Every finding on record at Bruce Community Living Center

Based on interview and record review, the facility failed to ensure notification of the Long-Term Care Ombudsman for one (1) of two (2) residents reviewed for discharge. Resident #40. Findings Include: Review of typed Statement dated 02/19/26 on facility letterhead, revealed that (proper name) facility did not have a policy to notify the local or state ombudsman of discharges to home. Record review of Resident #40's Physician Orders revealed an order dated 11/25/25 to D/C (Discharge) home today with (proper name) Home Health. Record review of Resident #40's Progress Note dated 11/25/25 revealed Resident #40 was propelled in wheelchair to private auto and transferred out of wheelchair into private auto with maximum assistance of one. No new orders noted. discharged to home with (proper name) Home Health. Record review of the facility's Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman for November 2025 revealed that Resident #40 was not included on the list of transfers/discharges completed for the month. An interview on 02/19/26 at 8:30 AM with Social Services Director (SSD), revealed that Resident #40 was admitted to the facility from the hospital in November 2025 with stroke-like symptoms. She revealed that she received therapy services and they discharged her home with home health services. SSD revealed that she did not send a notification of the discharge to the Ombudsman and did not know it was a requirement. She stated that she would get this fixed and that going forward, she would do so on all future discharges and transfers. Record review of Resident #40's admission Record revealed an admission date of 11/10/25 with diagnoses that included Cystitis and Generalized Muscle Weakness.

Based on record review, staff interview, and facility policy review, the facility failed to notify the State Mental Health Authority of a change in mental health status for a resident with a diagnosed mental illness for one (1) of three (3) Pre-admission Screening and Resident Review (PASRR) records reviewed. Resident #2.Findings Include:Review of the facility policy titled Change in a Resident's Condition or Status latest review 08/2023 revealed under Policy Interpretation and Implementation.7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability .Record review of the admission Record revealed the facility admitted Resident #2 on 4/29/25 with medical diagnoses that included bipolar disorder.Record review of Resident #2's Psychotherapy Progress Note dated 10/22/25 revealed, At approximately 11:05 AM, LCSW (Licensed Clinical Social Worker) met with the patient in her room to assess mood and safety after nursing staff reported signs of emotional distress. The patient was tearful, visibly upset, and expressed active suicidal ideation with both plan and intent. She stated, 'If I could, I would kill myself. I've been trying to figure out how to get cyanide pills. I just want to go be with my husband. I don't want to be here anymore.'Record review of Resident #2's Progress Notes dated 10/22/25 revealed the resident was transferred to a behavioral health facility for inpatient psychiatric services related to suicidal ideation.An interview with Social Services #1 on 2/18/26 at 9:30 AM revealed she was responsible for submitting status change referrals to the State Mental Health Authority. SS #1 stated she submitted status changes when a resident received a new mental illness diagnosis, a new psychiatric medication, or a medication change. SS #1 confirmed she did not submit a status change for Resident #2. She acknowledged the resident experienced worsening psychiatric symptoms and required inpatient psychiatric hospitalization in October 2025, which indicated a need for a status change submission to ensure the resident received required specialized services.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact. Section I indicated a psychiatric diagnosis of bipolar disorder.

Based on observation, resident and staff interview, and record review, the facility failed to ensure a suprapubic catheter drainage system was maintained in a manner to promote proper drainage and prevent backflow of urine for one (1) of three (3) residents reviewed for catheters. Resident #12.Findings Include:Review of the education provided for skill competency catheter care titled Urinary Catheter Care dated 3/17/08 revealed, When providing care for the resident who has a catheter there are some important guidelines for the caregiver to know. The drainage bag must be kept below the level of the bladder to prevent the backflow of urine. This can cause infection .An observation and interview with Resident #12 on 2/17/26 at 10:18 AM revealed he was sitting in his wheelchair in his room with a urinary catheter drainage bag resting on the wheelchair seat beside him and not positioned below the level of the bladder. The resident stated the drainage bag would not remain attached to the lower part of the wheelchair and frequently fell off. The resident was later observed at 10:42 AM propelling himself in the hallway with the drainage bag remaining in the same improper position and no staff intervention to correct the placement.An additional observation on 2/18/26 at 7:55 AM revealed Resident #12 again sitting in his wheelchair with the urinary drainage bag lying in the wheelchair seat and not below the level of the bladder. The resident was later observed at 8:45 AM propelling himself down the hallway with the drainage bag in the same position and no staff intervention to ensure proper drainage bag positioning.An interview with Registered Nurse (RN) #1 on 2/18/26 at 9:06 AM confirmed Resident #12's catheter drainage bag was not being maintained in a manner to prevent backflow of urine. RN #1 stated this was the typical way the resident kept the drainage bag and acknowledged that backflow of urine could cause a urinary tract infection.An interview with the Director of Nursing on 2/18/26 at 3:20 PM revealed staff were responsible for monitoring Resident #12's catheter drainage bag and ensuring it remained below the level of the bladder to prevent the potential for urinary tract infections.Record review of the admission Record revealed Resident #12 was admitted on [DATE] with diagnoses including End Stage Renal Disease.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/4/26 revealed under section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, and documented the presence of an indwelling catheter under Section H.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure call lights and frequently used items were maintained within residents' reach for three (3) of four (4) residents observed (Residents #1, #2, and #3).Findings include: Review of the facility policy titled, “Call Light, Use Of,” last revised August 2014, revealed: “ .Procedure: When providing care to residents be sure to position the call light conveniently for the resident to use . Resident #1During an observation and interview with Resident #1 on 8/19/25 at 3:35 PM, she stated that on the evening of 6/23/25 her call light and phone were not within her reach. She explained that her call light was often on the floor and her phone was also on the floor, leaving her unable to call for assistance when she needed help. An observation revealed Resident #1’s call light lying on the floor under the bed, with no clip observed on the cord to keep it accessible. An observation of Resident #1’s room on 8/19/25 at 5:30 PM with Certified Nurse Assistant (CNA) #1 confirmed the call light was not in reach and was located on the floor under the bed. Review of the “admission Record” revealed Resident #1 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD ) of 6/26/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired. Resident #2An observation of Resident #2 on 8/19/25 at 3:32 PM revealed she needed to be changed. When asked if she called for someone to help her, she stated she could not reach her call light. She was observed attempting to reach the call light, which was attached to the top of the upper side rail, and not accessible. An observation of Resident #2 on 8/19/25 at 4:34 PM with CNA #2 confirmed the resident’s call light was not in reach. CNA #2 stated that concerns with call lights being out of reach include residents missing needed care. Review of the “admission Record” revealed Resident #2 was admitted on [DATE] with a diagnosis of bilateral primary osteoarthritis of first carpometacarpal joints. Review of the Quarterly MDS for Resident #2 dated 7/17/25, Section C, revealed a BIMS score of 12, indicating the resident was moderately cognitively impaired. Resident #3An observation of Resident #3 on 8/19/25 at 3:48 PM revealed the resident’s call light lying on his nightstand across the room. During an interview, he stated he could not reach his call light. He explained that if he needed it, he would either climb across the bed or get in his wheelchair and roll out to the hallway for help but stated “that was hard to do.” An observation of Resident #3 on 8/19/25 at 5:36 PM with CNA #1 confirmed the call light was across the room and out of the resident’s reach. She stated concerns included the resident being unable to call for help, attempting to get the call light and risking a fall, or having unmet needs. Review of the “admission Record” revealed Resident #3 was admitted on [DATE] with a diagnosis of cerebral infarction. Review of the Quarterly MDS for Resident #3 dated 6/24/25, Section C, revealed a BIMS score of 15, indicating the resident was cognitively intact. An interview with Licensed Practical Nurse (LPN) #2 on 8/19/25 at 5:37 PM revealed if a resident’s call light was not in reach and the resident experienced a medical emergency, they would not be able to call for help. An interview with the Administrator on 8/19/25 at 6:34 PM confirmed that frequently used items such as call lights and phones should always be within residents’ reach. She stated concerns with items being out of reach, included residents being unable to call staff if needed, potentially delaying care.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's expressed preference for care and provide services in a manner that maintained and promoted dignity. This failure resulted in Resident #1 not receiving care as requested, leaving her wet and uncomfortable, for one (1) of four (4) residents reviewed for dignity concerns (Resident #1).Findings include: Review of the facility policy titled, “Resident Rights,” last revised November 28, 2016, revealed: “(a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. … (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident’s individuality. … The facility must protect and promote the rights of the residents . An interview with Resident #1 on 8/19/25 at 3:35 PM revealed that on the night of 6/23/25, she requested that Certified Nurse Assistant (CNA) #1 clean her back with a washcloth. She stated CNA #1 refused and attempted to use cleansing wipes instead. Resident #1 stated she told CNA #1 to leave if she would not do it the way she asked. She further stated that Licensed Practical Nurse (LPN) #1 came into her room and told her that if she did not allow CNA #1 to change her, she would have to wait until staff were finished with other residents. An interview with CNA #1 on 8/19/25 at 5:23 PM she stated that the night of 6/23/25 Resident #1 asked her to clean her back with a warm wet washcloth, but what she had on hand was wet wipes. CNA #1 stated she did not think at the time of just going get a washcloth as the resident asked and confirmed there were washcloths on the linen cart. Review of a Resident Investigation Report Form related to Resident #1 revealed an Interview Summary dated 6/24/25 conducted by the Administrator. CNA #1 stated: “I went in to dry her, and while I had the resident turned over on her side, she asked me to rinse her back off with a washcloth because they had left soap on her during her bath that day. I explained to Resident #1 I had wipes with me, so I wiped her back with a wipe and then started to change her. Resident #1 stated, ‘Well, they did not get all the soap off of me.’ I told her again that I had cleansing wipes with me but did not have a washcloth at the time.” Further review of the same Resident Investigation Report Form revealed an Interview Summary dated 6/26/25 conducted by the Director of Nursing. LPN #1 stated CNA #1 reported Resident #1 was refusing care because she had been cleaned with wipes instead of a washcloth. LPN #1 stated she told the resident it was her right to refuse, but if she did not allow staff to finish, “she would have to lay there wet until the staff finished with the other residents, and that could be a while.” In an interview with the Administrator on 8/19/25 at 6:34 PM, she confirmed the incident was a dignity concern. She stated CNA #1 should have provided care using a washcloth as the resident requested. She acknowledged that failing to do so could have made the resident feel her voice was not heard. Record review of the “admission Record” revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Record review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 6/26/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired.

