stated if the employees were salaried then she had to hand key those hours into the system. The CAS said she was not 100% sure she had any safeguards in place to ensure the correct data was entered for the facility's PBJ Report. She further stated she just took the data she had and entered it in the system. In interview with the Administrator on 03/06/2025 at 5:28 PM, she stated the CAS,who was over all of Human Resources (HR) for the facility's parent company, was responsible for doing the PBJ reporting right now. The Administrator stated she was supposed to learn how to do the PBJ reporting but she had not started training for that yet due to her training the new DON and other new staff at the current moment. She reported she, along with the DON, were salaried employees, and that information was put in manually since they did not clock in or out. The Administrator said when they (Administrator and DON) worked it would not show on the PBJ Report. She further stated they sent her the facility's daily census sheets and the dailies so she could see who was working and where they were working. She additionally stated she expected the facility's PBJ data to be submitted accurately and on time. `

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure all drugs were labeled in accordance with professional standards. Observation of the front hall medication room revealed a vial of Tubersol solution (an injectable medication used to test for tuberculosis) was not properly stored in the medication refrigerator. The findings include: Review of the facility policy titled, Storage of Medications, revised 2007, revealed the facility would store all drugs, and biological's in a safe, secure, and orderly manner. Continued review of the policy revealed the facility would not use discontinued, outdated, or deteriorated drugs or biological's. Further review revealed all such drugs were to be returned to the dispensing pharmacy or destroyed. Observation on 03/05/2025 at 9:47 AM, of the front hall medication room refrigerator, revealed one opened vial of Tubersol available for use, with an opened date of 01/30/2025. During interview with Licensed Practical Nurse (LPN) 1, on 03/05/2025 at 9:52 AM, she stated night shift nursing staff checked the medication refrigerators and discarded any expired items. She further stated once opened the vial of Tubersol expired after 30 days and should have been discarded and not used. During interview on 03/06/2025 at 4:39 PM, with the Director of Nursing (DON), she stated the nurses and med-techs (medication technicians) should check the medication refrigerator daily on all shifts and discard any expired medications. She stated the vial of Tubersol might have just gotten overlooked. The DON further stated using the Tubersol after the expiration date of 30 days could result in an inaccurate tuberculosis reading. In interview with the Administrator on 03/06/2025 at 5:28 PM, she stated nursing staff should properly discard any expired medications including Tubersol. She said it was nursing's responsibility to check medications for possible expiration dates prior to administration. The Administrator further stated if the expired Tubersol was given it could produce an inaccurate result.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain a proper infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases. Observation during wound care on 03/06/2025 at 9:50 AM, revealed Licensed Practical Nurse (LPN) 3 failed to clean the bedside table or place a barrier device to cover it, prior to placing the residents' clean wound dressing supplies on the table for 2 of 14 sampled residents (Resident (R)3 and R11). The findings include: Review of the facility's policy, Infection Control Policy undated, revealed the facility's objectives for its infection control policy included prevention of infection achieved through proper infection control procedures. Per review, the proper infection control procedures included, but were not limited to, handwashing; use of Personal Protective Equipment (PPE); isolation practices, and cleaning and disinfecting of equipment. Review of the facility's policy, Skin Care Management, revised 07/01/2019, revealed its purpose is to prevent the development of avoidable pressure injuries or ulcers. The policy further stated staff were to follow body substance isolation precautions and policies and procedures for dressing changes in regards to infection control. 1. Review of R3's Face Sheet revealed the facility admitted the resident on 04/08/2016, with diagnoses which included Cellulitis, Peripheral Venous Insufficiency, and Type 2 Diabetes Mellitus. Review of R3's medical record revealed the resident had a wound to the coccyx. Review of R3's Treatment Administration Record (TAR) revealed orders which included to cleanse the coccyx with wound cleanser, pat dry, apply MediHoney Ointment and Xeroform (a type of dressing) then cover with a Border Gauze dressing daily. Observation of R3's coccyx wound care on 03/06/2025 at 9:50 AM, revealed LPN 3 failed to clean the bedside table or cover it with a protective barrier prior to placing R3's wound care supplies on it. In an interview with Licensed Practical Nurse (LPN) 3 on 03/06/2025 at 2:18 PM, she stated there are not many places to put things in a resident's room when you are performing a dressing change. She further stated she should have wiped off the bedside table before she placed anything on it. In an interview with the Director of Nursing (DON) on 03/06/2025 at 4:30 PM, she stated typically the charge nurse is responsible for providing wound care to the resident. She further stated that her expectations would be for the the nurse performing wound care to clean the bedside table and place a barrier down before putting wound care supplies onto the table. In an interview with the Administrator on 03/06/2025 at 5:28 PM, she stated that her expectations are that staff perform wound care correctly, on time, and follow the infection control procedures of the facility. 2. Review of R11's Face Sheet revealed the facility admitted the resident on 07/02/2012, with diagnoses which included [NAME] Insufficiency, Lymphedema, and Type 2 Diabetes. Review of R11's medical record revealed additional diagnoses that included: [NAME] Ulcer to Right Plantar Foot; Unspecified Open Wound, Right Foot, Subsequent Encounter. Review of R11's Physician's orders and Treatment Administration Record (TAR) revealed the resident's wound care orders included: to continue cleaning areas with soap and water, apply Gentlan [NAME] (an antiseptic solution) to toes daily with Opticell ag rope (an antimicrobial wound dressing) and Kerlix (wrap dressing) to right plantar foot. Change twice daily. Observation on 03/06/2025 at 9:00 AM, of R11's right plantar foot and toes wound care revealed after removing the old dressing, LPN 3 failed to place a clean pad or protective barrier under the resident's right foot prior to providing the wound care. Per observation, LPN 3 failed to clean R11's wound bed prior to applying the new dressing. Continued observation revealed LPN 3 was wearing several items of jewelry on her bilateral hands which caused a tear in her gloves; however, the LPN failed to get a new pair of gloves prior to initiating R11's wound care procedure. In interview on 03/06/2025 at 2:18 PM, LPN 3 stated she received Infection Control Training in the facility which was provided at least annually. LPN 3 said she felt there were not many places for to place her stuff in the residents' rooms. She stated she should have wiped off the bedside table before placing the wound supplies on it. The LPN reported she should have gotten new gloves when her's tore, as those gloves didn't fit at all. She further stated it was important to clean surfaces where wound care supplies were to be placed to aid in prevention of the spread of infection. In interview on 03/06/2025 at 4:49 PM, the Director of Nursing (DON) stated she expected her nursing staff to perform residents' wound care orders as ordered by physician while following the facility's Infection Control Policy guidelines. She further stated she expected all staff to perform proper handwashing technique and use proper PPE, including gloves, to prevent the spread of infection between residents. In interview on 03/06/2025 at 5:15 PM, the Administrator stated she expected all staff to follow the facility's Infection Control Policy guidelines during wound care treatment to aid in prevention of spread of infection from one resident to another resident. 47567

Based on observation, interview and review of facility policy, the facility failed to have an effective pest control program. as there have been mouse droppings observed in the kitchen. Findings include: Review of facility policy titled, Pest Control, undated, revealed the facility maintained an on-going pest control program to ensure the building was kept free of insects and rodents. Review of the Pest Control Contract, dated 07/23/2012, revealed the pest control company would monitor the kitchen and dining room monthly and other areas as needed. Review of store receipts, dated 11/15/2021, 10/26/2021, 10/19/2021 and 10/07/2021 revealed the facility staff had purchased steel wool pads and mouse glue traps. Review of a diagram of the kitchen layout, identified the traps were located in various areas of the kitchen near the refrigerator, steam table, dishwasher/sink. Documentation on the diagram also revealed 2 rodents were caught on 12/21/2021 by the dishwasher, 12/17/2021 1 rodent was caught near the microwave, 11/03/1021 1 rodent was found under the sink, 11/30/2021 1 rodent was found under the refrigerator and on 11/18/2021 1 rodent was caught under the sink. Interview with the maintenance man, on 12/15/2021 at 11:59 AM, revealed he started at the facility in July 2021. He was notified by staff of rodents and he would put the glue strips down, set traps and plug holes with steel wool. Kitchen staff come in every morning and walk the kitchen and storage areas with a flashlight to monitor for mice or droppings. Kitchen staff notify maintenance when signs of rodents were noted. Interview with the dietary aide, on 12/17/2021 at 7:39 AM, revealed stated that cleaning of the kitchen was done at night and that the morning staff wipe stuff down when they arrive to work. She stated she had not seen any mouse droppings when she worked. Interview with the account manager (over housekeeping and laundry), on 12/20/2021 at 10:59 AM, revealed she had not seen mice or mouse droppings when at the facility. Interview with dietary aide / cook, on 12/20/2021, revealed he arrives to work about 4:30 AM and one day he found mouse droppings on the floor in the dry stock and he swept it up. He notified the maintenance man. He also reported that he has not seen mice. The maintenance man will come when called to lay some traps. Interview with CMT #2, on 12/21/2021 at 8:54 AM, revealed the CMT had seen mice in the dining room before and she reported it to the charge nurse in June 2021. Interview with the DON, on 12/22/2021 at 11:48 AM, revealed she would expect if there are mouse droppings for someone to clean the area well. Telephone interview with the owner of the facility, on 12/20/2021 at 3:37 PM, revealed the facility use traps outside and prebaited sticky traps on the inside.

Based on observations, interview and record review and review of facility policy, it was determined the facility failed to honor one (1) of eleven (11) residents rights, (Resident #3), related to their failure to answer the call light in a timely manner. On 12/21/2021, Resident #3 waited eleven (11) minutes to receive incontinent care while the call light was sounding. Findings include: Review of the facility policy for Resident's Rights, undated, revealed residents had the right to live in the home and receive services considering their special needs, likes and dislikes. Residents had the right to be treated with respect, dignity and consideration. Review of facility policy, Call Lights, undated, revealed it was the policy of the facility to provide an environment for residents where they felt secure in knowing the facility was there to insure their security, safety, and well-being. Call lights would be responded to promptly to provide, in part, the security residents desire. All staff had a responsibility to respond to call lights. Call lights were to be answered within five (5) minutes, if at all possible. All staff were aware of call lights as they walk down the hall. When a light is seen, the staff were to knock on the door and inquire of the nature of the resident's need. If the inquiring staff were unable to meet the need, they were to inform the resident and notify the responsible individual of the resident's need. Resident #3, was admitted by the facility on 01/18/2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Observation on 12/21/2021 at 10:48 AM, revealed Resident #3's call light was sounding. The call light sounded again at 10:51 AM, 10:54 AM and 10:57 AM. The resident would point at his/her brief, when staff would stop by to see what the resident needed but the staff would then leave the room until the resident received incontinent care at 10:59 AM by Certified Nurse Assistant (CNA) #1. Observation on 12/22/2021 at 11:34 AM, the call light rang at 11:34 AM, 11:36 AM, 11:37 AM, 11:38 AM and 11:41 AM while staff passed by the room without stopping. Interview with Licensed Practical Nurse (LPN) #1, at 12/22/2021 at 9:15 AM, revealed the process for the call lights was the call light would be answered as soon as possible. The resident should not have to wait ten to fifteen minutes (10-15 minutes) unless staff were attending to another resident. Interview with CNA #1, on 12/22/2021 at 10:46 AM, revealed if you saw a light it would need to be answered. If a call light is heard, it would be answered usually in less than a moment or two (2) if the staff is on the floor walking through. She would not have expected someone to wait ten to fifteen (10 - 15) minutes. She went on to state the facility had enough staff. Interview with the Director of Nursing, on 12/22/2021 at 11:48 AM, revealed staff were to acknowledge the call light and if unable to meet the need they would get someone else that was available. She would not typically expect for the resident to have to wait 10 - 15 minutes but it could happen if staff are providing care to other residents.

Based on observation, interview and review of facility policy and procedures, it was determined the facility failed to secure a medication cart while dispensing medications to seven (7) of eleven (11) sampled resident (#3, #6, #7, #8, #9, #10 and #11). Findings include: Review of facility policy titled, Administering Medications, last revision 12/2012, revealed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with the open drawers inward and al other sides closed. The cart must be clearly visible to the personnel administering medication, and all outward sides must be inaccessible to residents or others passing by. Observations on 12/15/2021 at 3:18 PM - 3:49 PM during medication pass with Certified Medication Technician (CMT) #1, revealed while passing medications, the CMT did not lock the cart while she was in residents rooms and the cart was out of her direct sight. Interview with CMT #1, on 12/15/2021 at 3:49 PM, revealed she should have locked the cart prior to going into the resident's rooms. Interview with LPN #2, on 12/15/2021 at 3:50 PM, revealed the medication cart should have been locked when it was out of the CMT's direct sight. Interview with the DON, on 12/22/2021 at 11:48 AM, revealed if a medication cart is out of view, it would be locked. If facing inward toward a residents room, with nothing on top of the cart, it could be left unlocked.

Based on observation, interview, and facility policy review, it was determined the facility failed to implement an effective Infection Control program in place. During meal pass on the floors Certified Nursing Assistant (CNA) #1 failed to wash and sanitize hands between tasks for different residents which involved the entry and exit to different resident rooms. The findings include: Review of facility policy titled, Standard Precautions Employee Information Sheet', not dated, revealed if hands were not visibly soiled, use alcohol based hand rub for routinely decontaminating hands (up to 3 times) before having direct contact with residents after contact with a resident's intact skin, after contact with inanimate objects in the immediate vicinity of the resident or whenever in doubt. Resident care equipment soiled with blood, body fluid, secretions, and excretions should be handled in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments. Observation on 10/27/2020 at approximately 11:50 AM, revealed Certified Nursing Assistant (CNA) #1 served trays and did not sanitizing hands between tray deliveries. Additionally, CNA #1 entered Unsampled Resident A's room (room [ROOM NUMBER]-A) and repositioned resident in bed; then exited and went into Unsampled Resident B's room (504-B) and acquired his/her coffee cup for refill and did not sanitize or wash hands between the rooms. CNA #1 then went to meal cart #1 to obtain refill of coffee by getting coffee pot from atop meal cart but did not have enough to fill cup so the CNA went to meal cart #2 and finished filling coffee cup. CNA #1 then took a straw retrieved from meal cart to Unsampled Resident C (room [ROOM NUMBER]-A) and then took the coffee to Unsampled Resident B (room [ROOM NUMBER]-B); without washing or sanitizing hands. Interview on 10/27/2020 at approximately 12 :00 PM, with CNA #1, revealed she should sanitize hands before handling trays and after going into each room and after each activity because of contamination. Interview on 10/28/2020 at 5:00 PM, with Infection Control Nurse (IFCN), revealed staff were required to sanitize hands and/or wash hands before going into any room. The IFCN stated staff were to be task conscious and hand wash, if hands were visibly soiled or they had direct contact with residents or contaminated surfaces. Additionally IFCN stated staff would need to hand sanitize before and after delivering the coffee, before providing care to another room; and another residents coffee cup should not be in another resident's room. 2. Review of facility policy titled. Visitor Screening, not dated, revealed visitors were to be screened upon entrance to the building and the nurse was responsible for the screening process and documentation findings. Review of the facility screening policy titled, Coronavirus (COVID-19) Visitor Log, not dated, revealed licensed nurses must follow below: Visitor must cleanse/sanitize hands when entering facility. Licensed nurse completes visitor screening tool for each visitor and provides the visitor a copy of the COVID-19 and handwashing-how-to information sheets. Observation on 10/27/2020 at approximately 10:30 AM, during screening process, revealed the visitor was not informed to sanitize hands and of location of sanitizing equipment; nor provided COVID-19 or handwashing-how-to information sheets, per facility guidelines for screening. Interview on 10/28/2020 at 5:00 PM, with IFCN revealed it was her fault for not asking the visitor to sanitize hands, and she failed to provide the forms related to handwashing and COVID information. IFCN stated she slipped up and made an error when letting the visitor in. Interview on 10/28/2020 at 5:31 PM, with Director of Nursing (DON), revealed visitors should be informed where to located sanitizer and to sanitize hands; and, the nurses should follow the facility guidelines for screening. The DON stated staff were to sanitize hands between each meal tray, when they come in/out of buildings, and between patient care and peri care, if visibly dirty. She stated the staff should have given the resident a new coffee mug and staff should have sanitized hands and then gone back with straw.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure food was prepared, distributed and served in accordance with professional standards for food service safety. Observation in the kitchen on 12/11/18, revealed the cook was using a soiled rag to clean the food thermometer prior to checking the temperature of foods and the cook was handling ready to eat foods with his soiled gloved hand. Review of the facility Census and Condition, dated 12/11/18, revealed fifty-two (52) of fifty-three (53) residents received their meals from the kitchen. The findings include: 1. Review of facility policy Food Temperatures, not dated, revealed to take temperatures, a clean, sanitized and air-dried thermometer is needed. Observation of the lunch trayline food temperature checks in the kitchen on 12/11/18 at 11:12 AM, revealed Cook #1 was cleaning the thermometer, used for checking food temperatures, with a rag that was visibly soiled with brown material on the rag in between checking the temperature of each food. Interview with Cook #1 on 12/11/18 at 11:15 AM, revealed he always used a wet rag to clean the thermometer in between checking the temperatures of each food. 2. Review of facility policy General Food Preparation and Handling, not dated, revealed food items will be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact of prepared foods. Observation of trayline on 12/11/18 at 11:25 AM, revealed Cook #1 was using his gloved right hand to grab country fried steak patties and dinner roll out of the pans to place on the residents' plates, after Cook #1 had handled various other utensils and items in the kitchen. Interview with Dietary Manager on 12/11/18 at 02:30 PM, revealed it was not appropriate to use a rag to clean the thermometer prior to using it and she expected the cooks to use alcohol swabs to clean the thermometer in between checking the temperature of foods. She stated it was not appropriate for the cook to use his hand to dish food out, and she expected all ready to eat foods to be handled with utensils.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure the comprehensive person-centered care plan was implemented for one (1) of sixteen (16) sampled residents (Resident #24). The facility failed to ensure Residents #24's care plan was being followed related to a chair alarm that was to be in place and functioning. The findings include: Review of facility policy Care Plans, not dated, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. It further states each resident's comprehensive care plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Record review revealed the facility readmitted Resident #24 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's Admission Minimum Data Set (MDS) Assessment, dated 12/05/18, revealed the facility coded this resident as requiring limited assistance of one staff for transfers and ambulation. Further review of this MDS, revealed the facility assessed this resident's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. However, an attempt to interview Resident #24 on 12/11/18 at 1:32 PM, revealed the resident was confused and unable to provide intelligible conversation. Review of Resident #24's Comprehensive 'At Risk for Falls/ Injury' Care Plan, initiated 12/11/18, revealed an intervention for this resident to have a pressure alarm to his/her wheelchair to alert staff of attempts of unassisted transfers and to check placement and function per physician's orders [REDACTED].#24's room on 12/11/18 at 1:31 PM, revealed Resident #24 was sitting in a wheelchair, stood up from wheelchair, and started ambulating in room with a unsteady gait. Further observation revealed a wheelchair alarm was in place to wheelchair; however, the alarm was not sounding. At 1:38 PM, the resident was up in the hallway by his/her room ambulating unassisted with a noted unsteady gait. Interview with Certified Nurse Aide (CNA) #1 on 12/11/18 at 1:58 PM, revealed she was expected to follow the residents' care plans. She stated she went and checked Resident #24's alarm after she was informed the resident had been up ambulating by self, and found the alarm was in fact off. She revealed she must have forgotten to turn the alarm on when she assisted the resident up in the wheelchair that morning. Interview with Director of Nursing (DON) on 12/11/18 at 1:53 PM, revealed she expected all staff to ensure they followed the facility care plans.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents; or the resident environment remains as free of accident hazards as possible for two (2) of sixteen (16) sampled residents (Resident #16 and #24). The facility failed to ensure Residents #16's room was free of trip hazards and Resident #24's chair alarm was turned on while resident was in chair. The findings include: 1. Review of facility policy titled, Accidents and Incidents, not dated, revealed it is the policy of the facility to provide a safe and healthful environment. Record review, revealed the facility readmitted Resident #24 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #24's Admission Minimum Data Set (MDS) Assessment, dated 12/05/18, revealed the facility assessed the resident's cogntion as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident required limited assistance of one staff for transfers and ambulation. An attempt to interview Resident #24 on 12/11/18 at 1:32 PM, revealed this resident was confused and unable to provide intelligable conversation. Review of Resident #24's re-admission physician's orders [REDACTED]. Review of Resident #24's Comprehensive 'At Risk for Falls/Injury' Care Plan, initiated 12/11/18, revealed this resident was at risk for falls due to he/she has a history of falls, has confusion, poor safety awareness and does not utilize call light effectively. Further review of this care plan, revealed an intervention for this resident to have a pressure alarm to his/her wheelchair to alert staff of attempts of unassisted transfers and to check placement and function per physician's orders [REDACTED]. Observation of Resident #24's room on 12/11/18 at 1:31 PM, revealed Resident #24 was sitting in a wheelchair, stood up from wheelchair, and started ambulating in room with a unsteady gait. Further observation revealed a wheelchair alarm was in place to wheelchair; however, the alarm was not sounding. Observation of Resident #24 on 12/11/18 at 1:38 PM, revealed the resident was up in the hallway by his/her room ambulating unassisted with an unsteady gait. Interview with Certified Nurse Aide (CNA) #1 on 12/11/18 at 01:58 PM, revealed she was taking care of Resident #24 and this resident should not be up by him/herself. She stated she must have forgot to turn the wheelchair alarm on when she had assisted Resident #24 up to the wheelchair earlier. She stated she went and checked Resident #24's alarm after she was informed the resident had been up ambulating by self and found the alarm was in fact off. Interview with Director of Nursing on 12/11/18 at 1:53 PM, revealed she stated Resident #24's alarm had not been turned on and that is why the resident had been up ambulating by self due to the alarm not being on did not warn staff this resident had gotten up unassisted. She further stated this resident is to be assisted with ambulation and transfers. She stated she expects the alarm for Resident #24 to be turned on when this resident is in the wheelchair. 2. Review of a current Resident Wander list, provided by the facility, revealed a total of four (4) residents. Record review revealed the facility admitted Resident #16 on 10/31/17, with [DIAGNOSES REDACTED]. Review of Resident #16's Annual MDS assessment dated [DATE], revealed the facility assessed the resident's cognition as intact, with a (BIMS) score of fourteen (14), which indicated the resident was interviewable. Observations of Resident #16's room on 12/11/18 at 9:58 AM and 12/12/18 at 8:55 AM, revealed an extension cord lying in the floor between both residents beds. Interview with Maintenance on 12/13/18 at 2:43 PM, revealed the residents should not have extension cords in the floor. He stated the extension cord had been removed from the room because it is considered a fall hazard for other residents, staff, and visitors. Interview with the Director of Nursing (DON) on 12/13/18 at 3:45 PM, revealed she would have expected any fall hazards to be identified by staff and corrected. She further stated the extension cord had been removed from Resident #16's room.

Based on observation, interview and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during medication administration. Observation of a medication administration pass on 12/11/18 revealed staff failed to ensure proper hand hygiene during medication administration. The findings include: Review of facility policy Handwashing, not dated, revealed handwashing and hand antisepsis shall be regarded by the facility as the single most important means of preventing the spread of infections. It further states staff will wash hands before having direct contact with residents and after direct contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. Observation of Licensed Practical Nurse (LPN) #1 on 12/11/18 between 3:08 PM to 3:12 PM, revealed LPN #1 administered medication to two (2) residents. LPN #1 administered medications to the first resident and then went back to the medication cart, and then prepared and administered medication to a second resident without washing or sanitizing hands. Interview with LPN #1 on 12/12/18 at 03:15 PM, revealed she is supposed to perform hand hygiene between residents when passing medications. She stated she is expected to follow facility policy and procedures. Interview with facility Infection Control Preventionist on 12/13/18 at 2:32 PM, revealed she expected all staff who passed medications to wash their hands after administering medications to one resident and before going to administer medications to another resident. She stated staff should do this to ensure there is no chance of spreading infections from one resident to the next resident. She further revealed this was an infection control issue. Interview with Director of Nursing (DON) on 12/12/18 at 3:33 PM, revealed she expected staff to perform hand hygiene in between giving different residents medications. She stated she expected staff to follow the facility policy and procedures.

Based on interview, record review, and review of facility policy, it was determined the facility failed to implement the care plan for one (1) of nine (9) sampled residents (Resident # 1). Resident #1 was care planned to provide treatment per physicians orders and Resident #1 had standing orders to apply oxygen at two (2) liters per minute (LPM) per nasal cannula (N/C) and titrate as needed to maintain oxygen saturations at eighty-eight percent (88%) or greater. However, on 05/10/18, staff assessed Resident #1 to have an oxygen saturation of eighty-one percent (81%) and staff failed to provide oxygen to the resident while waiting for the ambulance to arrive. The findings include: Closed record review revealed the facility admitted Resident #1 on 07/25/17, with [DIAGNOSES REDACTED]. Review of the Resident #1's Plan of Care for Urinary Tract Infection [MEDICAL CONDITION] and Respiratory infection, initiated 05/09/18, revealed to provide treatment per physicians orders. Review of Admission/Readmission orders [REDACTED]. However, review of a Nursing Note dated 05/10/18 and interview with Registered Nurse (RN) #1 on 05/24/18 at 10:43 AM, revealed when assessing Resident #1 the resident was identified to have an oxygen saturation of eighty-one percent (81%) (normal 100 %) and RN #1 failed to ensure oxygen was placed on the resident per the physician's orders [REDACTED].>Review of the Ambulance Service Patient Care Record, dated 05/10/18, and further interview with RN #1 on 05/24/18 at 10:43 AM revealed RN #1 did not put him/her on oxygen because the paramedics would have arrived at the facility faster than she could have ran across the building to get oxygen. Further review of the record revealed after the Paramedic placed oxygen at 2 L/M per N/C, the resident's oxygen saturation increased to one-hundred percent (100%). Interview with the DON, on 05/21/18 at 10:17 AM, revealed RN #1 should have called for help when she identified the resident was declining so she could have started oxygen per physician's orders [REDACTED].>

Based on interview, record review, and review of facility policy, it was determined the facility failed to provide oxygen and continued assessment to a resident requiring Emergency Medical Services (EMS) prior to the arrival of EMS personnel for one (1) of nine (9) sampled residents (Resident #1). On 05/10/18, staff assessed Resident #1 to have a low blood pressure (B/P), low oxygen saturation, elevated temperature, and not feeling well. The licensed staff left the room to contact the physician on call for orders and Emergency Medical Services (EMS) to transport but failed to obtain staff asistance so she could apply oxygen and monitor the resident until the Paramedics arrived on scene. The findings include: Review of facility's Oxygen Administration policy, not dated, revealed before administering oxygen an assessment should be performed to assess vital signs, lung sounds, oxygen saturation, and signs or symptoms of [MEDICAL CONDITION]. Review of facility's Pulse Oximetry policy, not dated, revealed the resident should be assessed for signs and symptoms of impaired oxygen saturation to include: altered respirations, difficulty breathing, and abnormal breath sounds. Closed record review revealed the facility admitted Resident #1 on 07/25/17, with [DIAGNOSES REDACTED]. Review of Admission/Readmission orders [REDACTED]. Review of a Nursing Note, dated 05/10/18 at 3:10 AM revealed Resident #1's vital signs were as follows: Blood Pressure (B/P) 126/78, Pulse 90, Respirations 18, Temperature 99.4, and Oxygen Saturation ninety percent (90%) on room air. Review of a Nursing Note, dated 05/10/18 at 7:50 AM, revealed Registered Nurse (RN) #1 documented the resident's vital signs as: Blood Pressure (B/P) - 86/38, Pulse - 62, Temperature - 102.9, oxygen saturation of eighty-one percent (81%) on room air, respirations even and unlabored but shallow at a rate of sixteen (16), and difficult to arouse. However, further review revealed RN #1 contacted the Attending Physician on call for orders after identifying the resident was declining but did not provide oxygen or call for help to provide supportive services while she left the room. Review of the Ambulance Service Patient Care Record, dated 05/10/18, revealed RN #1 reported Resident #1's oxygen saturation in the lower eighties (80's) and stated I did not put him/her on oxygen because you guys would have gotten here faster than I could have ran across the building to get oxygen. Further review of the record revealed after the Paramedic placed oxygen at 2 L/M per N/C, the resident's oxygen saturation increased to one-hundred percent (100%). Observation of South Nursing station, on 05/24/18 at 10:00 AM, revealed a crash cart and oxygen tank were available in the nursing station used by RN #1 to call the Physician and Ambulance Service. Interview with Certified Nurse Aide (CNA) #1 , on 05/20/18 at 8:30 PM, revealed she obtained v/s for Resident #1 at start of shift after getting assignment and noted the resident felt warm and the resident stated he/she did not feel good. CNA #1 stated she reported something was going with Resident #1 and gave the recorded vital signs to RN #1 and RN #1 stated she would check on the Resident. Interview with RN #1, on 05/24/18 at 10:43 AM, revealed she did assess Resident #1 after being notified Resident #1 had a change in condition by CNA #1 and then went to call the Physician, and Ambulance Service, She stated she also notified the family, and called report to the Emergency Department. RN #1 stated when she returned to check on Resident #1, EMS personnel were already at the bedside. She stated the Paramedic asked her why there was not any oxygen on the resident and she told her she needed to get 911 initiated. RN #1 stated after she got the resident sent to the Emergency Department the Director of Nursing (DON) came and escorted her to the office and told her she should have placed oxygen on Resident #1. She stated she told the DON she felt it was faster to get the resident out than to put oxygen on him/her. RN #1 stated the DON then fired her and walked her out of the building. Interview with the DON, on 05/21/18 at 10:17 AM, revealed she had pulled RN #1 to the office to talk to her about the incident after she was told Resident #1 did not have oxygen on when he/she left the building. The DON stated she asked RN #1 why she did not put oxygen on the resident and RN #1 kept arguing that she could get the resident transported out faster than she could provide oxygen. The DON revealed she talked to RN #1 and told her she should have called for help when she identified the resident was declining so she could have started oxygen and been available to monitor the resident until the Ambulance arrived. The DON stated she told RN #1 she was going to have to be out of the building while she performed an investigation of the incident and stayed with RN #1 until report was given to another nurse and then she suspended RN #1 and escorted her out of the building.