Based on staff interview, record review, and facility policy review, the facility failed to ensure allegations of abuse/neglect were reported to the State Agency within the required timeframe for one (1) of three (3) residents reviewed for reporting. (Resident #1) Findings include: Review of the facility policy titled, “Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Policy,” dated January 2019, revealed: “…7. Reporting/Response: …Immediately reporting all alleged violations to the …state agency, adult protective services and to all other required agencies within specified timeframes…” A phone interview with the Ombudsman on 8/19/25 at 10:00 AM revealed that she was at the facility on 6/24/25 when Resident #1 made allegations of verbal abuse and neglect involving a Certified Nurse Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1. The Ombudsman stated she immediately reported the allegations to the Administrator. She further stated that when she followed up with the Administrator on 7/8/25, she discovered the allegation had not been reported to the State Agency and subsequently reported it herself. During an interview with the Administrator on 8/19/25 at 4:39 PM, she confirmed the Ombudsman informed her on 6/24/25 of Resident #1’s allegations of verbal abuse and neglect. She acknowledged she did not notify the State Agency within the required timeframe and confirmed she should have. She stated the importance of reporting is that it is part of the investigation process and serves to keep residents safe. Review of the Investigation Report for Resident #1 revealed: “Date of Incident: 6/23/25. Date Incident Reported: 6/24/25 Ombudsman asked facility to investigate.” … Results reported to State Licensing Agency: 7/8/25. Review of the “admission Record” revealed Resident #1 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease.

Based on staff and resident interviews, record review, and facility policy review, the facility failed to consult with a cognitively intact resident about his Advance Directives, which resulted in a conflict between his documented preferences and his actual wishes for one (1) of sixteen (16) residents reviewed. Resident #6. Findings Included: Record review of the facility policy with reviewed date of ,d+[DATE] and titled, Advance Directives revealed The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so 5. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative An interview on [DATE] at 10:50 AM, with Resident #6 revealed that his brother signed the admission paperwork. He revealed that he didn't remember anyone discussing Cardiopulmonary Resuscitation (CPR) with him or asking him what his wishes were regarding resuscitation if he stopped breathing. Resident #6 confirmed that he did not know that his brother signed for him to be a DNR (Do Not Resuscitate). He confirmed that if he quit breathing, he wanted them to do CPR and everything they could to save him. An interview on [DATE] at 8:40 AM, with the Social Services Director (SSD) stated that Resident #6's representative signed the Code Status form marked DNR at the time of admission and confirmed that she did not discuss CPR options with Resident #6. The SSD revealed that Resident #6 was cognitively intact and should have been asked about his wishes. He should have made the choice and signed his own Advanced Directive. An interview on [DATE] at 8:45 AM, with the Administrator (ADM) confirmed that they were supposed to ask the residents about their code status choice and get them to sign if they were cognitively intact. She confirmed that Resident #6 was cognitively intact and capable of making his own decisions. ADM revealed that Resident #6 should have been asked about this choice and should have signed his own advanced directive on admission. Record review of Resident #6's Code Status form revealed that his representative initialed the Do Not Attempt Resuscitation choice and signed it on [DATE]. Record review of Resident #6's Physician Orders revealed an order effective [DATE] which revealed, Do Not Resuscitate in case of Arrest Record review of Resident #6's Admission Record revealed an admitted [DATE] with diagnoses that included Syncope and Collapse, End Stage Renal Disease, and Anemia. Record review of Resident #6's Care Plan revealed I am a DNR (Do Not Resuscitate) Record review of Resident #6's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated that he was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to provide written notification of discharge/transfer to the resident and/or resident representative (RR) upon transfer to the hospital for two (2) of two (2) residents reviewed for hospitalization . Resident #15 and Resident #30. Findings include: Review of the facility policy titled Notice of a Transfer and/or discharge date d February 26, 2003, revealed .3. The resident, and/or representative (sponsor) will be provided with the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged . Resident #15 Record review of Resident #15's Progress Notes dated 8/2/24 revealed the resident was transported to the emergency room accompanied by two facility staff members. Record review revealed there was no transfer/discharge notification for Resident #15's transfer to the emergency roiagnom on [DATE]. Record review of Resident #15's Admission Record revealed that he was admitted to the facility on [DATE] with diagnoses that included a Personal History of Traumatic Brain Injury, and Hydrocephalus. Resident #30 Record review of the Progress Notes for Resident #30 revealed on 8/6/24 that the resident was transferred to the emergency room . Record review revealed there was no transfer/discharge notification for Resident #30's transfer to the emergency roiagnom on [DATE]. On 10/29/24 at 11:37 AM, an interview with the Administrator (ADM) revealed that the facility failed to mail a written transfer/discharge notification to the Resident Representative (RR) for both Resident #15 and Resident #30 when they were transferred to the hospital. An interview on 10/29/24 at 3:00 PM, the Social Services Director (SSD) confirmed she was unaware that a copy of the transfer/discharge notification was supposed to be mailed to the Resident's RRs, but she would make sure to get them sent out from now on. Record review of the Admission Record revealed the facility admitted Resident #30 on 07/25/24 with medical diagnoses that included Aphasia and Metabolic Encephalopathy.

Based on observation, resident/family and staff interviews, record review, and facility policy review, the facility failed to provide care to maintain hygiene, as evidenced by the failure to provide shaving and nail care for two (2) of the 27 residents reviewed. Resident #3 and Resident #4. Findings include: Review of the facility policy titled Shaving the Resident, with a revised date of August 25, 2014, revealed, The purpose of this procedure is to promote cleanliness and to provide skin care. Review of the facility policy titled A.M. Care (Day Tour of Duty) dated August 25, 2014, revealed Purpose: 1. To refresh the resident. 2. To provide cleanliness, comfort, and neatness. Resident #3 An observation of Resident #3 on 10/28/24 at 10:50 AM, revealed sporadic facial hair approximately one-half (1/2) inch long to the chin and above the upper lip and sides of her mouth. Fingernails on bilateral hands were approximately one-fourth (1/4) inch long and jagged past the tips of her fingers with a brown substance under the fingernails. During an observation and interview on 10/28/24 at 3:35 PM, Resident #3 was lying in bed with no change in appearance. Resident #3's sister was present in the room and revealed that she was sure her sister would like to have those facial hairs removed. An interview and observation on 10/28/24 at 4:20 PM, with the Certified Nurse Aide (CNA) #2 revealed hospice bathes the resident three days a week and the facility CNAs are responsible for the other days. She confirmed the resident's facial hair should have been shaven and her nails cleaned. In an interview and observation on 10/28/24 at 4:30 PM, with Licensed Practical Nurse (LPN) #1 revealed we've talked to the hospice staff several times about ensuring Resident #3's facial hair is shaved when they bathe her. She confirmed that the resident had long facial hair and her fingernails were jagged with a brown substance under them. She revealed that she was unsure how long it had been since the resident's facial hair had been shaved and stated, The resident needs to be cleaned up. In an interview and observation on 10/28/24 at 4:40 PM, Registered Nurse (RN) #1 revealed we are all responsible for making sure the resident is properly groomed; even though she is on hospice services. She stated they are ultimately responsible for ensuring the resident's facial hair is shaved, and her fingernails are clean and trimmed. RN #1 confirmed Resident #3's facial hair needed to be shaved, and her fingernails needed to be cleaned and filed. Record review of Resident #3's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Osteoporosis with current pathological fracture, and Paroxysmal Atrial Fibrillation. 45598 Resident #4 An observation and interview on 10/28/24 at 10:45 AM, revealed Resident #4 lying in her bed with long, jagged fingernails, approximately one-half inch long past the fingertips bilaterally with brown substance underneath. Resident #4 also had two dime size patches of white curly hair on her left and right lower jaw area. She was pleasant and was fidgeting with her hair bonnet she held in her hands and when she was asked if she would like to have her facial hair removed, she stated, I think I would. An observation and interview with CNA #1 on 10/28/24 at 4:25 PM, revealed Resident #4 sitting up in her wheelchair across from the nurse's desk. CNA #1 confirmed that Resident #4 had long jagged fingernails with a brown substance underneath. CNA #1 also confirmed that Resident #4 had facial hair on both sides of her face that needed to be removed. CNA #1 revealed that it was the nurses' job to cut the fingernails, and the CNAs cleaned out from under the nails and took care of the facial hair. She revealed that Resident #4 was not assigned to her, but her nails should have been cleaned and her facial hair should have been removed during her bath or shower. CNA #1 revealed that long, jagged, dirty fingernails could cause infection if she scratched herself and stated, We can get that facial hair off. An interview on 10/28/24 at 4:35 PM with RN#1, confirmed that the nurses clipped resident fingernails, and the CNAs cleaned fingernails and shaved residents during their bath or shower time. RN #1 confirmed Resident #4 had long, jagged fingernails with a brown substance underneath and they should have been taken care of. She also confirmed the two patches of facial hair on both sides of Resident #4's face and agreed that this needed to be shaved. A phone interview with Resident #4's Resident Representative (RR) on 10/29/24 at 9:23 AM, revealed that he came to the facility and visited often. He revealed that the facility needed to do better about keeping her nails clipped. He also stated that he had noticed some facial hair and that she would want it to be removed. An interview on 10/29/24 at 10:20 AM, with the Director of Nursing (DON), revealed that seeing facial hair on ladies was one of her pet peeves and agreed that facial hair on ladies should be removed. She also confirmed that resident fingernails should be clipped and kept clean. Record review of Resident #4's Admission Record revealed an original admitted [DATE] and diagnoses that included Peripheral Vascular Disease and Muscle Weakness,. Record review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/10/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated that she had severe cognitive deficits. Section GG revealed that she required substantial to maximal assistance with her personal hygiene.