Based on interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned to have his/her urinary catheter changed monthly per physician's orders [REDACTED].{2} months). Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The findings include: Review of the facility's Comprehensive Care Plan Policy, revision date 09/10, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to reflect treatment goals, timetables, and objectives in measurable outcomes. The care plan was designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels. The care plan was designed to reflect currently recognized standards of practice for problem areas and conditions. Record review revealed the facility admitted Resident #1 on 02/13/13, with [DIAGNOSES REDACTED]. Further review revealed Resident #1 was discharged from the facility on 01/24/18. Review of Resident #1's Comprehensive Care Plan for risk for Urinary Tract Infections related to use of an indwelling urinary catheter, initiated on 09/08/17, revealed an intervention to change the urinary catheter as ordered. Review of Resident #1's Physician Orders, dated 01/11/18, revealed to change the urinary catheter every month and as needed. However, review of the (MONTH) and (MONTH) (YEAR), and (MONTH) (YEAR) Treatment Administration Record (TAR); and Nurse's Notes, dated 12/11/17 through 01/11/18 revealed the last time Resident #1's catheter was documented as being changed was 11/11/17. Review of Nurses' Notes dated 01/22/18 at 6:15 AM, revealed the physician noted Resident #1 had shallow respirations and his/her vital signs were: blood pressure 117/70 (normal:120/80), respirations 26 (normal:12-16), pulse 117 (normal: 60-100), temperature 100.1 degrees Fahrenheit (F) (normal: 97.7-99.0 F) and oxygen saturation of 92% (normal: 95-100%), on room air. The resident was sent to the emergency room (ER) for evaluation. Review of Resident #1's Hospital History and Physical dated 01/25/18, revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Resident #1 was treated with intravenous (IV) antibiotics. Interviews on 01/31/18 with Registered Nurse (RN) #2 at 10:07 AM, and RN #3 at 10:40 AM revealed RN #2 worked third shift on 12/10/17-12/11/17 and RN #3 worked third shift on 01/10/18-01/11/18. The RN's stated they changed Resident #1's catheter during each of their shifts. They stated that they failed to document the treatment on the TAR and the Nurses' Notes; and failed to scan the supplies used because the scanner was not working. Interview with the emergency room Registered Nurse (RN) #1, on 02/01/18 at 2:14 PM, revealed Resident #1's urine in the catheter bag and catheter tubing was burgundy in color. She said after removing the old catheter she noticed the tip had black/burgundy growth on it. Interview with Resident #1's Physician on 01/31/18 at 3:50 PM, revealed when making rounds on 01/22/18 he was concerned the resident may have pneumonia. He stated he had not looked at the resident's urine. He revealed the source of the infection was both urinary and [MEDICAL CONDITION]. He said it was possible the infection was due to the catheter not being changed. Interview with the Director of Nursing (DON) on 02/02/18 at 10:31 AM, revealed she had spoken with both nurses who worked the days the catheter should have been changed. She stated both nurses stated they had changed Resident #1's catheter but failed to document the treatments on the TAR and in the Nurses' Notes. She stated she expected staff to follow residents' care plans when providing care.

Based on interview, record review, and facility policy review, it was determined the facility's system to ensure residents with catheters were provided care to prevent Urinary Tract Infections was not followed for one (1) of three (3) sampled residents (Resident #1). Resident #1 had an indwelling urinary catheter; however, the facility to failed to change his/her indwelling urinary catheter every thirty days per facility policy. There was no documented evidence Resident #1's catheter had been changed from 11/12/17 through 01/22/18 (seventy-two {72} days). Resident #1 was sent to the hospital on [DATE] and the urine in his/her catheter bag and tubing was burgundy in color and the resident was diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled, Catheter Use/Care, dated 06/05/17, revealed all residents admitted with/or needing a indwelling catheter placed will have supporting [DIAGNOSES REDACTED]. Further review revealed Foley catheters are to be changed every month (30 days) and charted in the nurses notes. Record review revealed Resident #1 was admitted to the facility 02/13/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/21/17 revealed the Staff Assessment for Mental Status indicated Resident #1's cognition was severely impaired. Further review of the MDS assessment, dated 11/21/17, revealed the resident had an indwelling catheter. Further review of the record revealed Resident #1 was discharged from the facility on 01/24/18. Review of Resident #1's Comprehensive Care Plan for risk for Urinary Tract Infections related to use of an indwelling urinary catheter, initiated on 09/08/17, with a target date of 02/27/18, revealed a goal to have no signs/symptoms of infection daily through next review. Interventions included changing the indwelling urinary catheter as ordered. Review of Resident #1's Physician Orders, dated 08/28/17, (MONTH) and (MONTH) (YEAR); and (MONTH) (YEAR), revealed an order to change the indwelling urinary catheter every month. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR)revealed Resident #1's indwelling urinary catheter was changed on 11/11/17. However, review of Resident #1's (MONTH) (YEAR) and (MONTH) (YEAR) Treatment Administration Record (TAR), revealed there was no documented evidence Resident #1's catheter was changed from 11/12/17 through 01/21/18. Review of Nurse's Notes dated 12/11/17 through 01/11/18 revealed there was no documented evidence Resident #1's indwelling urinary catheter was changed. Interview with Registered Nurse (RN) #1 on 01/31/18 at 10:07 AM, revealed she had worked third shift on 12/10/17-12/11/17. She stated she changed Resident #1's catheter during her shift. RN #1 stated the aides were busy during that time so she changed the catheter without any assistance. She further stated she remembered changing Resident #1's catheter because it was really difficult. She stated she had placed Resident #1 on his/her side in order to place the catheter. RN #1 said she failed to document the treatment on the TAR and the Nurse's Notes. She said staff are supposed to scan supplies used for each resident for billing purposes; however, the scanner wasn't working and she was unable to do so. She stated the facility had two (2) scanners one on the North Unit and one of the South Unit. Further interview revealed the scanner on the North Unit was broken and the one on the South Unit was usually broken as well, but she failed to check. She further stated if a treatment was not documented she would think it was not done. Interview with RN #2 on 01/31/18 at 10:40 AM, revealed she had worked third shift on 01/10/18-01/11/18. She stated she knew Resident #1's catheter was due to be changed on this date because she keeps notes on a personal calendar at work. RN #2 revealed she changed Resident #1's catheter without any assistance because the resident was fairly easy to catheter while he/she was on their side. She said she failed to document the care provided on the TAR and the Nurse's Notes. RN #2 further stated she failed to scan the supplies because the scanner was not working. Interview with CNA #5, on 02/16/18 at 3:54 PM, revealed she worked from 2:00 PM-10:00 PM on 01/21/18. She stated Resident #1's urine was yellowish/orange in the catheter bag that night. She revealed Resident #1 had been on [MEDICATION NAME] (causes urine to be reddish orange) in the past and she was not sure if the resident was still on it, so she did not report this to the nurse. Further review of the (MONTH) (YEAR) Physician order [REDACTED]. Review of Nurses' Notes, dated 01/22/18 at 6:15 AM, revealed the physician was in the facility completing rounds and noted Resident #1 had shallow respirations and his/her vital signs were blood pressure: 117/70 (normal:120/80), respirations: 26 (normal:12-16), pulse: 117 (normal: 60-100), temperature 100.1 degrees Fahrenheit (F) (normal: 97.7-99.0 F), and oxygen saturation of 92% (normal: 95-100%), on room air. Family was notified and new orders received to send Resident #1 to the emergency room (ER) for evaluation. Interview with RN #3 on 02/01/18 at 8:39 AM, revealed she had taken care of Resident #1 on 01/22/18. She stated when the doctor came in around 5:30 AM to do rounds he was concerned with Resident #1's shallow, rapid respirations. She stated Resident #1 felt warm and she obtained vital signs on him/her. She stated she gave the set of vitals to the oncoming nurse and they were documented in the nurses notes. She further stated Resident #1's urine was yellow and nothing abnormal about the catheter bag or tubing was noted. She stated she had emptied Resident #1's catheter prior to the arrival of the ambulance and noted an output of 250 ml's of urine. Interview on 02/16/18 at 3:27 PM, with the Paramedic whom assisted in the transfer of Resident #1 to the hospital on [DATE], revealed there was nothing on the report about Resident #1's catheter and she could not recall seeing the catheter or tubing. She stated she was more focused on Resident #1's vital signs. Review of Resident #1's Hospital Labs, dated 01/22/18, revealed a white blood cell count of 23,250 (normal: 500-10,500). Further review revealed the urinalysis contained red blood cells, too numerous to count (normal: 4 red blood cells per high power field (RBC/HPF); 2 plus bacteria (normal:none), and mixed flora isolated. Review of Resident #1's Hospital History and Physical dated 01/25/18, revealed Resident #1 was admitted with [DIAGNOSES REDACTED]. Resident #1 was treated with intravenous (IV) antibiotics. Interview with Resident #1's family member/Responsible Party on 01/30/18 at 4:40 PM revealed the facility called them on 01/22/18 around 7:00 AM and told them the resident's physician had noted abnormal vital signs during rounds. The family requested the resident be sent out to the emergency room (ER) for evaluation. She stated while in the ER she noticed the resident's urine in the catheter bag and catheter tubing were dark burgundy in color. She revealed the nurse in the ER changed the resident's catheter and noted about 700 milliliters (ml) of output immediately. She stated the catheter tip was corroded, with black growth on the tip and the nurse said it looked as though the catheter had not been changed in a while. Further interview revealed the resident was admitted due to being Septic and having a Urinary Tract Infection. She said after requesting medical records from the facility she found there was no documentation on the resident's catheter since 11/11/17. She said she felt all of this could have been prevented if the facility had taken better care of the resident. She also stated the family found placement for the resident elsewhere because she was very unhappy with the care the facility provided. Interview with the emergency room Registered Nurse (ER/RN) #1, on 02/01/18 at 2:14 PM, revealed she recalled caring for the resident on 01/22/18 and the resident's urine in the catheter bag and catheter tubing was burgundy in color. She said after removing the old catheter she noticed the tip had black/burgundy growth on it. She stated when someone has an infection there can be growth on the tip and the tip looked as though it had barnacles on it. This RN stated she told the resident's responsible party the resident had an output of about 500-700 mls of urine after inserting a new catheter. She stated the family was very upset and took pictures of the catheter bag, catheter tubing, and the tip of the catheter. She further stated it took the assistance of two (2) additional staff members in order to catheterize Resident #1 because he/she had his/her legs so tightly closed together and didn't understand directions. She stated it was the most difficult catheter she had ever placed. Interview with Certified Nurse Aide (CNA) #1 on 02/01/18 at 3:20 PM, revealed he has assisted nurses in changing a dressing to Resident #1's buttocks. He stated it would take at least two (2) people to change Resident #1's catheter because he/she keeps his/her legs so tight together. He further stated during care Resident #1 would grab at staff a lot and a staff member would keep him/her occupied while holding the resident's hand. Interview with Resident #1's Physician on 01/31/18 at 3:50 PM, revealed when making rounds on 01/22/18 he noticed Resident #1 was febrile, tachypneic, and did not seem to be at his/her baseline. He stated the facility notified the resident's responsible party and they requested the resident be sent out for evaluation. The Physician stated he was concerned the resident may have Pneumonia. He stated the resident's urine culture grew out mixed flora and it was normal for someone who has had a catheter, chronically. He revealed the source of the infection was urinary and [MEDICAL CONDITION] and it was possible the infection may be due to the catheter not being changed. He stated it was always good practice to change an indwelling urinary catheter monthly. Interview with the Director of Nursing (DON) on 02/02/18 at 10:31 AM, revealed she had become aware of the catheter treatments not being documented after Resident #1's family requested copies of his/her medical records. She stated she had spoken with both nurses who worked the days the catheter should have been changed. She revealed both nurses stated they had changed Resident #1's catheter but failed to document the treatments on the TAR and Nurses' Notes. She said she had started inservicing nursing staff on documentation and was reviewing the facility's policies for possible changes. She further revealed she expected staff to follow residents' care plans when providing care. She stated she expected the nurses to follow the physicians' orders and to document the treatments provided on the TAR and in the Nurses' Notes. She also stated the facility has a scanner located at both nursing units, which were used to scan out supplies for each resident. She said she was not aware of any issues with the scanners.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the Comprehensive Care Plan was periodically reviewed and revised for seven (7) of fifteen (15) sampled residents (Residents #1, #4, #11, #12, #13, #16 and #17). On 04/12/13 at 1:00 AM, Resident #1 was found on the floor behind his/her room door with a laceration to his/her forehead, swelling to the left eye, and complaints of severe head and neck pain. Resident #1 was sent to the emergency room for evaluation and admitted to the hospital with [REDACTED]. Record review revealed Resident #1 had a history of [REDACTED]. On 11/05/12, at 6:25 AM Resident #1 was found on the floor under the bedside table with complaints of left shoulder pain and was diagnosed with [REDACTED]. Resident #1 also sustained three (3) falls in December 2012 on 12/04/12, 12/08/12, and on 12/10/12. Interview with the Administrator and record review revealed no documented evidence Resident #1's falls were thoroughly investigated to determine all causal factors, nor was the resident's Comprehensive Care Plan related to Falls revised in an attempt to prevent further falls. (Refer to F323) Resident #4 experienced five (5) falls from 03/21/13 to 05/09/13 all attempting to get out of bed unassisted. The Comprehensive Care Plan was not revised to include interventions to prevent further falls. Resident #11 experienced seven (7) falls from 04/30/13 to 07/16/13 with no documented evidence of revisions to the care plan to include interventions to prevent further falls. Resident #12 experienced four (4) falls from 02/21/13 to 06/18/13 with no documented evidence the resident's care plan had been revised. Resident #13 experienced four (4) falls from 05/01/13 to 07/23/13 with no documented evidence of revisions to the care plan. In addition, Residents #16 and #17's record revealed no documented evidence the Comprehensive Care Plan was revised to include the Psychologist's Care Plan Information. The facility's failure to have an effective system in place to ensure residents' Comprehensive Care Plans were revised to prevent future falls, and failure to thoroughly implement and ensure the Care Plan Policy was effective in the prevention of falls placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified at 42 CFR 483.20, Resident Assessment, F-280 at a Scope and Severity of "K". The Immediate Jeopardy was identified on 08/23/13 and determined to exist on 04/12/13. An acceptable Credible Allegation of Compliance, related to the Immediate Jeopardy, was received on 08/30/13. On 08/30/13, the Immediate Jeopardy was verified removed on 08/30/13 as alleged prior to exit. However, non-compliance continued to exist at 42 CFR 483.20 Resident Assessment at a Scope and Severity of an "E", as the facility had not completed the development and implementation of a Plan of Correction (PoC) to ensure the facility established and maintained an effective system to ensure residents' care plans were revised to ensure residents remained free from avoidable accidents. The findings include: Review of the facility's Care Plans Policy Statement, undated, revealed an individualized Comprehensive Care Plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was to be developed for each resident. According to the policy, a Comprehensive Care Plan was based on a thorough assessment that included, but was not limited to the Minimum Data Set (MDS). The policy indicated an assessment of the residents was ongoing and care plans were revised as information about the resident and the resident's condition changed. The policy stated each resident's Comprehensive Care Plan was designed to: incorporate identified problems; incorporate risk factors associated with identified problems; build on the resident's strengths; reflect the resident's expressed wishes regarding care and treatment goals; reflect treatment goals, timetables and objectives in measurable outcomes; identify the professional services that are responsible for each element of care; aid in preventing or reducing declines in the resident's functional status and/or function levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 02/21/06, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessments completed on 09/27/12, 07/17/12 and 04/28/13 revealed the facility assessed the resident to be severely cognitively impaired and to require assistance with all Activities of Daily Living (ADLs). Review of the Fall Risk Assessments dated 12/13/12, 03/09/13, and 04/15/13 revealed the facility assessed Resident #1 to be a high risk for falls. Review of the Comprehensive Care Plan revealed the facility assessed Resident #1 to require a Falls Care Plan related to his/her history of falls and high risk for falls. Interventions included administer medications as ordered; assess for side effects to medication use and document if any noted; assist of one (1) with transfers; use a gait belt; call light within easy reach at all times; keep bed at lowest level at all times; labs as ordered; observe for change in mental status; nonskid shoes/socks when ambulating; observe for decrease or loss of functional status; provide clutter free pathways; respond promptly to call light; use of walker when ambulating; vital signs weekly and PRN (as necessary); remind resident to utilize call light; perimeter defined pressure reduction mattress to be to help prevent resident from rolling out of bed due to lays on edge of bed; use of wedge cushion to wheelchair to prevent sliding; restorative per plan of care; and scheduled toileting per plan of care. Review of the Nursing Assistant Care Plans for November 2012 through April 2013 revealed the resident to be on Extreme Fall Risk Precautions. Review of a fall investigation for Resident #1, dated 04/12/13 at 1:00 AM, revealed the resident sustained [REDACTED]. Continued review of the Incident Log revealed Resident #1 was sent to the ER. Review of a Hospital Discharge Summary form revealed Resident #1 was diagnosed and treated for [REDACTED].