Based on observation, staff interviews, record review, and facility policy review the facility failed to implement a comprehensive care plan for residents who required assistance with Activities of Daily Living (ADL) for two (2) of thirteen sampled residents. Resident #3 and Resident #4. Findings include: Review of the facility policy titled Care Plan - Comprehensive undated, revealed, Policy Statement: It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .Procedure: 1. An interdisciplinary team, in coordination with the resident and his/her family or representative, develops and maintains a comprehensive care plan for each resident. Resident #3 A record review of Resident #3's care plan revealed, I have an ADL self-care performance deficit .Interventions/Tasks . Please shave when needed per my request . Check nail length and trim and clean on bath day and as necessary. On 10/28/24 at 10:50 AM, observation of Resident #3 revealed sporadic facial hair approximately one-half (1/2) inch long to the chin and above the upper lip and sides of her mouth. Fingernails on bilateral hands were approximately one-fourth (1/4) inch long and jagged past the tips of her fingers with a brown substance under the fingernails. On 10/28/24 at 4:40 PM, an interview and observation Registered Nurse (RN) #1 confirmed Resident #3's facial hair needed to be shaved, and her fingernails needed to be cleaned and filed. She confirmed the resident's ADL care plan was not being followed, and it should have been. In an interview on 10/29/24 at 10:10 AM, the Director of Nurses (DON) confirmed that Resident #3's ADL care plan was not being followed, and it should have been. During an interview on 10/30/24 at 11:46 AM, the Minimum Data Set (MDS) Coordinator revealed she and the team are responsible for developing the resident's individualized person-centered care plan. She revealed that when the residents were not being shaven and their nails cleaned and trimmed, then their ADL care plan was not being followed. She also revealed that everyone wants to look nice and neat, and the facility is responsible for ensuring this is being done. Record review of Resident #3's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Osteoporosis with current pathological fracture, and Paroxysmal Atrial fibrillation. 45598 Resident #4 Record review of Resident #4's Care Plan revealed that she had an ADL self-care performance deficit with interventions that included checking nail length and trim and clean on bath day and as necessary. On 10/28/24 at 10:45 AM, observation and interview revealed Resident #4 lying in bed with long, jagged fingernails approximately one-half inch long past the tips of her fingers bilaterally with a brown substance underneath. Resident #4 also had two dime size patches of white curly hair on her left and right lower jaw area. On 10/28/24 at 4:35 PM, observation and interview with RN #1 confirmed that Resident #4's fingernails were long and jagged with a brown substance underneath and that she had facial hair. RN #1 revealed that nail care, shaving and oral care were all included in personal hygiene provided in the Care Plan and confirmed that since it was not done, then they did not follow the care plan. Record review of Resident #4's Admission Record revealed an original admitted [DATE] and diagnoses that included Peripheral Vascular Disease and Muscle Weakness. Record review of Resident #4's MDS with Assessment Reference Date (ARD) of 10/10/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that she had severe cognitive deficits.

Based on staff interviews, record review, and facility policy review, the facility failed to have an informed consent for code status signed for two (2) of 16 sampled residents reviewed. Resident #3 and Resident #4 Findings include: Record review of facility policy titled, Advance Directives, dated ,d+[DATE], revealed, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. The policy also revealed, Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident or legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Resident #3 Record review of Resident #3's electronic Order Summary Report revealed an order dated [DATE] for DNR. Record review of Resident #3's handwritten Physician Orders dated [DATE], revealed an order for DNR. Record review of Resident #3's medical records revealed there was no signed consent by Resident #3 or Resident #3's Resident Representative that indicated the ordered DNR status was consented to. An interview with the Administrator on [DATE] at 8:15 AM, revealed the facility failed to have a signed code status or advance directive for Resident #3 to indicate the resident's or the resident representative's wishes for end-of-life care. She stated the facility had been in the process of developing a new form that would be consistent throughout the facility, but they realized several residents did not have a signed consent to indicate the resident's or the representative's wishes, only the electronic order and the signed physician order. She confirmed the residents' and the representatives' wishes needed to be honored and the code status needed to be discussed and verified by a signed consent to ensure proper care was given. An interview with the Social Services Coordinator on [DATE] at 3:05 PM, revealed she was responsible for having the advance directive and/or code status filled out on admission, as well as reviewing during each care plan meeting. She confirmed that Resident #3's code status form just slipped through the cracks, and therefore, it was not done. She confirmed the facility failed to have a consent signed to ensure the resident and family wishes were honored. Record review of Resident #3's Admission Record revealed the resident was originally admitted to the facility on [DATE] and the most recent admission was [DATE]. Resident #3's diagnoses included Chronic Obstructive Pulmonary Disease, Cognitive Communication Deficit, Hypertension, and Paroxysmal Atrial Fibrillation. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicated a Brief Interview for Mental Status (BIMS) of 0, which indicated the resident was severely cognitively impaired. 45598 Resident #4 Record review of Physician Orders documented order for Resident #4 dated [DATE] for DNR and signed by physician. Record review of Resident #4's Scanned Electronic Medical Records revealed that there was no signed consent for DNR (Do Not Resuscitate) status or Advanced Directive. An interview with the Administrator on [DATE] at 8:18 AM, revealed the facility failed to have a signed code status or advance directive for Resident #4 to indicate the resident's or the resident representative's wishes for end of life care. She stated the facility had been in the process of developing a new form that would be consistent throughout the facility, but they realized several residents did not have a signed consent to indicate the resident's or the representative's wishes, only the electronic order and the signed physician order. She confirmed the residents' and the representatives' wishes needed to be honored and the code status needed to be discussed and verified by a signed consent to ensure proper care was given. Record review of Resident #4's Admission Record documented admitted [DATE] with the following diagnoses to include: Peripheral Vascular Disease, Cognitive Communication Deficit, Gout, Benign Neoplasm of Unspecified Adrenal Gland, and History of Falling. Record review of the MDS with an ARD of [DATE] revealed Resident #4 had a BIMS score of 03 indicating the resident was severely cognitively impaired.

Based on staff interview, record review, and Resident Assessment Instrument (RAI) review, the facility failed to ensure that Minimum Data Set (MDS) was coded accurately for one (1) of 16 sampled residents. Resident #4. Findings Include: Record review of typed statement on company letterhead documented: The facility utilizes the MDS 3.0 Resident Assessment Instrument (RAI) Manual as the guide to complete the MDS. This document was signed by the Administrator but not dated. Record review of Resident Assessment Instrument (RAI) Version 3.0 Manual on page J-38 was documented under revealed, Coding Instructions for J1900C, Major Injury Code 0, none: if the resident had no major injurious fall since admission/entry or reentry or prior assessment Code 1, one: if the resident had one major injurious fall since admission/entry or reentry or prior assessment Record review of Resident #4's MDS with Assessment Reference Date (ARD) of 11/03/2023 Section J1900 question relating to number of falls since admission entry was answered 1 under B. Injury (except major). Under C. Major Injury, which included bone fractures was answered 0 which indicated that resident had no fall with a major injury. On 12/13/23 at 9:54 AM, an interview with Registered Nurse (RN) #1, revealed that Resident #4 had a fall on 09/17/23 and was sent out to the emergency room (ER) with fractured ribs. On 12/13/23 at 9:40 AM, an interview with MDS Coordinator revealed that she was aware of Resident #4's fall in September, and she was also aware the resident had a major injury from the fall. The MDS Coordinator revealed that she and the Administrator had discussed the fall with the injury. She revealed that when she did the MDS assessment in November, she mistakenly entered the fall as a fall with injury and not as a fall with a major injury. She stated that this was a mistake on her part when entering the information into the MDS system. She confirmed she would make a modification to ensure the entered information was accurate. On 12/13/23 at 9:42 AM, an interview with the Administrator (ADM) revealed she was aware of the fall with a major injury, and this was discussed with the MDS coordinator as well during the stand-up morning meetings. ADM confirmed the facility failed to accurately enter the information into the system and the information entered should be accurate since it reflects the resident's condition. Record review of Resident #4's After Visit Summary report from the hospital dated 09/18/2023 documented under Narrative .Impression: Minimally displaced left posterior ninth and 10th rib fractures. Record review of Resident #4's Admission Record documented admitted [DATE] with the following diagnoses to include: Peripheral Vascular Disease, Cognitive Communication Deficit, and History of Falling.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure that an as-needed (prn) [CONDITION(S)] drug was limited to14 days for one (1) of six (6) residents reviewed for [CONDITION(S)] medication use. Resident #9 A review of the facility policy titled [CONDITION(S)] Medications, dated 02/15/2018, revealed, PRN [CONDITION(S)] medications will have a 14-day period of administration time. If the prescribing MD/NP orders to continue the medication beyond 14 days, the MD/NP will document rationale and the duration for the medication in the clinical record. Record review of Resident #9's Order Summary Report for Order Date Range: 06/01/2022-08/31/2022 page 3, revealed an order for [MEDICATION(S)] Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for restlessness and anxiety. Order start date 06/13/2022, and no end date. Record review of Resident #9's Order Summary Report for Order Date Range: 06/01/2022-08/31/2022 page 3, revealed an order for [MEDICATION(S)] Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for restlessness and anxiety for 4 weeks. Start date 07/25/2022 and end date 08/22/2022. Record review of consultant pharmacist communication to the physician dated 06/29/22 revealed to continue therapy for 4 weeks then discontinue. No rationale by the physician was noted as to why the medication exceeded the 14 day duration. An interview on 09/22/22 at 12:12 PM with the Medical Records nurse confirmed that the PRN [CONDITION(S)] medication written on 06/13/22 did not have an end date. An interview on 09/22/22 at 12:37 PM with the Pharmacy consultant confirmed the PRN [CONDITION(S)] medication must be re-evaluated every 14 days unless the clinician determines that it is needed, and the physician must write a rationale to continue it beyond the 14 day requirement. He revealed that he gave the recommendation to either discontinue the [MEDICATION(S)] ([MEDICATION(S)]) or continue medication therapy and that he leaves the number of weeks or days blank for the Physician to fill in. He revealed that the pharmacy recommendation form dated 06/29/22 had a blank for the week or days to be specified by the Physician but that the physician filling out the form left that area blank. An interview on 09/21/22 at 10:15 AM, with the Director of Nurses (DON) revealed any resident that is on a [CONDITION(S)] as-needed (PRN) is supposed to be on the medication for fourteen (14) days and then re-evaluated by the physician to continue the medication. An interview on 09/22/22 at 12:48 PM with the DON confirmed the Consultant Pharmacist's communication to the Physician dated 06/29/22 with the recommendation to continue PRN [MEDICATION(S)] for four weeks does not have a rationale from the physician and there should be. An interview on 09/22/22 at 12:20 PM, with Resident #9's Attending physician revealed we try not to do any PRN [CONDITION(S)] medications and the order for the medication came from the hospice doctor, but I do co-sign everything. He revealed the resident, has been agitated ever since she came into the facility. She went on hospice a while back and all her medications were discontinued except for comfort medications from hospice. He confirmed the medication is supposed to be for 14 days and then the resident can be re-evaluated for further usage. He confirmed the PRN [MEDICATION(S)] did not have an end date on it when the order was written for hospice. He revealed that he told the DON today to make the [MEDICATION(S)] a scheduled medication because the resident is requiring it more. Record review of Resident #9's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included, Alzheimer's disease, dementia with behavioral disturbance, anxiety disorder, other specified depressive episodes, and brief psychotic disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of June 24, 2022, revealed Resident #9 is rarely/never understood indicating resident is Severely impaired.

Based on observation, staff interview, record review and facility policy review the facility failed to obtain a Physician order for [REDACTED]. Findings Include: Review of the facility's policy, Oxygen Administration, dated (MONTH) 25, 2014, revealed the purpose of this procedure is to provide guidelines for safe oxygen administration and under preparation to verify that there is a physician's order for the procedure. An observation on 11/08/2018 at 3:15 PM, revealed Resident #3 sitting in the chair in her room with oxygen by nasal cannula on at two (2) liters per minute. Review of Resident #3's Physician orders revealed no current oxygen orders. An interview with Resident #3 at 3:20 PM on 11/08/2018, confirmed that she used oxygen daily as needed. Review of Resident #3's Brief Interview for Mental Status (BIMS) score from the most recent Minimum Data Set (MDS), revealed a score of 15. A BIMS score of 13-15 means there is no cognitive impairment. In an interview on 11/8/18 at 3:40 PM, Licensed Practical Nurse (LPN) # 1 confirmed there was no current oxygen order for Resident #3. LPN #1 stated that Resident #3's oxygen had been discontinued when the resident went to the hospital and was not re-ordered upon hospital return. LPN #1 stated that Resident #3 used oxygen daily, as needed. In an interview on 11/8/18 at 3:50 PM, the Director of Nursing (DON) stated that when a resident goes to the hospital, the facility's process is for all orders to be discontinued and when the resident returns from the hospital, all new orders are written. The DON stated that orders are checked by Medical Records and a nurse for accuracy. An interview with the Administrator (Adm) on 11/08/2018 at 4:00 PM, confirmed that all new orders were to be checked by Medical Records and the MDS Coordinator for accuracy. The Adm. confirmed that in this case, the system had failed, and there was no order obtained for Resident #3's oxygen.

Based on observation, staff interview and facility policy review the facility failed to perform hand washing during medication administration in a manner to prevent the potential spread of infection for three (3) of five (5) opportunities during medication pass. This involved Residents in room N109, N110 and N111. Findings include: Review of the facility's Handwashing, policy, dated (MONTH) 1, 2000, revealed hand washing is the single most important means of preventing the spread of infections. The Policy noted: All personnel shall wash their hands to prevent the spread of infection and disease to other residents, personnel and visitors. Appropriate 10 to 15 second hand washing must be performed under the following conditions: d. Before preparing or handing medications. On 11/08/18 at 8:16 AM, an observation of medication pass, revealed Licensed Practical Nurse (LPN) #1 did not wash her hands or use a hand sanitizer before or while preparing the medication pass. During the preparation, LPN #1 opened and closed the trash container attached to the medication cart. LPN #1 was observed entering Room #N109, administered medications and returned to the medication cart, where she returned the eye drops to the cart and charted the medications. At 8:24 AM, LPN #1 began preparation of medication administration without washing her hands or using hand sanitizer. LPN #1 entered Room #N110 and administered medications without washing hands or using a hand sanitizer before assisting the resident with the medication administration. LPN #1 exited Room #N110 and returned to the medication cart and began the next medication preparation for the next resident, without cleaning her hands. At 8:35 AM, LPN #1 entered Room #N111 and administered the resident's medication without washing her hands or using a hand sanitizer. Observation of LPN #1 revealed she prepared and administered medication, charted, and discarded empty medication supplies into the trash container for three (3) different residents without washing her hands or using a hand sanitizer. On 11/08/18 at 3:17 PM, an interview with LPN #1 confirmed she did not wash her hands or use an antibacterial hand sanitizer before, during or after administering medications for three (3) different residents. LPN revealed she normally washed her hands before she starts the medication pass and then uses hand sanitizer between the next two (2) residents and then washes her hands the next time. LPN #1 revealed she had been in-serviced but stated it had been a while. LPN #1 confirmed by not washing her hands or using a hand sanitizer, between medication administration to residents, could result in a cross contamination and an infection. On 11/08/18 at 3:47 PM, an interview with the Director of Nursing (DON) confirmed that nurses should wash their hands or use hand sanitizer between residents when administering medications. The DON revealed the nurses have been in serviced and the Pharmacy consultant does observe nurses during medication administration. The DON confirmed that not washing hands or using the hand sanitizer between medication administration could be an infection control issue.

Based on observation, record review, staff interview and policy review the facility failed to ensure the licensed staff implemented infection control measures including: a. washing or sanitizing hands prior to providing care and between glove changes and b. not removing supplies from an isolation room and return the potentially contaminated supplies to the treatment cart. This affected Resident #1, one (1) of five (5) observations of infection control practices during care observations by facility staff. Findings include: A review of information from CDC (Center for Disease Control) documented the following information: Clostridium difficile also known as C.diff is a germ that can cause diarrhea. The elderly and people with certain medical problems have the greatest chance of getting C.diff. C.diff spores can live outside the human body for a very long time and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures and medical equipment. To prevent C.diff infections, doctors, nurses and other healthcare providers: clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. A review of the facility's policy titled Initiating Isolation Precautions, dated 06/01/2000, documented the following: It is the policy of this facility to initiate isolation precautions when there is reason to believe that a resident has an infectious or communicable disease. When isolation precautions are implemented the charge nurse on the section where isolation precautions are instituted shall: Place necessary equipment and supplies in the room that will be needed during isolation, make sure that an adequate supply of antiseptic soap and paper towels are maintained in the room during the isolation period. A review of the facility's policy titled Personal Protective Equipment-Gloves, dated 05/30/12, included the following documentation: Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Handwashing: Wash your hands after removing gloves. Employees must receive training relative to the use of gloves and other protective equipment prior to being assigned tasks that involve potential exposure to blood or body fluids. A review of the facility's policy titled Handwashing dated 06/01/2000, documented the following: It is the policy of this facility that hand washing to be regarded as the single most important means of preventing the spread of infections. All personnel shall wash hands to prevent the spread of infection and disease to other residents, personnel and visitors. Appropriated 10 to 15 second hand washing must be performed under the following conditions: before performing dressing care, after contact with residents on isolation. A review of Resident #1's physician's orders [REDACTED]. During an observation of wound care on 08/20/17 at 1:50 PM, Licensed Practical Nurse (LPN) #2 entered Resident #1's room with disposable gloves in her bare hands. The LPN placed the gloves and dressing supplies on the overbed table without cleaning the table, providing a barrier, or ensuring a clean field. The LPN obtained the gloves from the overbed table and donned gloves without washing or sanitizing her hands and proceeded to provide wound care for Resident #1. During the observation, the LPN changed gloves without washing or sanitizing her hands between glove changes. After completing the wound care, the LPN gathered the remaining supplies including a bottle of wound cleanser, multi-use package of 4 X 4's and [MEDICATION NAME] ointment from the overbed table and returned to the nursing station. An interview on 08/20/17 at 2:20 PM, revealed LPN #2 returned the dressing supplies from Resident #1's isolation room to the treatment cart at the nurses' station. The Director of Nursing (DON) was present and informed the LPN that the supplies would have to be discarded and the cart would have to be cleaned. The DON said placing items into the cart from an Isolation room was an infection control issue. An interview on 08/20/17 at 4:10 PM, with LPN #2, revealed the LPN was a part time employee, who usually worked on weekends and had not received any recent training on infection control from the facility. The LPN acknowledged placing dressing supplies on the overbed table in Resident #1's room without sanitizing the table, providing a barrier, or a clean field. The LPN also confirmed not washing her hands prior to providing a wound treatment for [REDACTED]. The LPN also acknowledged she did not wash her hands between gloves changes because there were no paper towels in the room. The LPN acknowledged she should have washed her hands between glove changes to prevent the spread of infection. The LPN also acknowledged that dedicated supplies/equipment should be used for residents in isolation to prevent the possible spread of infection. During an interview on 08/21/17 at 11:15 AM, the DON said the facility had been doing training with staff on infection control related to upcoming changes in infection control but had not included LPN #2, a part time staff. The DON said there was no record of providing in service on infection control or wound care to LPN #2 prior to 08/20/17. The DON said washing hands between glove changes is necessary to prevent the spread of infection. The DON also acknowledged that bringing items from an isolation room and returning them to the treatment cart is an infection control issue. The DON said there was a potential for contaminating the cart and supplies and spreading infection. The facility admitted Resident #1 on 04/24/17, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date of 07/24/17, identified the resident with severely impaired cognitive skills for daily decision making. Resident #1 required extensive to total dependence on staff for all Activities of Daily Living and incontinent of bowel and bladder. The MDS also identified the resident with a Stage III Pressure Ulcer.

Based on observation, record review, interview and policy review the facility failed to follow the plan of care to ensure Pressure Ulcer (PU) treatment was administered in a manner to prevent potential infection. This affected Resident #1, one (1) of nine (9) residents reviewed for following the plan of care. Findings include: A review of the facility's care plan policy, titled Goals and Objectives, dated 12/05/16, documented the following: It is the policy of this facility that care plans incorporate goals and objectives which lead to the resident's highest obtainable level of independence as determined by the interdisciplinary team and in accordance with resident's personal wishes and cultural preference. Goals and objectives are defined as the desired outcome for a specific focus. A review of the facility's policy titled Dressings, Dry/Clean included the following: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Review the resident's care plan, current orders, and [DIAGNOSES REDACTED]. A review of Resident #1's Care Plan revealed the following Focus Areas: 1. The resident has a stage 3 Pressure ulcer to the coccyx. Goals included The resident's pressure ulcer will remain free of infection. The target date documented 10/03/17. Interventions included Administer treatments as ordered. 2. The resident has C.Diff ([MEDICAL CONDITION]) and is on Contact Isolation. Goals included the resident will have no complications related to c.difficile. Target Date documented 10/31/17. Interventions included: Contact Isolation, disinfect all equipment used before it leaves the room. Educate staff regarding preventive measures to contain the infection. Use as much disposable equipment as possible or use dedicated equipment. A review of Resident #1's physician's orders [REDACTED]. Contact Isolation d/t (due to) positive culture for C.Diff. During an observation of wound care on 08/20/17 at 1:50 PM, Resident #1 was identified with a Stage III pressure ulcer on the coccyx. Licensed Practical Nurse (LPN) #2 was observed to provide wound care for Resident #1. During the observation, the LPN failed to establish a clean field prior to placing wound supplies on the overbed table and failed to wash or sanitize hands between glove changes. The LPN also removed potentially contaminated dressing supplies from Resident #1's room and returned the items to the treatment cart. During an interview with LPN #2 on 08/20/17 at 4:10 PM, the LPN acknowledged she did not provide wound care in a manner to prevent the potential spread of infection. The LPN acknowledged not ensuring a clean field for supplies, did not wash or sanitize hands between glove changes and removed potentially contaminated supplies from the resident's room to the treatment cart. The LPN said washing hands between glove changes and the use of dedicated equipment helps prevent the spread of infection. An interview on 08/21/17 at 2:55 PM with LPN #1, responsible for Completing Minimum Data Sets (MDS) and Care plans, revealed a care plan directs staff for patient care. The LPN said the care plan identifies goals and approaches for focus or problem areas. The LPN identified the focus for Resident #1 was the Stage III pressure wound and Isolation related to C.Diff. The LPN said the goal was to remain free of infection with contact isolation and standard precautions including washing hands between glove changes and dedicated equipment/supplies for the resident. The facility admitted Resident #1 on 04/24/17, with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date of 07/24/17, identified the resident with severely impaired cognitive skills for daily decision making. The resident required extensive to total dependence on staff for all Activities of Daily Living, and was incontinent of bowel and bladder. The MDS also identified the resident with a Stage III Pressure Ulcer.