#1 was discharged from the hospital on [DATE], with orders to wear a Miami J collar (neck collar) at all times. Review of the Comprehensive Care Plan revealed interventions of a sensor alarm and clip alarm were placed on Resident #1. Review of the Nurse's Note, dated 04/15/13 at 7:45 PM, revealed every fifteen (15) monitoring would be implemented. However, there was no documented evidence on the Comprehensive Plan of Care or on the Nursing Assistant Care Plan of the fifteen (15) minute monitoring of Resident #1 that was initiated, on 04/15/13 at 7:45 PM, when the resident returned to the facility from the hospital. Record review revealed the resident sustained [REDACTED]. Review of a fall investigation for Resident #1, dated 05/18/13 at 4:05 PM, revealed Resident #1 was found on the fall mat beside the bed and sustained no injury. Review of the Comprehensive Care Plan revealed the care plan was reviewed on 05/20/13. However, the facility failed to revise the resident's care plan to prevent further falls, even though the resident had a previous serious injury from a fall; had been assessed as a high risk for falls; and, had a history of [REDACTED]. Interview and record review revealed Resident #1 had a history of [REDACTED]. Review of a fall investigation for Resident #1, dated 11/05/12 at 6:25 AM, revealed Resident #1 was found on the floor under the bedside table and complained of left shoulder pain. The resident was diagnosed with [REDACTED]. Review of the Comprehensive Plan of Care for Resident #1 revealed the Falls Care Plan was reviewed on 11/05/12; however, the fall on 11/05/12 was not captured on the care plan. Continued review of the Comprehensive Nursing Care Plan revealed no documented evidence of additional interventions added to attempt to prevent additional falls. Review of the Nursing Assistant (NA) Care Plan revealed no documented evidence of changes or revisions put in place related to the fall. Review of a fall investigation for Resident #1, dated 12/04/12 at 10:30 PM, revealed the resident had transferred from his/her bed, and then fell trying to get out of his/her wheelchair. The fall investigation revealed the resident's blood sugar level was low; however, there was no evidence the facility attempted to determine the reason Resident #1's blood sugar was low. Review of the resident's care plan revealed it was not revised related to this fall. Review of a fall investigation for Resident #1, dated 12/07/12 at 4:30 PM, revealed Resident #1 was transferring from the bedside commode (BSC) to the wheelchair and sustained a fall. The IPOC Committee summarized that the resident would be checked for placement of the BSC and assessed for the need for personal alarms. However, review of the Comprehensive Care Plan revealed no documented evidence of revisions made to prevent additional falls and this fall was not reflected on the Care Plan. Review of a fall investigation for Resident #1, dated 12/10/12 at 11:00 PM, revealed Resident #1 sustained an unassisted fall with no injury. Review of the Comprehensive Care Plan revealed the care plan was reviewed on 12/10/12; however, there was no documented evidence of revisions made to prevent additional falls were identified. Interview with Certified Nursing Assistant (CNA) #9, on 8/22/13 at 5:50 PM, revealed she had been a Restorative Aid with the facility since February 2011 and was very familiar with caring for Resident #1. CNA #9 revealed Resident #1 would get up without putting on the call light and did not always understand how to use the call light and would get up independently. CNA #9 was uncertain if Resident #1 had falls mats or alarms in place before her falls when he/she fractured her collar bone in November 2012 and fractured her neck in April 2013. Interview with the Assistant Director of Nursing (ADON)/Minimum Data Set (MDS) Coordinator, on 08/22/13 at 2:00 PM, revealed she was responsible for updating Resident #1's plan of care with the interventions decided upon in the (IPOC) group meetings. The ADON was unsure why Resident #1's care plan had not been updated after the falls on 11/05/12, 12/04/12, 12/07/12, 12/10/12 and 05/18/13. Interview with the DON, on 08/23/13 at 2:05 PM, revealed the ADON/MDS Coordinator should have updated Resident #1's comprehensive care plan after every fall that the resident sustained [REDACTED]. The DON admitted the IPOC Committee was not implementing interventions to be put in place to prevent future falls. The DON revealed she was not monitoring to see that the residents' Comprehensive Care Plans and Nurse Aid Care Plans were updated after the IPOC meetings and that she did not follow up to ensure interventions were implemented. The DON revealed she was responsible to ensure interventions were put in place on residents' Nursing and Nursing Assistant care plans. The DON revealed she had only been in the DON position since 04/29/13, was a DON in training, and was only responsible for what occurred after she took the position. The DON stated that she did not have a monitoring system in place to make certain the residents' care plans were updated/revised when a resident's conditions changes or when a resident had a fall. 2. Review of the medical record for Resident #4 revealed the resident was admitted by the facility on 01/22/13, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessments completed on 01/29/13, 06/30/13, and 07/25/13, all revealed the facility assessed the resident to be severely cognitively impaired. A review of fall risk assessments completed by the facility on 01/22/13, 03/15/13, and 06/30/13, all revealed the resident was assessed by the facility to be at high risk for falls to occur. A review of the comprehensive plan of care dated 02/11/13 for Resident #4, revealed interventions which had been put into place to prevent falls by administering medications as ordered by the physician, provide the assistance of two (2) persons with transfers, staff were to keep the call light within the resident's reach, staff were to check for incontinence on rounds and as needed, staff were to observe for a change in the resident's mental status and alert the physician as needed, staff were to orient the resident to his/her surroundings, staff were to respond promptly to the resident's call light, staff were to monitor vital signs every week and as needed, staff were to use a wheelchair with a gel cushion and bilateral leg rests, and a bedside commode would be used by the resident for ease with toileting. Review of a fall investigation for Resident #4 dated 03/21/13 at 4:15 AM, revealed the resident fell again while attempting to use the bedside commode and sustained three (3) skin tears from the fall. A review of the Immediate Intervention Form dated 03/21/13, revealed education and instruction for the resident, and a walker had been added again as an intervention. A review of the incident log dated 03/21/13 at 4:15 AM, revealed education would be provided for the resident and since the resident had reached a plateau with therapy the resident would begin to receive restorative nursing services for safety had been added as interventions. However, review of the comprehensive plan of care for Resident #4 revealed the care plan had not been updated to reflect restorative nursing services. Review of a fall investigation for Resident #4 dated 04/04/13 at 11:00 AM, revealed the resident fell attempting to use the bedside commode. A review of the Immediate Intervention Form dated 04/04/13, revealed ensure clothing does not contribute to falls, and non-skid socks had been added as an interventions. A review of the incident log dated 04/04/13 at 11:00 AM, revealed non-skid socks, and to encourage the resident to call for assistance were added as interventions. However, review of the comprehensive plan of care for Resident #4 revealed there was no evidence the facility revised the care plan to address the resident's attempt to toilet self. Review of a fall investigation for Resident #4 dated 04/09/13 at 7:40 AM, revealed the resident fell attempting to use the bedside commode and sustained abrasions to the right upper back and a small "scratch" to the left upper back. A review of the Immediate Intervention Form dated 04/09/13 revealed ensure clothing does not contribute to falls, and access use of assistive devices had been added as interventions. A review of the incident log dated 04/09/13, revealed the resident would be educated about using the walker, and encourage to call for assistance were added as interventions. A review of the comprehensive plan of care for Resident #4 revealed the care plan had not been updated to educate the resident about using the walker or to encourage the resident to call for assistance after the resident sustained [REDACTED]. Review of a fall investigation for Resident #4 dated 04/09/13 at 11:00 AM, revealed the resident fell attempting to use the bedside commode and sustained laceration to the back of the head. A review of the Immediate Intervention Form dated 04/09/13 revealed ensure clothing does not contribute to falls, move bedside commode and walker closer to the bed had been added as an interventions. A review of the incident log dated 04/09/13 at 11:00 AM, revealed the resident would be placed on the toileting log which alerts staff to assist the resident with toileting, and the bedside commode would be moved had been added as interventions. A review of the comprehensive plan of care for Resident #4 revealed no interventions regarding placing the resident on the toileting log, nor moving the bedside commode had been added as interventions to the care plan. Review of a fall investigation for Resident #4 dated 05/09/13 at 12:10 AM, revealed the resident fell attempting to get out of bed and sustained two (2) skin tears to the back and a skin tear reopened on the left arm. A review of the Immediate Intervention Form dated 05/09/13 revealed assess for functional status changes, and increased monitoring when the resident was in bed had been added as interventions. A review of the incident log dated 05/09/13, at 12:10 AM, revealed float boots would be removed from the resident's feet was added as an intervention. A review of the comprehensive plan of care for Resident #4 revealed no intervention regarding the resident's float boots had been added as an intervention after the fall. An interview conducted with CNA #12 on 08/22/13, at 4:20 PM, and CNA #9 on 08/22/13, at 4:30 PM, both revealed Resident #4 had difficulty remembering things and required toileting every one to two (2) hours prior to the last couple of months. The CNA stated the resident had used a walker, but would attempt to get out of bed by himself/herself. The CNA's stated the resident could not recall to use the call light. Interview conducted with the Assistant Director of Nursing (ADON), on 08/22/13 at 1:40 PM, revealed she was also the MDS Coordinator and was responsible for coordinating the comprehensive plan of care. The ADON stated all falls are reviewed Monday through Friday at the morning meeting in which the interdisciplinary team meets. The ADON stated the interdisciplinary group meets and she was then responsible to update the plan of care with the interventions decided upon in the group. The ADON was unsure why the resident had fallen five (5) times before the resident was placed on a toileting program. The ADON stated she was unsure why Resident #4's care plan had not been updated after the resident had fallen on 03/21/13, at 4:15 AM, 04/09/13, at 7:40 AM, and 05/09/13, at 12:10 AM. The ADON stated a resident's care plan should always be updated after every fall. Interview conducted with the DON, on 08/22/13 at 2:05 PM, revealed the ADON was responsible for updating the comprehensive plan of care. The DON stated all falls were required to have a care plan update and were reviewed in the morning interdisciplinary team meeting. The DON stated the falls were discussed and interventions were decided upon by the interdisciplinary team. The DON stated she did not review the completed care plans to ensure the interventions decided upon had been placed on the care plan. The DON stated Resident #4's care plan should have been updated to reflect the falls the resident sustained [REDACTED]. 3. Review of the medical record for Resident #11, revealed the resident had been admitted by the facility on 02/23/09, with [DIAGNOSES REDACTED]. A review of a significant change in condition MDS assessment for Resident #11, dated 03/21/13, and a quarterly MDS assessment, dated 06/06/13, revealed the facility had assessed the resident to be severely cognitively impaired on both assessments. A review of the Care Area Assessments (CAA) for the 03/21/13, revealed the resident was assessed as being at risk for falls. Review of a fall investigation for Resident #11 dated 04/30/13 at 3:48 PM, revealed the resident fell attempting to toilet him/herself after having had an enema. The fall investigation revealed the resident had not sustained an injury, an intervention had been added for the nurse to be be reminded to stay with the resident until results were obtained after administering an enema to the resident. A review of the incident log dated 04/30/13, revealed the nurse would remain with the resident after administering an enema would be added as an intervention. A review of the comprehensive plan of care for Resident #11 revealed the care plan had not been updated with an intervention for the nurse to remain with the resident after administering an enema. Review of a fall investigation for Resident #11 dated 05/30/13 at 7:30 PM, revealed the resident fell while a staff person was attempting to transfer the resident from a wheelchair to the shower chair. The fall investigation revealed the resident had not sustained an injury, an intervention had been added for the resident to be transferred with the assistance of two (2) staff. A review of the incident log dated 05/30/13, two (2) staff persons would be required to transfer the resident was added as an intervention. A review of the comprehensive plan of care for Resident #11 revealed no intervention had been added for the resident to be transferred with the assistance of two (2) staff. Review of a fall investigation for Resident #11 dated 05/31/13 at 7:15 AM, revealed the resident fell by sliding out of the bed. The fall investigation revealed the resident had not sustained an injury, and an intervention had been added for a physical therapy evaluation. A review of the incident log dated 05/31/13 revealed physical therapy orders had been received. A review of the comprehensive plan of care for Resident #11 revealed the care plan had not been updated to reflect the intervention. Review of a fall investigation for Resident #11 dated, 06/05/13 at 3:48 PM, revealed the resident fell attempting to get out the bed unassisted. The fall investigation revealed the resident had not sustained an injury, and an intervention had been added for the resident to be placed up at the nursing station. A review of the incident log dated 06/05/13 revealed an order was obtained for [MEDICATION NAME] related to the resident not sleeping. A review of the comprehensive plan of care for Resident #11 revealed the care plan had not been updated to reflect the intervention. Review of a fall investigation for Resident #11 dated 06/06/13 at 12:45 AM, fell from the bed to the floor and had not sustained an injury. The fall investigation also revealed physical therapy had assessed the resident and bed position, and had changed the bed position to ninety (90) degrees as an intervention. A review of the incident log dated 06/06/13 revealed physical therapy would assess the resident's bed and bed height, the bed was locked out, and tape was placed on the wall indicating where the bed should be placed was added as an intervention. A review of the comprehensive plan of care for Resident #11 revealed the care plan had not been updated to reflect the changes identified as interventions to be used. Review of a fall investigation for Resident #11 dated 07/07/13 at 4:50 AM, revealed the resident fell from the bed to the floor and had not sustained an injury. The fall investigation also revealed "interventions currently being used for the resident were effective and no changes were made." A review of the incident log dated 07/07/13 revealed "the current interventions being used by the facility were effective." A review of the comprehensive plan of care for Resident #11 revealed the care plan had not been updated to reflect the fall had occurred, nor did it address why if the interventions were effective the resident was continuing to fall. Review of a fall investigation for Resident #11 dated 07/16/13 at 12:10 PM, fell from the bed to the floor and had not sustained an injury. The fall investigation also revealed "interventions currently being used for the resident were effective and no changes were made." A review of the incident log dated 07/16/13, revealed "the current interventions being used by the facility were effective." A review of the comprehensive plan of care for Resident #11 revealed the care plan had not been updated to reflect the fall had occurred, nor did it address why if the interventions were effective the resident was continuing to fall. An interview conducted with the ADON on 08/23/13, at 4:35 PM, revealed she was responsible to update Resident #11's plan of care with the interventions decided upon in the interdisciplinary group. The ADON was unsure why Resident #11's care plan had not been updated after the falls and stated it should have been. The ADON stated a resident's care plan should always be updated after every fall. An interview conducted with the DON on 08/23/13, at 4:30 PM, revealed all falls were required to have a care plan update. The DON stated Resident #11's comprehensive plan of care should have been updated after every fall the resident sustained [REDACTED]. 