Based on observation, record review, staff interview and policy review the facility failed to ensure the Licensed staff provided wound care to a Pressure Ulcer (PU) in a manner to promote healing and prevent potential infection. This affected Resident #1, one (1) of three (3) residents observed for wound care. Findings include: A review of the facility's policy titled Dressings, Dry/Clean, dated 08/25/14, included the following documentation: The purpose of this procedure is to provide guidelines for the application of dry, clean dressing. Equipment and Supplies: Clean Dressings, cleaning solution, tape, scissors, personal protective equipment as needed. Steps in the procedure: Clean bedside stand. Establish a clean field. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. Wash and dry hands thoroughly. Put on clean gloves. Remove soiled dressing. Wash and dry your hands thoroughly. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. Using clean technique, open other products. Wash and dry hands thoroughly. Put on clean gloves. Cleanse the wound, change gloves, apply the ordered dressing. Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Clean the bedside stand. Wash and dry your hands thoroughly. A review of the facility's policy titled Handwashing dated 06/01/2000, documented the following: It is the policy of this facility that hand washing to be regarded as the single most important means of preventing the spread of infections. All personnel shall wash hands to prevent the spread of infection and disease to other residents, personnel and visitors. Appropriate ten (10) to fifteen (15) second hand washing must be performed under the following conditions: before performing dressing care, after contact with residents on isolation. A review of Resident #1's physician's orders [REDACTED]. Clean with wound cleanser, pat dry, apply [MEDICATION NAME], Max orb and cover with Opti foam qd (every day.) Contact Isolation d/t (due/to) positive culture for [MEDICAL CONDITIONS]. During an observation of wound care, on 08/20/17 at 1:50 PM, the Registered Nurse (RN) #1 identified the area on Resident #1's coccyx as a healing Stage III pressure ulcer measuring 2.2 centimeters (cm) by 2.0 cm with a depth of 0.5 cm. Licensed Practical Nurse (LPN) #2 entered Resident #1's room with disposable gloves in her bare hand and treatment supplies, including wound cleanser, a multi-use package of 4 x 4 gauze sponges, ointment ([MEDICATION NAME]) a package of Max orb dressing, a package of Opti foam dressing and tape. The LPN placed the supplies, including loose gloves, on the overbed table without cleaning/sanitizing or placing a barrier to ensure a clean field. The LPN obtained gloves from the overbed table and donned gloves without washing or sanitizing hands. The LPN cleaned the PU with wound cleanser and 4 x 4 sponges, removed gloves and donned gloves from the overbed table without washing/sanitizing hands. The LPN used a gloved finger to apply ointment to the wound bed and changed gloves without washing or sanitizing hands. The LPN opened the package of [MEDICATION NAME] dressing and tore a corner of the dressing with gloved fingers to apply to the wound, stating that she forgot scissors to cut the dressing. The LPN opened the package of Opti foam dressing from the overbed table and covered the PU. The LPN removed gloves, picked up supplies from the overbed table, including wound cleanser, remaining package of 4 X 4 sponges and ointment and left the resident's room. An interview, on 08/20/17 at 4:10 PM, with LPN #2, revealed the LPN works part time on weekends The LPN acknowledged she had not received any current training on infection control or wound care from the facility until after the wound care observation on Resident #1. The LPN affirmed she did not sanitize the overbed table, provide a barrier or ensure a clean field for supplies. The LPN also acknowledged she did not wash hands between glove changes and used a gloved finger to apply ointment to Resident #1's wound bed. The LPN said a tongue blade or Qtip (applicator) should have been used because the glove could have had a hole. The LPN said washing hands between glove changes and dedicated equipment helps prevents spread of infection. During an interview, on 08/21/17 at 11:15 AM, the DON acknowledged that Resident #1 had a positive culture for[DIAGNOSES REDACTED], a toxin in the stool that produces infection and was on contact isolation. The DON said nurses should wash hands before putting on gloves and between glove changes to prevent potential spread of infection and/or infection to the wound. The DON said the LPN should have used a tongue blade or an applicator to apply ointment to the wound bed. The DON said the facility had been doing training with staff on infection control but failed to include part time staff. The DON said there was no record of providing in-service on infection control or wound care to LPN #2 prior to 08/20/17. The DON affirmed a skills competency on Dressing Change Clean Technique was not provided to LPN #2 until after the observation of wound care to Resident #1. The facility admitted Resident #1 on 04/24/17, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/17, identified Resident #1 with severely impaired cognitive skills for daily decision making. The resident required extensive to total dependence on staff for all Activities of Daily Living, incontinent of bowel and bladder. The MDS also identified the resident with a Stage III Pressure Ulcer.

Based on observation, resident record review, facility policy and staff interviews, the facility failed to ensure interventions detailed in the policy and procedure were implemented to prevent the potential spread of infection as evidenced by: the failure to have personal protective equipment (PPE) available for use for a resident identified as having MRSA (Methacillian Resistant Staphococus Areus). Secondly, the facility failed to ensure a sharps container was present in the room for disposal of used needles. This affected Resident Identifier (RI) # 5, one of one resident's identified with an active infection requiring contact precautions. Findings Include: RI# 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/11/2016, she was identified as having an infection that required the resident to be on contact isolation precautions. Review of the physician's orders [REDACTED].# 5 was ordered to be on Contact Isolation due to MRSA of the eye. The facility policy and procedure for Isolation documented, Standard Precautions: .Gloves- gloves should be worn weather exposure . is planned or anticipated .Sharps Precautions-safety engineered sharps should be used and used sharps should be placed in an appropriately labeled puncture resistant container . Contact Precautions: .E. After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. During the initial walk thru of the facility on 06/20/16 at 10:25 AM, the over the door storage for PPE's (gloves, gowns, mask and booties) revealed all boxes were empty and contained no supplies. The door was open and the housekeeper identified the person in the room as a family member. The family member was touching the resident while leaning over the bed. The Director of Nursing identified that the resident had MRSA in the eye and she verified that there were no PPE available on the over the door holder. At 11:40 AM the medication nurse was observed going into RI # 5's room with a syringe. She left the door open, put on gloves before going into the room, administered the shot, removed the gloves, washed her hands and walked out of the isolation room with a safety needle wrapped in a paper towel. When asked if there was a sharps container in the room she stated no, she revealed she was taking the needle to dispose of it, she disposed of it in the medication cart sharps container. A second interview was conducted with the Director of Nursing on 06/21/16 at 1:15 PM. During the interview she stated that PPE should include gowns, gloves, and shoe covers for RI # 5. She further revealed that a sharps container should have been in the room for needle disposal.

Based on observation, record review, staff interview and facility policy review, the facility failed to store and date insulin vials after opening for use for one (1) of one (1) medication carts. Findings Include: Review of the facility policy titled, Vials and Ampules of Injectable Medications, dated, 11/01/08 stated, The date opened and the initials of the first person to use the vial are recorded on the multidose vials or on the label. Observation on 06/20/16 at 11:25AM of the medication cart in the facility, it was observed to have five (5) vials of opened insulin with no open date on the bottles or boxes that contained the insulin. Two vials of Levemir 100u/ml Two vials of Novolog 70/30 One vial of Novolog 100u/ml Interview with Registered Nurse #3 confirmed that the vials of insulin are not dated and are opened and stated, I would discard these and I would open a new bottle of insulin and date it. Interview with the DON at 11:40AM on 06/20/16 stated that the nurses check the carts each time they use a medication and the pharmacist checks the medication cart one time a month when he is here, but we do not have one particular person who checks the medications on the cart. DON confirmed that all insulin should be dated and initialed when a vial is opened. Interview on 06/21/16 at 1:00PM with the Pharmacist confirmed that he has provided education to the nurses on the medication cart that they should date and initial vials of insulin after they have opened them.