4. Review of the medical record for Resident #13 revealed the resident had been admitted by the facility on 01/03/07 with [DIAGNOSES REDACTED]. A review of quarterly MDS assessment dated [DATE] revealed the resident had been assessed by the facility to have moderately impaired cognition. Review of a fall investigation for Resident #13 dated 05/01/13 at 12:20 PM, revealed the resident fell from the chair to the floor and had not sustained an injury. The fall investigation also revealed an intervention would be put into place to assess the resident's chair and to remind the resident to call for assistance if needed. A review of the Immediate Intervention Form dated 05/01/13 revealed interventions to assess the use of assistive devices, and for a walker. A review of the incident log dated 05/01/13, revealed interventions for a chair assessment, and to remind the resident to call for assistance would be put into place. A review of the comprehensive plan of care for Resident #13 revealed the care plan had not been updated to reflect the interventions fall. Review of a fall investigation for Resident #13 dated 05/07/13 at 01:30 PM, revealed the resident fell from the bed to the floor and had not sustained an injury. The fall investigation also revealed an intervention would be put into place for the resident to receive restorative nursing services. A review of the Immediate Intervention Form dated 05/07/13 revealed interventions to assess and to ensure current interventions were being used and were functioning, and to provide education/instruction to the resident. A review of the incident log dated 05/07/13 revealed interventions for the resident to receive restorative nursing services. A review of the comprehensive plan of care for Resident #13 revealed the care plan had not been updated to reflect the interventions. Review of a fall investigation for Resident #13 dated 05/30/13 at 5:20 PM, revealed the resident fell from the bed to the bedside commode and had not sustained an injury. The fall investigation also revealed an intervention would be put into place to follow up with the family member of Resident #13 regarding the placement of the bedside commode. A review of the Immediate Intervention Form dated 05/30/13 revealed interventions would be put into place to move the bedside commode to the end of the resident's bed. A review of the incident log dated 05/30/13 revealed interventions to move the bedside commode to the end of the resident's bed would be put into place. A review of the comprehensive plan of care for Resident #13 revealed the care plan had not been updated to reflect the interventions. Review of a fall investigation for Resident #13 dated 07/23/13, at 9:30 AM, revealed the resident fell from the bedside commode to the floor and had complained of right side pain, right hip pain, and left knee pain. The fall investigation revealed an intervention would be put into place to assess the resident's chair and to remind the resident to call for assistance if needed. A review of the Immediate Intervention Form dated 07/23/13, revealed interventions to make environmental modifications. A review of the incident log dated 07/23/13, revealed interventions for environmental modifications, and the resident would use a walker for ambulation. A review of the comprehensive plan of care for Resident #13 revealed the care plan had not been updated to reflect these interventions. Interview conducted with the ADON on 08/23/13 at 4:35 PM, revealed she was responsible to update Resident #13's plan of care with the interventions decided upon in the interdisciplinary group. The ADON was unsure why Resident #13's care plan had not been updated after the falls and stated it should have been. Interview conducted with the DON on 08/23/13, at 4:30 PM, the ADON should have updated Resident #13's comprehensive plan of care after every fall the resident sustained [REDACTED]. 5. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed on 02/21/13 at 5:55 PM, Resident #12 was found on the floor of his/her room and was assessed to have had no injury. An IPOC meeting was held on 02/25/13 and review of the IPOC Worksheet revealed under the summary section: Resident was found sitting on the floor on his/her buttocks in front of the bedside commode (BSC). Further review of the IPOC Worksheet revealed the resident stated he/she had gotten up from the BSC and was going to bed. He/She complained of right knee pain and stated it always hurt. It further revealed urine was noted under resident; he/she had a history of [REDACTED]. Continued review of the IPOC Worksheet revealed a recommendation was made for a Physical Therapy (PT)/Occupational Therapy (OT) screening and to place a mat on the floor. However, review of the Resident 12's Comprehensive Care Plan revealed no documented evidence of revisions made after this fall to prevent further falls. On 04/25/13 at 4:10 PM, Resident #12 was found in the floor following a non-injury fall. The resident related that she was putting clothes in her closet and fell . It was recommended to Resident #12 to call for assistance. However, there was no revision made to Resident #12's care plan after this fall. On 05/30/13 at 11:00 AM, Resident #12 slid out of tub chair into the tub, with no injury. Review of the resident's plan of care revealed no changes in interventions to prevent further falls. On 06/18/13 at 3:00 AM, the resident was observed sitting on the floor beside her bed. Resident stated the floor was slick and urine was noted on the floor and the resident was wearing house shoes with a slick bottom. However, there was no documented evidences of revisions made to the care plan at that time. An interview with the MDS coordinator on 08/28/13 at 12 noon revealed that on 04/25/13, measures were taken to encourage the resident to call for assistance; however, the care plan was not up-dated to encourage to call for assistance. The Nursing Care Plan should have been up-dated. An interview with the Director of Nursing on 08/28/13 at 11:15 AM revealed that Resident #12 had always been independent with toileting and transfer. The resident's Care Plan was not changed or revised on 02/21/13, 04/25/13, 05/30/13, and 06/18/13. The IPOC said to encourage resident to call for assistance and it should have been on the resident's Care Plan. 6. Review of the clinical record for Resident #16, revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The facility compl

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system to ensure residents received adequate supervision and assistive devices to prevent falls for five (5) of fifteen (15) sampled residents (Residents #1, #4, #11, #12, and #13). The facility failed to have an effective system in place to thoroughly identify the root cause of falls in order to identify interventions to prevent further accidents for these residents. On 04/12/13, Resident #1 fell and sustained a cervical neck fracture. Record review revealed Resident #1 had a history of [REDACTED]. Record review and interview revealed the facility failed to identify the root cause of the falls and there were no changes in interventions implemented to prevent further falls for Resident #1 per facility policy and procedures. Resident #4 sustained a fall on 03/14/13, with no injury sustained by the resident. On 03/21/13, Resident #4 sustained a fall which resulted in three (3) skin tears. Resident #4 sustained a fall on 04/04/13, and sustained no injury. Resident #4 experienced two (2) falls on 04/09/13 which resulted in abrasions to the right upper back and a small "scratch" to the left upper back and a laceration to the back of the head. Additionally on 04/11/13, Resident #4 fell three (3) times and sustained a small laceration to the back of his/her head and a scrape to his/her left back. Resident #4 sustained a fall on 04/26/13, and had no injury. Resident #4 also experienced a fall on 05/09/13, which resulted in Resident #4 sustaining two (2) skin tears to the back and a skin tear reopened on the left arm. Residents #11, #12, and #13 also experienced falls between November 2012 and July 23, 2013 with no injury. The facility failed to identify the root cause of the falls and there were no changes in interventions implemented to prevent further falls for these residents per facility policy and procedures. In addition, the facility failed to ensure the facility's hot water system was maintained at a temperature to ensure water temperatures in resident care areas did not exceed State regulatory requirements based on 902 KAR 20:310-16(5)(g) and per facility policy, on one (1) of two (2) resident units. The facility also failed to monitor water temperatures in residents' individual rooms on two (2) of two (2) resident units. The facility's failure to ensure each resident received adequate supervision and assistive devices to prevent falls, failure to have an effective system in place to identify causal factors of falls in order to put effective interventions in place to prevent avoidable accidents, and failure to thoroughly implement the facility's Falls Policy to ensure the policy was effective in the prevention of avoidable accidents placed Resident #1 and the other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 08/23/13 and determined to exist on 04/12/13. Immediate Jeopardy was identified at Quality of Care, F-323 at a Scope and Severity of a "K". An acceptable Credible Allegation of Compliance, related to the Immediate Jeopardy, was received on 08/30/13. On 08/30/13, the Immediate Jeopardy was verified removed on 08/30/13 as alleged prior to exit. However, non-compliance continued to exist at Quality of Care, F-323 at a Scope and Severity of a "E", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained effective systems to ensure residents remain free from avoidable accidents, the facility effectively implements their policy. The findings include: Review of the facility's policy regarding Falls, undated, revealed the facility was to provide care and an environment that would allow every resident to be free from falls or injury to the best of the facility's ability. The facility was to ensure each resident received adequate supervision and assistive devices to prevent accidents. If a resident experienced a fall, an Incident Report was to be completed and a causative factor analysis conducted to aid in identifying contributing factors. According to the policy, the Incident Report was to be reviewed by the Interdisciplinary Plan of Care (IPOC) team following any incident. The facility was to implement immediate changes in the care plan, if assessment indicated the need. The Director of Nursing (DON) or designee was to follow up on the investigation, utilizing the IPOC team and therapy department for input. The facility used a three part fall investigation process the facility referred to as the Incident Report form, a Causative Factor Analysis Form, and a Fall Management-Immediate Interventions form. In addition to the fall investigation forms, the facility also used an Incident Log Form on which the Interdisciplinary Plan of Care (IPOC) Committee documented information on each resident's individual fall. The facility also utilized a form titled IPOC (Interdisciplinary Plan of Care) Worksheet which was used by the IPOC Committee to summarize follow up of falls and incidents. 1. Review of the Incident Log dated, 04/12/13 at 1:00 AM, revealed Resident #1 was found lying on the floor behind the door in his/her room with a laceration to the head, and a bruise to the left eye. Continued review of the Incident Log revealed the resident was sent to the emergency room (ER). Record review revealed no documented evidence of an Interdisciplinary Plan of Care (IPOC) Worksheet. Review of a Fall Investigation for Resident #1 for a fall sustained on 04/12/13 revealed no documented evidence of the completion of the Incident Report form or the Falls Management-Immediate Interventions Form. Continued review of the Fall Investigation forms revealed a Causative Factor Analysis Report for 04/12/13 at 1:00 AM, which provided no documented evidence of the cause of the injury. Continued review of the Causative Factor Analysis Report form revealed under the "alarms attached" section the Nurse had checked N/A (not applicable); and under the "what exactly was the resident doing prior to the event" section the nurse noted "sitting in bed". Further review of the Fall Investigation revealed it did not address the root cause of the resident's fall. Record review revealed no documented evidence in the Nurse's Notes, regarding the details of Resident #1's fall on 04/12/13. Review of a Nurse's Note dated 04/12/13 at 1:20 AM, revealed Resident #1 was transferred to the ER was complaining of pain and was transferred to the ER. Review of a Hospital Discharge Summary form revealed Resident #1 was diagnosed with [REDACTED]. Continued review of the Discharge Summary revealed Resident #1 was discharged from the hospital on [DATE] with orders to wear a Miami J collar (neck collar) at all times. Review of the Nurse's Note, dated 04/15/13 revealed Resident #1 was now to have a sensor alarm and clip alarm and was to have every fifteen (15) minute monitoring of the resident was initiated. However, record review revealed no evidence the 15 minute checks were completed. Review of the Comprehensive Care Plan revealed on 04/17/13 it was reviewed and revisions were put in place. Resident #1 was to have assistance of two (2) verses the one (1) person assistance he/she required prior to the fall. Resident #1 was to have a low bed with a fall mat on the floor; and pressure and personal alarm at all times. Record review revealed Resident #1 sustained another fall on 05/18/13 at 4:05 PM. Review of the facility's three (3) part Fall Investigation forms revealed an Incident Report, dated 05/18/13 at 4:05 PM. Review of the Causative Factor Analysis Form, identified sensor and clip alarms were in place; however, there was no documented evidence the root cause of the fall was identified. Continued review of the Falls Investigation forms revealed no documented evidence of the Falls Management-Immediate Interventions Form. Further review of the Fall Investigation revealed no new interventions were addressed in order to to prevent recurrence of falls. Review of the Incident Log, dated 05/18/13 at 4:05 PM, revealed Resident #1 was found on the mat beside the bed. Continued review of the Log revealed Resident #1 sustained no injury and the alarms were sounding. Record review revealed no documented evidence of an IPOC Worksheet to indicate the IPOC Committee had investigated the fall, addressed if interventions in place were effective, and whether new interventions were required. Review of Resident #1's medical record revealed the facility admitted the resident on 02/21/06, with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 07/17/12, the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired. Review of the Fall Assessments dated 12/13/12, and 03/09/13 revealed the facility assessed Resident #1 to be a high risk for falls. Review of the Comprehensive Care Plan dated 08/03/12, revealed Resident #1 was at risk for falls related to a history of falls, a [DIAGNOSES REDACTED]. Review of the Nursing Assistant Care Plans for 11/2012 revealed Resident #1 was on Extreme Fall Risk Precautions. Review of the Significant Change MDS assessment, dated 04/28/13, revealed the facility assessed the resident to be severely cognitively impaired the facility assessed Resident #1 to require limited assistance of one (1) staff person for transfers. Further review revealed the facility assessed Resident #1 to require extensive assistance of two (2) staff for transfers. Review of the Fall Assessments dated 04/15/13 revealed the facility continued to assess Resident #1 as a high risk for falls. Record review revealed Resident #1 had a history of [REDACTED]. Review of the facility's three (3) part Fall Investigation forms revealed an Incident Report dated 11/05/12 at 6:25 AM in which it noted Resident #1 was complaining of left shoulder pain; under the "injuries noted" section there was no documented evidence of an injury. Continued review of the Incident Report revealed the Director of Nursing (DON) or her designee documented it appeared Resident #1 rolled out of bed. Review of the Fall Management-Immediate Intervention form dated, 11/05/12, revealed Resident #1 was assessed for injury, assisted to bed, the Physician was notified, and the resident was noted to have had left shoulder x-rays. Further review of the form revealed no documented evidence of new interventions to be added to prevent further falls. Review of the Causative Factor Analysis form dated, 11/05/12 revealed Resident #1 had been wearing non-skid slippers; and under the "alarm attached" section N/A (not applicable) was checked. However, further review of the Causation Factor Analysis form revealed no documented evidence it addressed the root cause of the resident's fall. Review of the the Interdisciplinary Plan of Care (IPOC) Work Sheet dated 11/06/12 revealed Resident #1 had a perimeter defined mattress (pdm) in place; his/her legs "were rolled up" with the blanket and had to be untangled to get Resident #1 up off the floor. Continued review of the IPOC Work Sheet form revealed Resident #1 was noted to lay or sit on the side of his/her bed and lean over to "get into" his/her bedside table or overbed table. Further review revealed Resident #1 was placed on Physical Therapy's (PT's) caseload. Review of the Incident Log, dated 11/05/12, revealed Resident #1 was to be placed on PT caseload. Review of the Nurse's Note, dated 11/05/12 at 9:25 AM, revealed an x-ray of the left shoulder was completed. Continued review of the Nurse's Notes revealed no documented evidence of the results of the shoulder x-ray. Review of a Nurse's Note, dated 11/05/12 at 10:00 AM, revealed the resident was complaining of shoulder pain. Review of a Nurse's Note, dated 11/05/12 at 1:40 PM, revealed Resident #1 was "yelling" out in pain; had left shoulder edema (swelling); the left shoulder was noted to be uneven; the left hand had edema and the resident could not move the fingers. Record review revealed a Physician Telephone Order dated 11/05/12 at 4:15 PM, to transfer Resident #1 to the emergency room (ER), post fall, for increased pain of the left shoulder. Review of the hospital's shoulder x-ray, completed on 11/05/12 at 5:53 PM, revealed an acute fracture of the distal clavicle (collar bone). Review of Resident 1's Comprehensive Care Plan revealed a care plan for Falls which was noted to have been reviewed on 11/05/12; however, there was no documented evidence of implementation of interventions to prevent recurrence of falls. Interview, on 08/23/13 at 3:15 PM, with the Administrator revealed on 11/05/12 Resident #1 had been toileted at 6:00 AM, so toileting was not a factor in the fall. She stated the IPOC Committee would have looked at Resident #1's blood sugars as these were "very unstable". The Administrator stated Resident #1 had placed a pillow under the perimeter defined mattress which made the mattress "wibbly wobbly" and he/she "just rolled right out" of the bed. The Administrator indicated Dycem (a non-slip mat which grips items in place, preventing any movement) was placed under Resident #1's mattress. However, she was unable to provide documented evidence this was performed. Continued interview with the Administrator revealed Resident #1 had a history of [REDACTED]. She stated the IPOC Committee did not identify a need for "anything else" other than the PT referral. Review of the facility's three (3) part fall investigation forms revealed an Incident Report, dated 12/04/12 at 9:45 AM. Review of this Incident Report revealed Resident #1 had experienced an unassisted fall with no injury. Further review of the Incident Report revealed the Director of Nursing (DON) noted Resident #1's fingerstick blood sugar (fsbs) was decreased to 75 mg (milligrams)/dl (deciliter); the resident was given a protein to increase the fsbs and assisted up to the wheelchair. Review of the Causative Factor Analysis revealed Resident #1's blood sugar level was low; however did not reflect the reason the blood sugar was low. Review of the Immediate Intervention Form, dated 12/04/12, revealed the facility would evaluate a change in Resident #1's insulin. Record review revealed no documented evidence the facility evaluated Resident #1's insulin for a possible change. Review of the Incident Log indicated Resident #1 had transferred from the bed and fell trying to get into his/her wheelchair. Further review of the Incident Log intervention section revealed Resident #1's fingerstick blood sugar (fsbs) was 75 mg (milligrams)/dl (deciliter); however, there was no documented evidence a change in insulin was to be performed. Review of the IPOC Worksheet dated 12/06/12, revealed no documented evidence the IPOC Committee assessed Resident #1 for a change in his/her insulin related to the low fsbs. Review of Resident #1's Comprehensive Care Plan revealed no documented evidence it was revised to include evaluating Resident #1's insulin for a possible change. Further review revealed the Falls Care Plan was reviewed on 12/06/12; however, there was no documented evidence of implementation of additional interventions to prevent further falls from occurring. Interview, on 08/23/13 at 3:15 PM, with the Administrator revealed all three (3) parts of the Fall Investigation forms were completed. She stated the Falls Management-Immediate Intervention form indicated to evaluate Resident #1's insulin for a change related to his/her low fsbs. The Administrator indicated the cause of this fall was the resident's low fsbs. According to the Administrator, Resident #1 had been eating a pimento cheese sandwich prior to the fall. She stated staff performed an immediate intervention of giving Resident #1 a carbohydrate and protein. The Administrator stated staff contacted the Physician and "kept an eye" on Resident #1. She stated, after reviewing the Director of Nursing's (DON's) documentation on the Incident Log, there was no indication the DON performed any further follow-up to ensure Resident #1's insulin was evaluated for a possible change. The Administrator stated the IPOC Committee reviewed Resident #1's Comprehensive Care Plan for interventions already in place and made no changes. Review of the facility's three (3) part Investigation report for Resident #1 revealed an Incident Report, dated 12/07/12 at 4:30 PM. Review of the Incident Report form revealed Resident #1's fsbs was 262 mg/dl; however there was no indication of what the resident was doing at the time of the fall. Review of the the Fall Management-Immediate Interventions form, dated 12/07/12, revealed interventions to be put in place were, to keep frequently used items in reach, increase monitoring of the resident, and place Resident #1's bedside commode (BSC) closer to the bed. Review of the Causative Factor Analysis form revealed Resident #1 was assessed for injuries, assisted up, a fsbs was "retaken" and the Physician was notified. Review of the Incident Log, dated 12/08/12 at 4:30 PM, revealed Resident #1 was transferring self from the bedside commode (BSC) to the wheelchair. Further review of the Incident Log revealed under the "interventions" section staff were to check for placement of the BSC and were to re-assess Resident #1 for the use of alarms. Review of the summary on the IPOC Worksheet, dated 12/10/12, revealed the fall as occurring on 12/08/12 versus 12/07/12. Review of the IPOC Worksheet revealed no documented evidence of the cause of the fall on the worksheet. Further review revealed the IPOC Committee indicated staff were to check Resident #1's BSC for placement and the resident was to be re-assessed for the use of alarms. Review of Resident #1's Comprehensive Care Plan revealed no documented evidence it was revised to include the immediate interventions indicated on the Fall Management-Immediate Intervention form or of the IPOC Committee's recommendations. Review of the Nurse's Notes revealed the fall occurred, on 12/08/12 at 4:30 PM, even though the Fall Investigation forms indicated the fall occurred on 12/07/12. The Nurse's Notes indicated no injuries were sustained and Resident #1 was found sitting on his/her bare behind on the floor beside the BSC. Review of a Personal Alarm/Safety Assessment Form, dated 12/10/12 revealed Resident #1 could not comprehend danger and had a history of [REDACTED].#1 would have no alarms at that time related to the resident having a history of disconnecting alarms. Review of the fall investigation for Resident #1, dated 12/10/12 at 11:00 PM, revealed Resident #1 sustained an unassisted fall with no injury. Review of the Incident Report form dated 12/10/12 revealed Resident #1 the DON or designee had documented the resident had experienced "some changes"; the Physician had been at the facility at 6:30 AM and ordered Resident #1 "sent to ER". Further review of the Incident Report form revealed Resident #1 was admitted to the hospital with [REDACTED]. Review of the Causative Factor Analysis form revealed Resident #1 was assessed for injuries; however, there was no documented evidence a root cause was identified for the fall. Review of the Fall Management-Immediate Interventions form, undated revealed interventions included a bedside commode, perimeter defined mattress, and the resident's bed against the wall. Review of the Incident Log revealed the resident was noted with some changes and the Physician was there at 6:30 AM and sent Resident #1 to emergency room (ER) which resulted in admission to the hospital. The falls investigation did not investigate the root cause of the fall or put interventions in place to prevent future falls. An interview, on 08/22/13 at 4:00 PM, with Resident #1's family member, (FM) revealed Resident #1 needed assistance with transfers, was unable to use the call light unless cued, was unstable on his/her feet, and would get up independently. The staff had reported to the FM that Resident #1 would get up independently and look through drawers for picture albums and jewelry. The FM stated there were no alarms in place and no falls mats in place before the fall in April 2013 when the Resident broke her neck. The FM commented the family had asked the facility to move the Resident closer to the Nurse's Station so that he/she could be monitored more closely. The FM was told there were no rooms available closer to the nurses desk. Interview, on 08/22/13 at 5:50 PM, with Certified Nursing Assistant (CNA) #9 revealed she had been a Restorative Aide with the facility since February 2011 and was very familiar with caring for Resident #1. CNA #9 revealed Resident #1 was in Restorative Care in April 2013 and still was. CNA #9 revealed it was not safe for the Resident to walk in his/her room independently or transfer self. CNA #9 revealed Resident #1 would get up without putting on the call light. CNA #9 revealed the Resident did not always understand how to us the call light and would get up independently. CNA #9 was uncertain if Resident #1 had falls mats or alarms in place before her falls when he/she fractured her collar bone in November 2011 and fractured her neck in April 2013. Interview with the DON, on 08/23/13 at 2:05 PM, revealed the ADON/MDS Coordinator should have updated Resident #1's comprehensive care plan after every fall the resident sustained [REDACTED]. The DON stated the IPOC Committee had not been determining the root cause of the falls and was not implementing interventions to be put in place to prevent future falls. The DON revealed she was responsible to see that the root cause of an incident was determined and that interventions were put in place on residents' care plans. The DON revealed she had only been in the DON position since 04/29/13, was a DON in training, and was only responsible for what occurred after she took the position. 2. A review of the medical record for Resident #4 revealed the resident was admitted by the facility on 01/22/13, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessments completed on 01/29/13, 06/30/13, and 07/25/13 all revealed the facility assessed the resident to be severely cognitively impaired. A review of fall risk assessments completed by the facility on 01/22/13, 03/15/13, and 06/30/13, all revealed the resident had been assessed by the facility to be at high risk for falls. Review of a fall investigation for Resident #4 dated 03/14/13 at 3:40 PM, revealed Resident #4 had fallen while attempting to use the bedside commode. Review of the nurses notes for Resident #4 dated 03/14/13 at 3:40 AM, revealed the resident had not sustained any injury. Review of the Immediate Intervention Form dated 03/14/13, revealed non-skid strips on the floor, and a walker to be placed in the resident's room by therapy had been added as interventions. Review of the incident log dated 03/14/13 at 3:30 PM, therapy to leave a walker to assist with transfers was added as an intervention. Review of the comprehensive plan of care for Resident #4 revealed a walker to aid with transfers was added as an intervention. However, the fall investigation did not address the root cause of the resident's fall. Review of a fall investigation for Resident #4 dated 03/21/13 at 4:15 AM, revealed the Resident #4 fell while attempting to use the bedside commode, and according to nurses notes for Resident #4 dated 03/21/13 at 5:20 AM, the resident sustained [REDACTED]. No measurements of the skin tears were documented in the nurses notes or the fall investigation. Review of the Immediate Intervention Form dated 03/21/13 revealed education and instruction for the resident and a walker had been added as interventions. Review of the incident log dated 03/21/13 at 4:15 AM, revealed education would be provided for the resident and since the resident had reached a plateau with therapy the resident would begin to receive restorative nursing services for safety had been added as interventions. However, the fall investigation did not address the root cause of the resident's fall. Review of the comprehensive plan of care for Resident #4 revealed the care plan had not been updated to reflect any change in interventions related to the fall. Review of a fall investigation for Resident #4 dated 04/04/13 at 11:00 AM, revealed the Resident #4 fell while attempting to use the bedside commode, and according to nurses notes for Resident #4 dated 04/04/13 at 11:00 AM, the resident sustained [REDACTED]. Review of the Immediate Intervention Form dated 04/04/13 revealed ensure clothing does not contribute to falls, and non-skid socks had been added as an interventions. Review of the incident log dated 04/04/13 at 11:00 AM, revealed non-skid socks, and to encourage the resident to call for assistance were added as interventions. Review of the comprehensive plan of care for Resident #4 revealed the interventions had been added as interventions. However, the fall investigation did not address the root cause of the resident's fall. Review of a fall investigation for Resident #4 dated 04/09/13, at 7:40 AM, revealed Resident #4 fell attempting to use the bedside commode. Review of the nurses notes for Resident #4 dated 04/09/13 at 7:40 AM, revealed the resident sustained [REDACTED]. No measurements were documented in the nurses notes or the fall investigation. Review of the Immediate Intervention Form dated 04/09/13, revealed ensure clothing does not contribute to falls, and access use of assistive devices had been added as interventions. Review of the incident log dated 04/09/13, revealed the resident would be educated about using the walker, and encourage to call for assistance were added as interventions. However, the fall investigation did not address the root cause of the resident's fall. Review of the comprehensive plan of care for Resident #4 revealed the care plan had not been updated to reflect the fall. Review of a fall investigation for Resident #4 dated 04/09/13, at 11:00 AM, revealed Resident #4 fell attempting to use the bedside commode and according to nurses notes for Resident #4 dated 04/09/13, at 11:00 AM, the resident sustained [REDACTED]. No measurements were documented in the nurses notes or the fall investigation. Review of the Immediate Intervention Form dated 04/09/13, revealed ensure clothing does not contribute to falls, move bedside commode and walker closer to the bed, had been added as an interventions. Review of the incident log dated 04/09/13 at 11:00 AM, revealed the resident would be placed on the toileting log, and the bedside commode would be moved, had been added as interventions. However, the fall investigation did not address the root cause of the resident's fall. Review of the comprehensive plan of care for Resident #4 revealed no interventions had been added to the care plan to reflect the fall. Review of a fall investigation for Resident #4 dated 04/11/13 at 3:15 AM, revealed Resident #4 fell attempting to use the bedside commode and according to nurses notes for Resident #4 dated 04/11/13, at 3:15 AM, the resident sustained [REDACTED]. No measurements were documented in the nurses notes or the fall investigation. Review of the Immediate Intervention Form dated 04/11/13, revealed remove clutter and obstacles, keep frequently used items in reach, increased monitoring, ensure clothing does not contribute to falls, and access use of assistive devices had been added as interventions. Review of the incident log dated 04/11/13, at 3:15 AM, revealed call light within the resident's reach, and physical therapy orders were obtained were added as interventions. However, the fall investigation did not address the root cause of the resident's fall. A review of the comprehensive plan of care for Resident #4 revealed a urinal to be placed within the resident's reach had been added as an intervention. Review of a fall investigation for Resident #4 dated 04/11/13, at 11:15 AM, revealed Resident #4 fell attempting to use the bedside commode and review of the nurses notes for Resident #4 revealed the resident sustained [REDACTED]. Review of the Immediate Intervention Form dated 04/11/13, revealed placing the oxygen concentrator at the head of the resident's bed had been added as an intervention. Review of the incident log dated 04/11/13, also revealed the oxygen concentrator would be placed at the head of the resident's bed, had been added as an intervention. Review of the comprehensive plan of care for Resident #4 revealed an intervention dated 04/12/13 for the oxygen concentrator to be placed at the head of the resident's bed to decrease the risk of the resident becoming tangled in the oxygen tubing had been added as an intervention. However, the fall investigation did not address the root cause of the resident's fall. Review of a fall investigation for Resident #4 dated 04/11/12 at 11:00 PM, revealed Resident #4 fell attempting to use the bedside commode and according to nurses notes for Resident #4 dated 04/11/13 at 11:00 PM, the resident sustained [REDACTED]. No measurements were documented in the nurses notes or the fall investigation. Review of the Immediate Intervention Form dated 04/11/13, revealed a urinal, and moving the resident's bed against the wall had been added as interventions. Review of the incident log revealed the urinal to be placed at the resident's bedside, remove the bedside commode from the resident's room, and to encourage the resident to use the urinal were added as interventions. Review of the comprehensive plan of care for Resident #4 revealed the interventions had been placed on the care plan. However, the fall investigation did not address the root cause of the resident's fall. Review of a fall investigation for Resident #4 dated 04/26/13 at 12:30 AM, revealed Resident #4 fell by sliding out of the bed and sustained no injury. Review of the Immediate Intervention Form dated 04/26/13, revealed moving the resident's bed against the wall, and adding a drawsheet to the resident's bed had been added as interventions. Review of the incident log dated 04/26/13 at 12:30 AM, revealed adding a drawsheet to the resident's bed had been added as an intervention. A review of the comprehensive plan of care for Resident #4 revealed on 04/30/13, the facility added a drawsheet to the resident's care plan as an intervention. However, the fall investigation did not address the root cause of the resident's fall. Review of a fall investigation for Resident #4 dated 05/09/13, at 12:10 AM, revealed Resident #4 fell attempting to get out of bed and according to nurses notes dated 05/09/13 at 12:10 AM, the resident sustained [REDACTED]. No measurements were documented in the nurses notes or the fall investigation. Review of the Immediate Intervention Form dated 05/09/13, revealed assess for functional status changes, and increased monitoring when the resident was in bed, had been added as interventions. Review of the incident log dated 05/09/13 at 12:10 AM, revealed float boots would be removed from the resident's feet was added as an intervention. However, the fall investigation did not address the root cause of the resident's fall. A review of the comprehens