Based on policy review, job description review, record review and interview with the facility Administrator, the facility's Administration failed to ensure that the facility used it's resources effectively to maintain the highest physical well being for five (5) of seven (7) residents reviewed as evidenced by the nursing staff's failure to follow the established facility policy for Neurological checks. The facility's nursing staff failed to perform neurological checks at the proper frequency/time frame. The practice of the facility not having an effective system to ensure that resources were used to monitor the implementation of the facility's established policy for neuro checks for five (5) of seven (7) residents, placed residents who required neurological checks due to signs/symptoms of head injury related to falls, in a situation that was likely to cause serious injury, impairment, harm, or death. This situation resulted in an Immediate Jeopardy (IJ) that began on 02/24/14, after Resident #1 fell and sustained a head injury which lead to an [MEDICAL CONDITION] and death. The State Survey Agency determined the Immediate Jeopardy was removed on 02/28/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (F-490), was lowered to an "E", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled "Administrator", dated June 1, 2000, revealed, "POLICY STATEMENT it is the policy of this facility that a licensed administrator be responsible for the day-to-day functions of this facility". "PROCEDURE: a. managing the day-to-day functions of this facility. d. Implementing established resident care policies, personnel policies, and other operational policies and procedures necessary to remain in compliance with required laws, regulations, and guidelines". Review of the facility's form entitled "Job Description & Orientation Checklist", signed and dated 5/1/12 by the Administrator, revealed "Supervisory Responsibilities: Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring and training employees". Interview with the Administrator on 02/26/14 at 2:30 PM, revealed the nurses were performing neuro checks based on a sticky note at the nurses station instead of the facility's established neuro check policy. According to the Administrator, the sticky note read "Neuro checks q (every) 15 X 4, q hour X 4, q 4 hour X 4, q 8 hours x 4". The Administrator revealed the handwritten note had been at the nurses station for years, and she was not aware of who wrote it. When asked about the nursing staff's knowledge and in-servicing regarding the facility's Neurological Policy the Administrator stated, "I don't know of an in-service on neuro checks in the last two (2) years since I've been Administrator". Review of the facility's established policy for Neurological Checks, dated April 18, 2011, revealed "Policy: It is the policy of this facility to conduct and document a Neurological checks when the resident's condition warrants" The "Purpose: To conduct a 5 point neurological check to identify gross neurological deficits in the event of a head, neck, or face injury, a suspected neurological event, or for unwitnessed, unexplained events involving an observed change in the resident's position (ex. Observed on the floor even if there is no injury obvious at the time of the event). " "Special Observations: Observe for and document any pertinent observations. (i.e. the presence of [MEDICAL CONDITION], vomiting, paralysis). TIMING of NEUROLOGICAL CHECKS: If the resident remains in the facility, neuro checks are to be done as follows until 72 hours are completed or as ordered by the physician. Every 15 minutes X 4 Every 30 minutes X 4 Every 1 hour X 4 Every 4 hours X 4 Every 8 hours X 3 "Documentation: Document findings on the Neurological Assessment Flow Sheet (located in the Forms and Guidelines Manual). The Neurological Assessment Flow Sheet may be placed in the (Medication Administration Record) MAR until completion, then it is placed in the active medical record. Document notification of the physician and the responsible party in the nurse's notes as needed". Interview with the Administrator at 8:50 AM on 02/27/14, revealed all the nursing policies were on the company's intranet. The Administrator confirmed there is not a signed approval form by Quality Assurance (QA) or the Medical Director for the policy approval. The Administrator explained there are no individual facility policies but company wide nursing policies. The Administrator went on to say that the company notifies the facility of any policy changes by email and nurses have a computer at the nurse's desk where they can access policies 24/7. Resident #1 Review of the facility's incident report, nurse notes, and neurological assessment flow sheet revealed Resident #1 had a fall with head injury on 02/24/14 and neuro checks were initiated but were not completed per policy. The facility's nursing staff failed to perform neurological checks at the proper frequency/time frame. Neuro checks were done every 15 minutes for 1 hour then hourly. Neuro checks were not completed at 30 minute intervals. Resident #2 Record review of the incident reports and the medical record revealed that Resident #2 experienced falls with documented neuro checks on 12/30/13, 01/04/14, 02/14/14 and 02/23/14. Review of the Neurological Assessment Flow Sheet revealed the neuro checks were not completed as required per facility policy for any of the falls. Resident #4 Record review of the incident reports and the medical record revealed that Resident #4 experienced falls with documented neuro checks on 11/27/13, 12/27/13, 01/17/14, and 01/31/14. Review of the Neurological Assessment Flow Sheet revealed the neuro checks were not completed per facility policy for any of the falls. Resident #5 Record review of incident reports and the medical record revealed Resident #5 experienced falls requiring neuro checks on 11/20/13, 11/26/13, 12/11/13, 12/31/13, 01/03/14, 01/26/14, 01/28/14 and 01/31/14. Review of the Neurological Assessment Flow Sheet revealed the neuro checks were not completed per facility policy for any of the falls. Resident #7 Review of the incident reports and the medical record revealed Resident #7 experienced falls requiring neuro checks on 11/19/13, 12/06/13, 12/09/13 and 01/22/14. Review of the Neurological Assessment Flow Sheet revealed the neuro checks were not completed per facility policy for any of the falls. The facility submitted an acceptable credible Allegation of Compliance on 2/28/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy : 1. On 02/24/14 at 1:00 PM the Director Of Nursing (DON) initiated in-services with the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the following policies: "Accidents and Incidents", "Falls", "Physician Notification of Change in Condition or Status", "[MEDICATION NAME] Therapy", "Care Plans" and "Charting and Documentation Guidelines". The in-service review of the Accidents and Incidents policy included that any incident involving a resident should be immediately reported to the physician and the responsible party. Documentation in the medical record should reflect that these actions have been carried out and should include the time and date of notifications by nursing staff. The in-service review of the Physician Notification of Change in Condition or Status included notifying the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. The in-service review of the Falls Policy included to initiate a fall assessment on admission, quarterly, with each fall and to update the fall Care Plan with an intervention after each fall. The in-service review of the [MEDICATION NAME] Therapy policy included that the DON must be notified as soon as possible for any resident who takes blood thinners and has a fall. The notification should be done immediately after initial treatment is provided to the resident. The in-service review of the Care Plan policy included that the Care Plan is to be updated with an intervention with each fall. The Care Plan should be followed as written. The in-service review of the Charting and Documentation Guidelines included that documentation in the medical record should include the date and time of the MD and the RP notifications with all incidents. The documentation should be concise, accurate and complete. 2. An investigation of Resident #1's incident was initiated on 02/24/14 at 3:20 PM by the Administrator and the DON. 3. On 2/24/14 at 4:10 PM, the Administrator and the DON met with LPN #1 which resulted in the termination of LPN #1 due to the falsification of Resident #1's medical record which falsely indicated the MD had been notified of the fall. 4. On 02/24/14 at 4:30 PM, the DON notified the MSDH (Mississippi State Department of Health) by voicemail. 5. On 02/25/14 at 12:00 PM, the DON notified the Mississippi Board of Nursing by telephone. 6. On 02/25/14 at 1:19 PM, the DON submitted a report to the Mississippi Attorney General Web Submission by email. 7. On 02/25/14 at 2:55 PM, the DON submitted the final report to the Mississippi Board of Nursing by fax. 8. On 02/25/14 at 3:37 PM, the DON submitted the final report to the Mississippi Attorney General Office by fax. 9. On 02/25/14 at 3:54 PM, the DON submitted the final report to the MSDH by fax. 10. To identify other residents that have the potential to be affected by the deficient practice, a 100% chart review of all residents was performed by the Medical Records Nurse and the MDS (Minimum Data Set) Nurse on 02/26/14. Those residents having had a fall with neurological checks since 11/1/13 were reviewed. The review revealed that 11 of 11 residents with falls requiring neurological checks did not have the neurological checks performed every 30 minutes x 4 as per the facility policy. 11. On 02/26/14 at 1:00 PM the DON in-serviced all RNs and LPNs on neurological checks . This in-service review of the Neurological Checks included that the neurological checks are to be performed every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 4 hours x 4 and every 8 hours x 3. The findings should be documented on the Neurological Assessment Flow Sheet by the nurse that performed the neurological check. 12. On 02/26/14 at 4:30 PM an emergency Quality Assurance meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topics discussed were the Accidents and Incidents, Neurological Checks, Falls, Physician Notification of Change in Condition or Status, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies. These policies were reviewed and action plans were put in place. 13. Beginning 02/27/14, at 9:00 AM, all falls resulting in neurological checks being performed will be reviewed 7 days a week by the DON, or designee, to ensure compliance with the facility policy for neurological checks. ? Incidents and documentation will be reviewed by the Quality Assurance/Performance Improvement Committee monthly. This committee will be responsible for any needed action to ensure the effectiveness of the monitoring process for residents who fall and require neurological checks. This committee will monitor the policies: Neurological Checks, Notification of MD Regarding Change in Condition or Status, Accidents and Incidents, Falls, [MEDICATION NAME] therapy, Care Plans, Charting and Documentation Guidelines and Abuse, Neglect and Misappropriation of Property to ensure they are being followed. 14. On 02/27/14 at 11:00 AM, an in-service was initiated by the DON for "Abuse and Neglect and Misappropriation of Property" to include all RNs, LPNs and Certified Nursing Assistants (CNAs), Housekeeping, Dietary and Maintenance. The in-service review of the Abuse, Neglect and Misappropriation of Property policy included the definitions of Abuse, Neglect and Misappropriation, examples of what constitute abuse and neglect and the consequences. 15. On 2/27/14 at 6:30 PM, an in-service was initiated by the Nurse Consultant for the Administrator and the Medical Director to review the duties of each role. The roles include oversight of the facility to ensure that the facility is in compliance with current rules, regulations, and guidelines, and to monitor the implementation of policy and procedures. **No staff will be allowed to work until attending required in-services. 16. On 2/27/14 at 10:45 AM a second emergency QA meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topic discussed was the Abuse and Neglect and Misappropriation of Property policy. This policy was reviewed and an action plan was put in place. The facility alleged the Immediate Jeopardy was removed on 2/27/14. On 02/28/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 2/28/14 across all disciplines beginning at 1:30 PM through 4:04PM. These interviews included LPNs, RNs, CNAs, Social Services, Activities, Dietary Staff, Housekeeping Staff, Maintenance Staff, Business Office Manager, Director of Nurses and the Administrator. The content of the in-services held on 02/24/14 through 02/27/14 were verified during each interview. Two (2) Registered Nurses and five (5) Licensed Practical Nurses (LPNs) verified being in-services on the facility's policy/procedures for Abuse and Neglect, Care Plans, Neuro Checks, Accidents and Incidents, Falls, Medical Doctor notification of change in resident condition and status, [MEDICATION NAME] Therapy and Charting and Documentation guidelines. Five (5) Certified Nurses Aides (CNAs), Two (2) Dietary Staff, Two (2) Therapy Department Staff, Three (3) Housekeeping Staff, One (1) Maintenance Staff, the Business Office Manager, One (1) Activity Staff, and One (1) Social Services Staff were interviewed and verified being in-serviced on the facility's policy and procedure on Abuse and Neglect. The Administrator verified being in-serviced on the facility's Abuse and Neglect policy, Neuro Check Policy, Care Plan Policy, Medical Doctor notification in Resident Changes and Status policy, Falls, [MEDICATION NAME] Therapy and Charting and Documentation guidelines by the Company's Consultant. Record review to verify the Allegation of Compliance revealed a 100 % audit of Resident medical records to review falls and neuro checks performed since 11/01/2013. Record review of Licensed Practical Nurse (LPN) #1's personnel file confirmed termination of employment from the facility following the completion of the facility's investigation. Review of the Quality Assurance meetings dated 02/26/14 and 02/27/14 confirmed the meetings consisted of covering the facility's Neuro Check policy, Notification of the Medical Doctor with changes in Resident condition and status and the incident involving Resident #1, and other topics included Accidents and Incidents, Falls, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies.