Based on interview, record review, and facility policy review it was determined the facility's Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility's Administration failed to have oversight in the overall safe environment in order to evaluate the facility's "Falls Policy" to ensure the policy was effective for prevention of avoidable accidents. On 04/12/13, Resident #1 experienced a fall which resulted in a cervical [MEDICAL CONDITION]. Resident #1 had a history of [REDACTED]. Review of the investigations of Resident #1's falls revealed the facility's Administration failed to ensure thorough investigations were conducted for falls to identify the causative factors. Additionally, the facility's Administration failed to ensure care plans were revised to include interventions to avoid further falls and failed to ensure follow up to the investigations by the Director of Nursing (DON) as indicated in the facility's policy. The facility's failure to have an effective Administration, with oversight to ensure an overall safe environment, in order to evaluate the facility's "Falls Policy" to ensure the policy was effective in the prevention of avoidable accidents placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified at 42 CFR 483.20, Resident Assessment, F-280; 42 CFR 483.25, Quality of Care, F-323; 42 CFR 483.75, Administration F-490 and F-520 all at a Scope and Severity of a "K". An acceptable Credible Allegation of Compliance, related to the Immediate Jeopardy, was received on 08/30/13. On 08/30/13, the Immediate Jeopardy was verified removed on 08/30/13 as alleged. However, non-compliance continued to exist at 42 CFR 483.20 Resident Assessment; 42 CFR 483.25, Quality of Care, F-323; and 42 CFR 483.75, Administration, F-490 and F-520 all with a Scope and Severity of an "E", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained effective systems to ensure residents remain free from avoidable accidents, the facility effectively implements their policy, and Administration oversight is provided. The findings include: Review of the facility's policy, "Falls Policy", undated, revealed the facility was to provide care and an environment that will allow every resident to be free from falls or injury to the best of the facility's ability. The policy stated the facility was to ensure each resident received adequate supervision and assistive devices to prevent accidents. The policy indicated if a resident experienced a fall, an Incident Report was to be filled out and a causative factor analysis was to be conducted to aid in identifying contributing factors. According to the policy, the Incident Report was to be reviewed by the Interdisciplinary Plan of Care (IPOC) team following an incident and the facility was to implement immediate changes in the care plan, if assessment indicated the need. The policy stated the Director of Nursing (DON) or designee was to follow up on the investigation, utilizing the IPOC team and Therapy Department for input. The facility failed to implement its written policy to provide adequate supervision and assistive devices to prevent accidents for five (5) of fifteen (15) sampled residents (Residents #1, #4, #11, #12 and #13) who experienced multiple falls between November 2012 and August 20, 2013. On 04/12/13, Resident #1 experienced a fall which resulted in a cervical [MEDICAL CONDITION]. Record review revealed Resident #1 had a history of [REDACTED]. Review of investigations into Resident #1's, #4's, #11's, #12's, and #13's falls revealed the facility's Administration failed to conduct thorough investigations into the falls and failed to thoroughly identify causative factors. Additionally, the facility's Administration failed to ensure care plans were revised to include interventions to avoid further falls and failed to ensure follow up to the investigation by the Director of Nursing (DON) as indicated in facility policy. (Refer to F-280 and F-323) Interview, on 08/23/13 at 3:15 PM, with the Administrator revealed she was aware of Resident #1's fall on 11/05/12 at 6:25 AM, during which the resident fractured his/her clavicle, and the fall had been discussed in the Interdisciplinary Plan of Care (IPOC) team meeting. The Administrator stated Resident #1 had placed a pillow under his/her mattress and "just rolled right out" of the bed. She stated she was "pretty certain" Dycem (a non-slip mat used to grip items in place, and prevent any movement) had been placed under Resident #1's mattress. However, she was unable to provide documented evidence this was implemented and review of the resident's care plan revealed Dycem was not added as an intervention. The Administrator indicated she was also aware of the falls Resident #1 experienced in December 2012. She stated on 12/04/12, Resident #1 experienced a fall when his/her fingerstick blood sugar (fsbs) was 75 milligrams (mg) per deciliter (dl). The Administrator stated the IPOC team determined Resident #1's insulin needed to be evaluated after this fall; however, she was unable to provide documented evidence Resident #1's insulin was evaluated after this fall, per the IPOC team recommendations. In regards to the 12/07/12 fall, the Administrator stated Resident #1 had fallen while transferring from the bedside commode (BSC). She stated the IPOC team determined staff needed to check the placement of the BSC and the resident was to be re-assessed for the use of alarms. However, review of a Personal Alarm/Safety Assessment Form revealed an assessment for alarms was not performed until 12/10/12, three (3) days later, and after the resident had sustained another fall on 12/10/12. Further interview, on 08/23/13 at 3:15 PM, with the Administrator revealed she attended the IPOC meetings Monday through Friday where falls were reviewed and discussed. If a resident experienced a fall an Incident Report was filled out and a "check off" list was also completed. She stated a Causative Factor Analysis form was completed at that time. The Administrator stated the fall was reviewed in the IPOC team meeting the next day unless it happened on a weekend in which case it would be reviewed on the following Monday. Per interview, the Administrator revealed all three forms of the three part investigation form (Incident Report Form, Causative Factor Analysis Form, and Fall Management-Immediated Interventions Form) were completed and stapled together after being reviewed in the IPOC team meeting. However, in regards to Residents #1's, #4's, #11's, #12's and #13's falls, the Administrator was unable to provide documented evidence the three part investigation form was completed for all falls, as per interview. There was no documented evidence of a thorough investigation into the falls to identify causal factors, and ensure revisions to the Comprehensive Care Plans to prevent avoidable accidents as indicated in the facility's "Fall Policy". Interview, on 08/30/13 at 9:05 AM, with the Director of Nursing (DON) revealed she had only been employed by the facility since 04/29/13. She stated she had not performed follow up to the fall investigations since becoming DON. According to the DON, she had not monitored to ensure interventions, discussed in the IPOC team meetings, were placed on residents' Comprehensive Care Plans and Nurse Aide Care Plans and implemented. Additionally, during the 08/23/13 at 3:15 PM interview, the Administrator revealed she was unable to provide documented evidence of the former DON's follow up to fall investigations as per facility policy. The facility provided an acceptable credible Allegation of Compliance (AoC) on 08/30/13 that alleged removal of the Immediate Jeopardy (IJ) on 08/30/13, based on the following: 1. Resident #1's Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Plan were reviewed to ensure no revisions were needed. 2. Nineteen (19) residents who had experienced a fall in the past sixty (60) days had a new Fall Log completed by the Interdisciplinary Management team to assist with tracking and trending patterns and issues with their individual falls. Out of those residents reviewed, ten (10) care plans were revised based on the review and causal factors identified for the residents. Using the Fall Log and Fall Assessment information, the Interdisciplinary Management team completed the review and revision of the care plan and CNA Care Plan for the residents who had fallen in the past sixty (60) days, to determine these reflect the fall management interventions indicated by the residents' fall risk assessments, facility Fall Log and Nurse Consultant suggestions for fall management interventions. These items were completed 08/27/13. 3. A new Fall Scene Investigation form was implemented to assist the facility in identifying and addressing causative factors of residents' falls. The form was to be completed by the Fall Team staff with each resident fall, to assist in determining the appropriate immediate interventions for the identified causative factor. The Fall Team members would include the Charge Nurse, the CNA, Housekeeper, and/or Laundry personnel for the resident who had fallen. The Charge Nurse was to complete and sign the Fall Team Investigation Report upon completion of the form. All resident falls were to be reviewed by the Interdisciplinary Management team Monday through Friday with residents' Comprehensive Care Plan and CNA Care Plan updated as needed. The Weekend Registered Nurse (RN) Supervisor was to review all incidents including falls within twenty-four (24) hours when the Interdisciplinary Management team was not present, to determine that all indicated interventions were in place and to ensure additional interventions were added if indicated. 4. A new event follow up form was to be completed after all Incident/Fall investigations to assist the Interdisciplinary Management team in reviewing and monitoring the effectiveness of fall management interventions after a fall. Documentation on the form would note if the interventions were successful, and if any modifications or new/additional interventions were indicated. 5. The Fall Team staff, licensed nurses, Housekeepers, and Laundry personnel were inserviced by the DON and Staff Development on the comprehensive investigation of all falls utilizing the Fall Scene Investigation form, and the immediate implementation of the interventions indicated by the investigation, and the need to implement alternative interventions when those first attempted were unsuccessful. These inservices were conducted 08/26-29/13. Facility staff who were unable to attend these inservices by 08/30/13 (due to vacations, medical leave, etc.) were to complete the inservice prior to being allowed to work their next shift. These staff would not be placed on the work schedule until completion of the inservice. 6. A meeting of the facility's Continuous Quality Improvement (CQI) committee which included the Medical Director was held on 08/30/13 to review the Allegation of Compliance, the new forms and procedures. 7. The CQI indicator for the monitoring of compliance with the facility fall management policies and procedures was to be utilized monthly times two (2) months and then quarterly as per the established CQI calendar under the supervision of the DON. 8. The Nurse Consultant was to review fall investigations, and the associated interventions with each quarterly visit. 9. The CQI indicator for the monitoring of the CQI program effectiveness was to be utilized monthly times three (3) months, then quarterly thereafter under the supervision of the Administrator. On 08/30/13, the State Survey Agency verified the immediacy of the Immediate Jeopardy was removed and the facility implemented corrective actions as alleged in the AoC, effective 08/30/13 based on the following: 1. Review of the Interdisciplinary Management meeting notes dated 08/27/13 revealed Resident #1's Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Plan were reviewed to ensure no revisions were needed. 2. Additional review revealed nineteen (19) residents who had experienced a fall in the past sixty (60) days had a new Fall Log completed by the Interdisciplinary Management team. Review revealed ten (10) residents' care plans were revised based on the Interdisciplinary Management team's review. 3. Review of the facility's new "Falls Procedure" revealed the Charge Nurse was to complete a Fall Scene Investigation form to assist the facility in identifying and addressing causative factors of residents' falls. Review revealed the Fall Scene Investigation was included in the "Fall Procedure" packet. Continued review of the "Fall Procedure" revealed the staff member either witnessing or discovering a resident's fall was to notify the Charge Nurse who would page the Fall Team to the location of the fall. The Charge Nurse would assess the resident for injuries and the Fall Team would assess the environment and resident for causative factors of the fall. The Charge Nurse was to complete the Incident Report, Fall Scene Investigation Report form, and implement any needed interventions and adjust the care plan accordingly. The Charge Nurse was to notify the Director of Nursing (DON), Administrator, Physician, and Responsible Party of the fall. The resident was to be assessed every shift for seventy-two (72) hours. 4. Further review revealed the Incident Report and interventions were to be evaluated for effectiveness within twenty-four (24) hours by the Interdisciplinary Management team or the Registered Nurse (RN) Supervisor and any additional interventions were to be implemented. The Fall Team members would include on day shift the Charge Nurse, the Certified Nursing Assistant (CNA), and Housekeeper; on evening shift the Fall Team was to include the Charge Nurse, CNA, and Laundry personnel; on night shift the Fall Team was to include the Charge Nurse and CNA. Review revealed a new Event Report-Witness Statement Form was to be completed if an employee witnessed a fall. 5. Review of inservice sheets revealed the following number of facility employees had been inserviced on the new Fall Procedures and forms: three (3) of the facility's four (4) RN's; sixteen (16) of the facility's seventeen (17) Licensed Practical Nurses (LPNs); twenty-one (21) of the facility's thirty-three (33) CNAs; five (5) of the facility's seven (7) Housekeepers; and two (2) of the facility's two (2) Laundry personnel were inserviced on the new fall procedures 08/27-29/13. Interviews were conducted on 08/30/13 with the following staff to verify the facility had educated them on the new Fall Procedures and to ensure their knowledge of the facility's new procedure and documents: Assistant Director of Nursing (ADON/Minimum Data Set (MDS) Coordinator at 2:55 PM; Weekend RN Supervisor #1, who worked the 6:00 AM to 2:00 PM shift, at 1:26 PM, and Weekend RN Supervisor #3, who worked the 10:00 PM to 6:00 AM shift, at 1:41 PM; LPN #3, who worked the 6:00 AM to 2:00 PM shift, at 1:19 PM; LPN #4, who worked the 6:00 AM to 2:00 PM shift, at 1:26 PM; LPN #2, who worked the 6:00 AM to 2:00 PM shift, at 2:15 PM; LPN #1, who worked the 10:00 PM to 6:00 AM shift, at 2:15 PM; LPN #11, who worked the 2:00 PM to 10:00 PM shift, at 2:38 PM; LPN #8, who worked the 2:00 PM to 10:00 PM shift, at 2:40 PM; LPN #5, who worked the 6:00 PM to 6:00 AM shift, at 2:42 PM; LPN #10, who worked the 2:00 PM to 10:00 PM shift, at 2:46 PM; CNA #9, who worked the 6:00 AM to 2:00 PM shift, at 1:10 PM; CNA #6, who worked the 6:00 AM to 2:00 PM shift, at 1:30 PM; CNA #8, who worked the 6:00 AM to 2:00 PM shift, at 1:45 PM; CNA #7, who worked the 6:00 AM to 2:00 PM shift, at 1:55 PM; CNA #4, who worked the 6:00 AM to 2:00 PM shift, at 2:00 PM; CNA #5, who worked the 6:00 AM to 2:00 PM shift, at 2:10 PM; CNA #3, who worked the 2:00 PM to 10:00 PM shift, at 2:20 PM; CNA #10, who worked the 2:00 PM to 10:00 PM shift, at 2:45 PM; CNA #18, who worked the 10:00 PM to 6:00 AM shift, at 3:06 PM; CNA #12, who worked the 2:00 PM to 10:00 PM shift, at 3:10 PM, and CNA #11, who worked the 2:00 PM to 10:00 PM shift, at 3:25 PM Housekeeper #1, who was working the 6:00 AM to 2:00 PM shift on 08/30/13, at 1:38 PM; and Laundry Personnel #1, who was working the 6:00 AM to 2:00 PM shift on 08/30/13, at 1:51 PM. All of the above staff were knowledgeable of the facility's new Falls Procedures, and Falls Team members and duties. All nursing staff interviewed were knowledgeable of the Fall Scene Investigation Report form and when to complete it. All staff verified they had received inservice education regarding these matters by the facility. Interview, on 08/30/13 at 3:10 PM, with the Administrator revealed most of the facility's staff had received inservice education on the new Fall Procedure/Policy, the Fall Scene Investigation Report form, the revision to the Incident Report form. According to the Administrator, any staff who had not received the inservice education would not be allowed to work until they had received it and would not be put on the schedule to work until they had received the education. 6. Interview, on 08/30/13 at 3:10 PM, with the Administrator revealed the Medical Director had been informed of the Immediate Jeopardy findings and had been updated on the facility's Allegation of Compliance on 08/30/13 during the CQI Committee meeting. She stated the CQI Committee members had discussed the new forms and procedures the facility had implemented. The Administrator indicated the facility would use the CQI indicator for the monitoring of compliance with the facility fall management policies and procedures monthly times two (2) months and then quarterly as per the established CQI calendar under the supervision of the DON. She stated the CQI indicator for the monitoring of the CQI program effectiveness was to be utilized monthly times three (3) months, then quarterly thereafter. The Administrator stated a Nurse Consultant would visit quarterly and review fall investigations, and the associated interventions. Interview, on 08/30/13 at 12:33 PM, with the Medical Director revealed the facility's CQI Committee, which he was a member of, had met that morning and discussed the facility's AoC plan and what interventions had been put in place to correct the Immediate Jeopardy. 7. Interview, on 08/30/13 at 3:10 PM, with the Director of Nursing (DON) revealed all falls for the past sixty (60) days had been reviewed and the care plans revised as necessary. The DON stated the Assistant Director of Nursing (ADON) would be responsible for updating Comprehensive Care Plans and CNA Care Plans during the Monday through Friday Interdisciplinary Management team meeting. She stated the Falls Policy had been revised and new Falls Teams had been implemented for each shift. The DON stated staff had been educated on the new policy, new forms, and Falls Teams duties. According to the DON, the CQI Committee had met that morning and the Medical Director had signed off on the facility's new policy, and new forms implemented by the facility. 8. Interview, on 08/30/13 at 3:10 PM, with the facility's Nurse Consultant revealed she or another Nurse Consultant would be making quarterly visits to the facility to monitor. She stated residents' Comprehensive Care Plans and CNA Care Plans are now being brought to the Monday through Friday Interdisciplinary Management Team meeting and updated as interventions are discussed. 9. The Nurse Consultant stated during the Interdisciplinary Management Team meeting a date would be set to review the revisions recommended by the team to ensure the new interventions were effective or see if additional interventions needed to be added. She indicated a Nurse Consultant would be coming to the facility on a quarterly basis to review falls and follow up performed, review the monthly CQI monitoring performed to ensure the AoC plan was followed. The facility remained out of compliance at a lower Scope and Severity of a "E", a pattern deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).