Based on policy and procedure review, record reviews and staff interviews, the facility failed to provide care in a manner that promoted the highest physical well-being for five (5) of seven (7) residents who experienced falls (Residents #1, #2, #4, #5 and #7) as evidenced by the facility's failure to perform neurological checks per the facility's established policy. Two (2) of the five (5) residents (Resident #1 and Resident #2) who experienced falls, were on [MEDICATION NAME] (blood thinner), and received trauma to the head. The practice of not following the facility's established policy for Nerological Checks placed residents, who required neurological checks due to signs/symptoms of head injury related to falls, in a situation that was likely to cause serious injury, impairment, harm, or death. This situation resulted in an Immediate Jeopardy that began on [DATE], after Resident #1 fell and sustained a head injury which lead to an [MEDICAL CONDITION] and death. The facility's Administrator was notified of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. An acceptable credible Allegation of Compliance was received on [DATE] which alleged the Immediate Jeopardy was removed on [DATE]. The State Survey Agency validated and determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.25 (F-309), was lowered to an "E", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy and procedure entitled "Neurological Checks", dated [DATE], revealed "Policy: It is the policy of this facility to conduct and document Neurological checks when the residents condition warrants". The "Purpose: To conduct a 5 point neurological check to identify gross neurological deficits in the event of a head, neck, or face injury, a suspected neurological event, or for unwitnessed, unexplained events involving an observed change in the resident's position (ex. Observed on the floor even if there is no injury obvious at the time of the event)". "Special Observations: Observe for and document any pertinent observations. (i.e. the presence of [MEDICAL CONDITION], vomiting, paralysis)". "TIMING of NEUROLOGICAL CHECKS: If the resident remains in the facility, neuro checks are to be done as follows until 72 hours are completed or as ordered by the physician". Every 15 minutes X 4 Every 30 minutes X 4 Every 1 hour X 4 Every 4 hours X 4 Every 8 hours X 3 "Documentation: Document findings on the Neurological Assessment Flow Sheet (located in the Forms and Guidelines Manual). The Neurological Assessment Flow Sheet may be placed in the (Medication Administration Record) MAR until completion, then it is placed in the active medical record. Document notification of the physician and the responsible party in the nurse's notes as needed". This policy was not followed for Neurological Checks (neuro checks) on the five (5) residents as follows: Resident #1 Record review revealed the facility admitted Resident #1 on [DATE] with the following Diagnosis: [REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) of 15 indicating the resident was independent in decision making. This MDS also documented the resident was coded as independent in transfers and ambulation, and used a wheelchair for mobility. Review of physician's [DATE] monthly orders revealed [MEDICATION NAME] 7.5 milligram (MG) by mouth (PO) was ordered for daily at 5 PM. The most recent PT/INR ([MEDICATION NAME] Time/International Normalized Ratio - a test to check the bloods ability to clot) was performed on [DATE] with the [MEDICATION NAME]-34.1 (Ref. Range 9XXX,[DATE].4) and INR-3.11 (Ref. Range 0XXX,[DATE].2). Record review of the incident, facility investigation and medical record, revealed Resident #1 was found on the floor in her room on [DATE] at 5:40 AM by Certified Nurse's Aide (CNA) #1. Licensed Practical Nurse (LPN) #1 was called to the room and assessed Resident #1. Neuro checks (Neurological Checks/Assessment- an assessment to check for possible Intracranial bleeding) were then started and Resident #1 was assisted back to bed. Neuro checks were performed [DATE] at 5:40 AM, 5:55 AM, 6:10 AM, 6:25 AM, 6:40 AM, 7:40 AM, 8:40 AM and 9:40 AM. According to the facility policy/procedure for Neurological Checks, neuro checks should have been performed at 5:40 AM, 5:55 AM, 6:10 AM, 6:25 AM, 6:55 AM, 7:25 AM, 7:55 AM, 8:25 AM, 9:25 AM. The resident was found unresponsive at 9:40 AM. The facility failed to document neuro checks at 6:55 AM, 7:25 AM, 7:55 AM, 8:25 AM and 9:25 AM. Review of the documented vital signs on the "Neurological Assessment Flow Sheet" revealed a negative change in the vital signs while neuro checks were being obtained. Vital signs documented at the time of the fall on [DATE] at 5:40 AM were ,[DATE] mm/Hg (millimeters of Mercury)-blood pressure; 97 degrees Fahrenheit (F)-temperature; 68 beats per minute-pulse; and 18 breaths per minute-respiration. Resident #1 was alert and oriented, pupils response was equal and reactive to light, hand grasps were equal, pain response was appropriate. On [DATE] at 8:40 AM, the resident's blood pressure, pulse, and respirations had increased to ,[DATE] mm/Hg-blood pressure, 78 beats per minute -pulse, 24 breaths per minute-respirations. Documentation stated Resident #1 was alert and oriented, pupils response was equal and reactive to light, hand grasps were equal, pain response was appropriate. On [DATE] at 9:40 AM, Resident #1 was found in bed, unresponsive to verbal and physical stimuli with the following vital signs documented ,[DATE] mm/Hg-blood pressure, 55 beats per minute-pulse; and 32 breaths per minute-respirations. Resident #1 was transferred by helicopter to the closest trauma unit where she expired at 2:43 PM that day. Review of the facility's incident report completed by LPN #1 dated [DATE] revealed "Site of Injury: Finger Right index" and "Toe right 3rd", head was not marked. Review of the facility's investigation revealed a written witness statement signed by LPN #1, dated [DATE], that read "she only hit her head a little bit". Resident #1, who was on [MEDICATION NAME] therapy, fell and sustained a head injury on [DATE] at 0540 AM, and was not monitored per the facility's established policy/procedure for neurological checks which lead to an [MEDICAL CONDITION] and death. Resident #2 Record review revealed the facility admitted Resident #2 on [DATE] with the [DIAGNOSES REDACTED]. Review of [DATE] monthly Medical Doctor (MD) orders revealed a medication of [MEDICATION NAME], 2.5 milligram (MG) by mouth daily at 5:00 PM. Review of the most recent quarterly minimum data set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a brief interview of mental status (BIMS) of 12 which indicated resident was able to make daily decisions with minimal assist. Record review of incidents related to falls revealed that Resident #2 experienced four (4) falls with documented neuro checks on [DATE], [DATE], [DATE] and [DATE] as follows: On [DATE] a fall at 4:15 PM resulted in neuro checks. Neuro checks were not completed every hour times 4 then every 4 hours times 4 then every 8 hours times 3 (three) per the facility's policy. The facility failed to document neuro checks at 8:00 PM, 9:00 PM, 10:00 PM, 3:00 PM, 11:00 PM, 7:00 AM and 3:00 PM. Resident #2 fell on [DATE] at 2:30 AM and neuro checks were initiated. The facility failed to document neuro checks at 3:45 AM, 4:45 AM, 8:15 AM, 9:15 AM, 1:15 PM, 5:15 PM, 9:15 PM 1:15 AM, 9:15 AM, 5:15 PM and 1:15 AM as required. Neuro checks were not completed every 30 min times 4 (four) as per facility's policy. There was a head injury documented on the incident report, and that the resident fell while attempting to go to the bathroom by herself. The MD orders dated [DATE] at 3:00 AM read to "Monitor 4 X 4 cm goose egg to forehead daily til healed". Additional record review revealed that the forehead was noted as healed on [DATE]. On [DATE] Resident #2 fell at 9:50 AM which resulted in neuro checks being performed. The facility failed to document neuro checks at 11:05 AM, 12:05 PM, 3:35 PM, 4:35 PM, 8:35 PM, 12:35 AM, 4:35 AM, 8:35 AM, 4:35 PM, 12:35 AM and 8:35 AM. Neuro checks were not completed every 30 min times four (4) per facility's policy. Review of facility [DATE] incident report revealed the resident was "trying to go to bathroom by herself. Don't know what happened, woke up on floor." There were no injuries noted. On [DATE] a fall at 7:30 PM resulted in neuro checks again being performed. The facility failed to document neuro checks at 9:15 PM, 9:45 PM, 10:15 PM, 11:15 PM, 12:15 AM, 1:15 AM, 2:15 AM, 6:15 AM, 10:15 AM, 2:15 PM, 6:15 PM, 2:15 AM, 10:15 AM and 6:15 PM. Neuro checks were not completed every 30 min per facility's policy. Review of the facility incident report date [DATE] revealed the resident denied hitting her head, and there were no apparent injuries. Resident #4 Record review of Resident #4 revealed the facility admitted the resident on [DATE] with the [DIAGNOSES REDACTED]. Review of resident's [DATE] Medical Doctor (MD) orders revealed a medication of Aspirin 81 mg daily. Review of the significant change MDS with an ARD of [DATE] revealed a BIMS of 14 meaning the resident was independent in daily decision making. Record review of incident and medical records revealed Resident #4 experienced four (4) falls with documented neuro checks on [DATE], [DATE], [DATE] and [DATE] as follows: On [DATE], fall at 6:25 PM, resulted in neuro checks performed. The facility failed to document neuro checks at 7:40 PM, 8:40 PM, 10:10 PM, 1:10 AM, 5:10 AM, 9:10 AM, 1:10 PM, 5:10 PM 1:10 AM, 9:10 AM and 5:10 PM. Neuro checks were not completed every 30 minutes per facility's policy. No injuries were noted, and no new MD orders noted. On [DATE], a fall at 9:15 AM, resulted in neuro checks performed at 9:15 AM, 9:30 AM, 9:45 AM and 10:00 AM with no injuries noted. Resident #4 was then transferred and admitted to the hospital due to Myelo[DIAGNOSES REDACTED] syndrome. Resident #4 had a fall on [DATE] at 9:15 PM which resulted in neuro checks being performed. Neuro checks were not completed every 30 minutes times four per facility's policy. The facility failed to document neuro checks at 10:30 PM, 11:30 PM, 3:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 4:00 AM, 12:00 PM and 8:00 PM. On [DATE], a fall at 8:45 PM, resulted in neuro checks. The facility failed to document neuro checks at 10:00 PM, 11:00 PM, 2:30 AM, 3:30 AM, 7:30 AM, 11:30 AM, 3:30 PM, 7:30 PM, 3:30 AM, 11:30 AM and 7:30 PM. Neuro checks were not completed every 30 minutes times four (4) per the facility's policy. Resident #5 Record review of Resident #5 revealed the facility admitted the resident on [DATE] with the [DIAGNOSES REDACTED]. Review of the residents most recent quarterly MDS, with an ARD of [DATE], revealed a BIMS of 11 meaning the resident was able to make daily decision with minimal assist. She did not have a prescribed blood thinner. Record review of incident and medical record revealed Resident #5 experienced eight (8)falls requiring neuro checks on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] as follows On [DATE], a fall at 8:30 AM, resulted in neuro checks performed. Neuro checks were not completed every 30 min times four (4) per the facility's policy as evidenced by the facility failed to document neuro checks at 9:45 AM, 10:45 AM, 2:15 PM, 3:15 PM, 7:15 PM, 11:15 PM, 3:15 AM, 7:15 AM, 3:15 PM, 11:15 PM and 7:15 AM. No injuries were noted. Resident denied pain. Resident #5 fell on [DATE] at 6:15 PM and the fall resulted in neuro checks being performed. Neuro checks were not completed every 30 min times four nor every hour times four (4) per the facility's policy. The facility failed to document neuro checks for 7:30 PM, 8:00 PM, 8:30 PM, 9:00 PM, 10:00 PM, 12:00 AM, 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, 1:00 AM, 9:00 AM and 5:00 PM. Resident denied pain