Based on interview, record review and review of the facility's policy, it was determined the facility's Quality Assurance Program failed to identify quality issues related to fall investigations, causal factor identification, and failed to develop and implement appropriate plans of action to correct identified quality deficiencies. On 04/12/13, Resident #1 experienced a fall which resulted in cervical neck fractures. Resident #1, who was assessed to be at high risk for falls, had a known history of falls. The resident had a fall on 11/05/12 which resulted in a fractured clavicle, and three (3) falls in 12/12. Residents #4, #11, #12 and #13 also experienced falls from 11/2012 to 08/2013. Review of the falls investigations for all these residents revealed the facility had not thoroughly investigated the falls. The facility provided no documented evidence that the causal factors were identified for all falls. In addition, the facility failed to ensure Comprehensive Care Plans were revised to include effective interventions to prevent further falls for these residents. The facility also failed to effectively implement their Falls Policy. Additionally, the facility could provide no documented evidence the Quality Assurance Program had identified quality issues related to falls, and had developed action plans to prevent recurrence of residents' falls. The facility's failure to identify quality issues related to fall investigations, causal factor identification, and failure to develop and implement appropriate plans of action to correct identified quality deficiencies placed Resident #1 and the other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified at 42 CFR 483.20, Resident Assessment, F-280; 42 CFR 483.25, Quality of Care, F-323; 42 CFR 483.75, Administration F-490 and F-520 all at a Scope and Severity of a "K". An acceptable Credible Allegation of Compliance, related to the Immediate Jeopardy, was received on 08/30/13. On 08/30/13, the Immediate Jeopardy was verified removed on 08/30/13 as alleged. However, non-compliance continued to exist at 42 CFR 483.20 Resident Assessment; 42 CFR 483.25, Quality of Care, F-233; and 42 CFR 483.75, Administration, F-490 and F-520 all with a Scope and Severity of a "E", as the facility had not completed the development and implementation of the Plan of Correction (PoC) to ensure the facility established and maintained effective systems to ensure residents remain free from avoidable accidents, the facility effectively implements their policy, and Administration oversight is provided. The findings include: Record review revealed on 04/12/13, Resident #1 experienced a fall which resulted in a cervical [MEDICAL CONDITION]. Review revealed Resident #1 had a history of [REDACTED]. Residents #4, #11, #12, and #13 also experienced falls from 11/2012 to 08/2013. Review of the falls investigations for all these residents revealed the facility had not thoroughly investigated the falls. The facility provided no documented evidence the causal factors were identified for all falls. Review of the facility's, "Falls Policy" undated, revealed the facility was to provide care and an environment that would allow every resident to be free from falls or injury to the best of the facility's ability and ensure each resident received adequate supervision and assistive devices to prevent accidents. The policy stated falls were to be tracked and results reviewed in the monthly Quality Assurance Committee meeting. Interview, on 08/30/13 at 9:05 AM, with the Director of Nursing (DON) revealed she had only been employed by the facility since 04/29/13. She stated she was a member of the monthly CQI (Continuous Quality Improvement) which was the facility's Quality Assurance. The DON indicated falls statistics were discussed in the monthly meetings; however, she didn't recall there being an issue identified with the facility's Fall Program. According to the DON, she thought the facility's system for falls was effective. The DON stated the facility had a "limited number of residents with falls" and felt the falls had been managed and measures put into place to "limit" falls. Interview, on 08/30/13 at 12:33 PM, with the Medical Director revealed he was a member of the facility's Continuous Quality Improvement (CQI) Committee which met monthly. He indicated the facility's Administration had discussed the fall's policy in the CQI Committee meeting before; however, he was unable to recall when that had taken place. Additionally, the Medical Director stated he was unable to recall the last time the facility's Administration had discussed the fall system during the CQI Committee monthly meeting. According to the Medical Director, in the monthly CQI Committee meeting the total number of falls was discussed, but the individual falls and procedures were not discussed in depth. Interview, on 08/23/13 at 3:15 PM, with the Administrator revealed falls information was taken to the monthly CQI committee meeting where the falls were "trended" quarterly. She stated the facility had "specific residents with multiple falls, not multiple residents with multiple falls". She stated falls would be tracked and trended; however, she was unable to provide documented evidence of this. Further interview, on 08/23/13 at 6:12 PM, with the Administrator revealed the Medical Records Clerk gathered all the falls information each month and broke the information down "per category". She stated this was the information taken to the monthly CQI committee meeting; however, there was no documented evidence of this as the discussion was not written down. She stated the CQI committee discussed patterns, trends, policies and procedures related to the falls system to see if it "worked" or if there was a failure. The Administrator indicated there had been no failure noted with the falls system. However, the Administrator was unable to provide documented evidence falls were being tracked and results were reviewed in the monthly Quality Assurance Committee meeting, per the facility's policy and procedure. The facility provided an acceptable credible Allegation of Compliance (AoC) on 08/30/13 that alleged removal of the Immediate Jeopardy (IJ) on 08/30/13, based on the following: 1. Resident #1's Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Plan were reviewed to ensure no revisions were needed. 2. Nineteen (19) residents who had experienced a fall in the past sixty (60) days had a new Fall Log completed by the Interdisciplinary Management team to assist with tracking and trending patterns and issues with their individual falls. Out of those residents reviewed, ten (10) care plans were revised based on the review and causal factors identified for the residents. Using the Fall Log and Fall Assessment information, the Interdisciplinary Management team completed the review and revision of the care plan and CNA Care Plan for the residents who had fallen in the past sixty (60) days, to determine these reflect the fall management interventions indicated by the residents' fall risk assessments, facility Fall Log and Nurse Consultant suggestions for fall management interventions. These items were completed 08/27/13. 3. A new Fall Scene Investigation form was implemented to assist the facility in identifying and addressing causative factors of residents' falls. The form was to be completed by the Fall Team staff with each resident fall, to assist in determining the appropriate immediate interventions for the identified causative factor. The Fall Team members would include the Charge Nurse, the CNA, Housekeeper, and/or Laundry personnel for the resident who had fallen. The Charge Nurse was to complete and sign the Fall Team Investigation Report upon completion of the form. All resident falls were to be reviewed by the Interdisciplinary Management team Monday through Friday with residents' Comprehensive Care Plan and CNA Care Plan updated as needed. The Weekend Registered Nurse (RN) Supervisor was to review all incidents including falls within twenty-four (24) hours when the Interdisciplinary Management team was not present, to determine that all indicated interventions were in place and to ensure additional interventions were added if indicated. 4. A new event follow up form was to be completed after all Incident/Fall investigations to assist the Interdisciplinary Management team in reviewing and monitoring the effectiveness of fall management interventions after a fall. Documentation on the form would note if the interventions were successful, and if any modifications or new/additional interventions were indicated. 5. The Fall Team staff, licensed nurses, Housekeepers, and Laundry personnel were inserviced by the DON and Staff Development on the comprehensive investigation of all falls utilizing the Fall Scene Investigation form, and the immediate implementation of the interventions indicated by the investigation, and the need to implement alternative interventions when those first attempted were unsuccessful. These inservices were conducted 08/26-29/13. Facility staff who were unable to attend these inservices by 08/30/13 (due to vacations, medical leave, etc.) were to complete the inservice prior to being allowed to work their next shift. These staff would not be placed on the work schedule until completion of the inservice. 6. A meeting of the facility's Continuous Quality Improvement (CQI) committee which included the Medical Director was held on 08/30/13 to review the Allegation of Compliance, the new forms and procedures. 7. The CQI indicator for the monitoring of compliance with the facility fall management policies and procedures was to be utilized monthly times two (2) months and then quarterly as per the established CQI calendar under the supervision of the DON. 8. The Nurse Consultant was to review fall investigations, and the associated interventions with each quarterly visit. 9. The CQI indicator for the monitoring of the CQI program effectiveness was to be utilized monthly times three (3) months, then quarterly thereafter under the supervision of the Administrator. On 08/30/13, the State Survey Agency verified the immediacy of the Immediate Jeopardy was removed and the facility implemented corrective actions as alleged in the AoC, effective 08/30/13 based on the following: 1. Review of the Interdisciplinary Management meeting notes dated 08/27/13 revealed Resident #1's Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Plan were reviewed to ensure no revisions were needed. 2. Additional review revealed nineteen (19) residents who had experienced a fall in the past sixty (60) days had a new Fall Log completed by the Interdisciplinary Management team. Review revealed ten (10) residents' care plans were revised based on the Interdisciplinary Management team's review. 3. Review of the facility's new "Falls Procedure" revealed the Charge Nurse was to complete a Fall Scene Investigation form to assist the facility in identifying and addressing causative factors of residents' falls. Review revealed the Fall Scene Investigation was included in the "Fall Procedure" packet. Continued review of the "Fall Procedure" revealed the staff member either witnessing or discovering a resident's fall was to notify the Charge Nurse who would page the Fall Team to the location of the fall. The Charge Nurse would assess the resident for injuries and the Fall Team would assess the environment and resident for causative factors of the fall. The Charge Nurse was to complete the Incident Report, Fall Scene Investigation Report form, and implement any needed interventions and adjust the care plan accordingly. The Charge Nurse was to notify the Director of Nursing (DON), Administrator, Physician, and Responsible Party of the fall. The resident was to be assessed every shift for seventy-two (72) hours. 4. Further review revealed the Incident Report and interventions were to be evaluated for effectiveness within twenty-four (24) hours by the Interdisciplinary Management team or the Registered Nurse (RN) Supervisor and any additional interventions were to be implemented. The Fall Team members would include on day shift the Charge Nurse, the Certified Nursing Assistant (CNA), and Housekeeper; on evening shift the Fall Team was to include the Charge Nurse, CNA, and Laundry personnel; on night shift the Fall Team was to include the Charge Nurse and CNA. Review revealed a new Event Report-Witness Statement Form was to be completed if an employee witnessed a fall. 5. Review of inservice sheets revealed the following number of facility employees had been inserviced on the new Fall Procedures and forms: three (3) of the facility's four (4) RN's; sixteen (16) of the facility's seventeen (17) Licensed Practical Nurses (LPNs); twenty-one (21) of the facility's thirty-three (33) CNAs; five (5) of the facility's seven (7) Housekeepers; and two (2) of the facility's two (2) Laundry personnel were inserviced on the new fall procedures 08/27-29/13. Interviews were conducted on 08/30/13 with the following staff to verify the facility had educated them on the new Fall Procedures and to ensure their knowledge of the facility's new procedure and documents: Assistant Director of Nursing (ADON/Minimum Data Set (MDS) Coordinator at 2:55 PM; Weekend RN Supervisor #1, who worked the 6:00 AM to 2:00 PM shift, at 1:26 PM, and Weekend RN Supervisor #3, who worked the 10:00 PM to 6:00 AM shift, at 1:41 PM; LPN #3, who worked the 6:00 AM to 2:00 PM shift, at 1:19 PM; LPN #4, who worked the 6:00 AM to 2:00 PM shift, at 1:26 PM; LPN #2, who worked the 6:00 AM to 2:00 PM shift, at 2:15 PM; LPN #1, who worked the 10:00 PM to 6:00 AM shift, at 2:15 PM; LPN #11, who worked the 2:00 PM to 10:00 PM shift, at 2:38 PM; LPN #8, who worked the 2:00 PM to 10:00 PM shift, at 2:40 PM; LPN #5, who worked the 6:00 PM to 6:00 AM shift, at 2:42 PM; LPN #10, who worked the 2:00 PM to 10:00 PM shift, at 2:46 PM; CNA #9, who worked the 6:00 AM to 2:00 PM shift, at 1:10 PM; CNA #6, who worked the 6:00 AM to 2:00 PM shift, at 1:30 PM; CNA #8, who worked the 6:00 AM to 2:00 PM shift, at 1:45 PM; CNA #7, who worked the 6:00 AM to 2:00 PM shift, at 1:55 PM; CNA #4, who worked the 6:00 AM to 2:00 PM shift, at 2:00 PM; CNA #5, who worked the 6:00 AM to 2:00 PM shift, at 2:10 PM; CNA #3, who worked the 2:00 PM to 10:00 PM shift, at 2:20 PM; CNA #10, who worked the 2:00 PM to 10:00 PM shift, at 2:45 PM; CNA #18, who worked the 10:00 PM to 6:00 AM shift, at 3:06 PM; CNA #12, who worked the 2:00 PM to 10:00 PM shift, at 3:10 PM, and CNA #11, who worked the 2:00 PM to 10:00 PM shift, at 3:25 PM Housekeeper #1, who was working the 6:00 AM to 2:00 PM shift on 08/30/13, at 1:38 PM; and Laundry Personnel #1, who was working the 6:00 AM to 2:00 PM shift on 08/30/13, at 1:51 PM. All of the above staff were knowledgeable of the facility's new Falls Procedures, and Falls Team members and duties. All nursing staff interviewed were knowledgeable of the Fall Scene Investigation Report form and when to complete it. All staff verified they had received inservice education regarding these matters by the facility. Interview, on 08/30/13 at 3:10 PM, with the Administrator revealed most of the facility's staff had received inservice education on the new Fall Procedure/Policy, the Fall Scene Investigation Report form, the revision to the Incident Report form. According to the Administrator, any staff who had not received the inservice education would not be allowed to work until they had received it and would not be put on the schedule to work until they had received the education. 6. Interview, on 08/30/13 at 3:10 PM, with the Administrator revealed the Medical Director had been informed of the Immediate Jeopardy findings and had been updated on the facility's Allegation of Compliance on 08/30/13 during the CQI Committee meeting. She stated the CQI Committee members had discussed the new forms and procedures the facility had implemented. The Administrator indicated the facility would use the CQI indicator for the monitoring of compliance with the facility fall management policies and procedures monthly times two (2) months and then quarterly as per the established CQI calendar under the supervision of the DON. She stated the CQI indicator for the monitoring of the CQI program effectiveness was to be utilized monthly times three (3) months, then quarterly thereafter. The Administrator stated a Nurse Consultant would visit quarterly and review fall investigations, and the associated interventions. Interview, on 08/30/13 at 12:33 PM, with the Medical Director revealed the facility's CQI Committee, which he was a member of, had met that morning and discussed the facility's AoC plan and what interventions had been put in place to correct the Immediate Jeopardy. 7. Interview, on 08/30/13 at 3:10 PM, with the Director of Nursing (DON) revealed all falls for the past sixty (60) days had been reviewed and the care plans revised as necessary. The DON stated the Assistant Director of Nursing (ADON) would be responsible for updating Comprehensive Care Plans and CNA Care Plans during the Monday through Friday Interdisciplinary Management team meeting. She stated the Falls Policy had been revised and new Falls Teams had been implemented for each shift. The DON stated staff had been educated on the new policy, new forms, and Falls Teams duties. According to the DON, the CQI Committee had met that morning and the Medical Director had signed off on the facility's new policy, and new forms implemented by the facility. 8. Interview, on 08/30/13 at 3:10 PM, with the facility's Nurse Consultant revealed she or another Nurse Consultant would be making quarterly visits to the facility to monitor. She stated residents' Comprehensive Care Plans and CNA Care Plans are now being brought to the Monday through Friday Interdisciplinary Management Team meeting and updated as interventions are discussed. 9. The Nurse Consultant stated during the Interdisciplinary Management Team meeting a date would be set to review the revisions recommended by the team to ensure the new interventions were effective or see if additional interventions needed to be added. She indicated a Nurse Consultant would be coming to the facility on a quarterly basis to review falls and follow up performed, review the monthly CQI monitoring performed to ensure the AoC plan was followed. The facility remained out of compliance at a lower Scope and Severity of a "E", a pattern deficiency with potential for more than minimal harm in order for the facility to develop and implement the Plan of Correction (PoC).