and no injuries were noted. On [DATE], Resident #5 fell at 3:15 PM and required neuro checks to be performed. The facility failed to document neuro checks at 4:30 AM, 5:30 AM, 9:00 PM, 10:00 PM, 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, 10:00 PM, 6:00 AM and 2:00 PM. Neuro checks were not completed every 30 min times four (4) per the facility's policy. Resident #5 fell on [DATE] at 7:28 PM which resulted in neuro checks being performed. Neuro checks were not completed every 30 min times four (4) per the facility's policy. The facility failed to document neuro checks at 6:15 AM, 10:15 AM, 2:15 PM, 6:15 PM, 2:15 AM, 10:15 AM and 6:15 PM. No injuries noted. Resident went to the bathroom unassisted. On [DATE], Resident #5 fell at 8:30 PM which resulted in neuro checks being performed. Neuro checks were not completed every 30 min times four per the facility's policy. The facility failed to follow policy and failed to document neuro checks at 2:15 AM, 3:15 AM, 7:15 AM, 11:15 AM, 3:15 PM, 7:15 PM, 3:15 AM, 11:15 AM and 7:15 PM. The resident had again turned off the wheelchair alarm and a motion sensor did not sound when the resident moved in her room. No injuries were noted. Resident #5 fell on [DATE] at 1:20 AM which resulted in neuro checks being performed. Neuro checks were not completed every 30 min per the facility's policy as evidenced by the facility failed to document neuro checks at 2:35 AM, 3:35 AM, 7:05 AM, 8:05 AM, 12:05 PM, 4:05 PM, 8:05 PM, 12:05 AM, 8:05 AM, 4:05 PM and 12:05 AM. Review of the incident report revealed the resident was found lying on floor beside the bedside commode. Blood was noted coming from a laceration on forehead. The resident was complaining of a headache at front of forehead. The alarm floor mat was sounding but faintly. Staff had asked the resident if she needed to be toileted 10 minutes prior to this fall. On [DATE], Resident #5 had a fall at 8:25 AM which resulted in neuro checks being performed. Neuro checks were not completed every 30 min per the facility's policy. The facility failed to document neuro checks at 9:40 AM, 10:40 AM, 2:10 PM, 3:10 PM, 7:10 PM, 11:10 PM, 3:10 AM, 7:10 AM, 3:10 PM, 11:10 PM and 7:10 AM as required by the facility policy. Report revealed the resident fell while trying to brush her teeth unassisted. No injuries noted during assessment. Resident #5 fell on [DATE] at 5:10 PM and neuro checks were performed. Neuro checks were not completed every 30 min times four (4) per the facility's policy. The facility failed to document neuro checks at 6:25 PM, 7:25 PM, 10:55 PM, 11:55 PM, 3:55 AM, 7:55 AM, 11:55 AM, 3:55 PM, 11:55 PM, 7:55 AM and 3:55 PM. The report revealed the resident turned off the wheelchair alarm before standing up to brush her teeth. Resident #7 Record review revealed the facility admitted Resident #7 on [DATE] with [DIAGNOSES REDACTED]. Review of [DATE] monthly MD orders revealed the resident took Aspirin 81 mg daily. Review of the most recent quarterly MDS with an ARD of [DATE] revealed a BIMS of four (4) meaning resident was unable to make decisions of daily living safely. Review of the incident and medical record revealed Resident #7 experienced four (4) falls requiring neuro checks on [DATE], [DATE], [DATE] and [DATE] as follows: On [DATE] at 3:50 PM Resident #7 fell and neuro checks were performed. Neuro checks were not completed every 15 min times four (4), every 30 min times four (4), every hour times four (4), every four (4) hours times four (4), every eight (8) hours times four per the facility's policy. The facility failed to document neuro checks at 3:50 PM, 4:05 PM, 4:20 PM, 4:35 PM, 5:05 PM, 5:35 PM, 6:05 PM, 6:35 PM, 7:35 PM, 8:35 PM, 9:35 PM, 10:35 PM, 2:35 AM, 6:35 AM, 10:35 AM, 2:35 PM, 10:35 PM, 6:35 AM and 2:35 PM. Review of the incident report revealed the bed alarm was heard sounding, and the resident was found lying on the floor at bedside on right hip. She complained of right hip pain. an order for [REDACTED]. Resident #7 fell on [DATE] at 4:00 PM and neuro checks were performed. Neuro checks were not completed every 30 in times four (4) per the facility's policy. The facility failed to document neuro checks at 5:15 PM, 5:45 PM, 6:15 PM, 6:45 PM, 7:45 PM, 8:45 PM, 9:45 PM, 10:45 PM, 2:45 AM, 6:45 AM, 10:45 AM, 2:45 PM, 10:45 PM, 6:45 AM and 2:45 PM. Review of the incident report revealed no apparent injury was noted during the assessment. The resident was found on the floor mat at her bedside. The bed alarm was sounding. Resident stated she "hit her head". Witness statement in facility investigation written by Director of Nurses (DON) stated "She says she hit her head but there is no redness or indication of it". Resident #7 again fell on [DATE] 1:15 PM and neuro checks were performed. Neuro checks were not completed every 30 min per the facility's policy as evidenced by the facility failed to document neuro checks at 2:30 AM, 3:30 AM, 7:00 PM, 8:00 PM, 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 8:00 PM, 4:00 AM and 12:00 PM. The incident report indicated the resident had no apparent injuries. The resident was found with non-skid socks on, bed alarm sounding, fall mat beside bed, and call light was in reach. On [DATE] at 7:00 AM, Resident #7 had a fall and neuro checks were performed. Neuro checks were not completed every 30 min times four (4) per the facility's policy. The facility failed to document neuro checks at 8:15 AM, 8:45 AM, 9:15 AM, 9:45 AM, 10:45 AM, 11:45 AM, 12:45 PM, 1:45 PM, 5:45 PM, 9:45 PM, 1:45 AM, 5:45 AM, 1:45 PM, 9:45 PM and 5:45 PM. The facility report documented the staff heard an alarm sounding and found the resident sitting on the floor beside the wheelchair and bedside commode. No injuries were noted on assessment. In an interview with LPN #2 on [DATE] at 4:25 PM, LPN #2 explained the procedure for neuro checks as follows: "There was a note at the desk that had q (every) 15 minutes X (times) 4, q 1 hour X 4, q 4 hour X 4 then q 8 hour for 24 hours. This is what we (facility nurses) went by when doing neuro checks. I want to say it was on a sticky note." Interview with the Administrator again on [DATE] at 2:30 PM, confirmed "At the nurses' station, there is a sticky note that says Neuro checks q 15 X 4, q hour X 4, q 4 hour X 4, q 8 hours x 4. I don't know who wrote it, its handwritten. It's been there for years. The nurses were going by the handwritten sticky at the nurses' station instead of our neuro check policy/protocol. I have removed this sticky and thrown it away today. I don't know of an in-service on neuro checks in the last 2 years since I've been administrator. Neuro checks are done on any resident with an unwitnessed fall or a fall and hit their head. Our current neuro check policy dated [DATE] is the current Standard of Practice." Interview with the Administrator at 8:50 AM on [DATE] revealed "All nursing policies are on the company's intranet, everything, human resources, infection control, all of them. There is not a signed approval form by Quality Assurance (QA) or the Medical Director for policy approval. There are no individual (Name of Facility) policies. We have company wide nursing policies. We are notified by email if there are policy changes. The nurses have a computer at the nurse's desk where they can access policies ,[DATE]. There are no paper policies in this facility. We do not have a policy or protocol on why we would send residents to the hospital." Interview with the Medical Director at 3:00 PM on [DATE] revealed, the way I usually have neuro checks done are 1 X q hour X 4 instead of q 30 minutes X 4. Her PT/INRs were on the high side with no changes in [MEDICATION NAME] because she was at risk for [MEDICAL CONDITION] (blood clots) related to massive leg swelling, so, "I kept her PT/INR a little high." On [DATE] at 10:25 AM, the Medical Director brought the surveyor a policy used at another facility (where he also served as Medical Director) and stated he thought this facility's neuro check policy was like the other facility. He was shown a copy of this facility's neuro check policy at this time. The Medical Director revealed at this time "I'm not aware of the neuro check policy at this facility. I didn't know it was different." On [DATE], the Medical Director presented the surveyors with a signed written statement on his letterhead about neuro checks: "I have served as the Medical Director of the (Name of Facility) (formally known as the (prior name of this facility) to 2011) since its inception. Since the beginning of this facility, from time to time, it was necessary to order neuro checks for a suspected head injury. The nurse on duty would immediately assess the resident for need for further evaluation. The time frame for this neurological exam from the beginning of the nursing home was a neurological exam every 15 minutes for one hour, then every hour for 4 hours, then every 4 hours for 24 hours, and then once a shift for one day. This is also the same policy that is currently in place at the (Name of local nursing home) of which I am also the Medical Director and several other nursing homes in this area. When this facility became (Name of this facility) under the auspices of (name of company), apparently they had a document with a different time frame for neurological checks. However, I have no recollection of ever being presented that new policy and was not aware that it was in place." Interview with the Director of Nurses on [DATE] at 11:50 AM revealed "I cannot find any in-service of the neuro check policy dated 2011 to now." The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy : 1. On [DATE] at 1:00 PM the Director Of Nursing (DON) initiated in-services with the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the following policies: "Accidents and Incidents", "Falls", "Physician Notification of Change in Condition or Status", "[MEDICATION NAME] Therapy", "Care Plans" and "Charting and Documentation Guidelines". The in-service review of the Accidents and Incidents policy included that any incident involving a resident should be immediately reported to the physician and the responsible party. Documentation in the medical record should reflect that these actions have been carried out and should include the time and date of notifications by nursing staff. The in-service review of the Physician Notification of Change in Condition or Status included notifying the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. The in-service review of the Falls Policy included to initiate a fall assessment on admission, quarterly, with each fall and to update the fall Care Plan with an intervention after each fall. The in-service review of the [MEDICATION NAME] Therapy policy included that the DON must be notified as soon as possible for any resident who takes blood thinners and has a fall. The notification should be done immediately after initial treatment is provided to the resident. The in-service review of the Care Plan policy included that the Care Plan is to be updated with an intervention with each fall. The Care Plan should be followed as written. The in-service review of the Charting and Documentation Guidelines included that documentation in the medical record should include the date and time of the MD and the RP notifications with all incidents. The documentation should be concise, accurate and complete. 2. An investigation of Resident #1's incident was initiated on [DATE] at 3:20 PM by the Administrator and the DON. 3. On [DATE] at 4:10 PM, the Administrator and the DON met with LPN #1 which resulted in the termination of LPN #1 due to the falsification of Resident #1's medical record which falsely indicated the MD had been notified of the fall. 4. On [DATE] at 4:30 PM, the DON notified the MSDH (Mississippi State Department of Health) by voicemail. 5. On [DATE] at 12:00 PM, the DON notified the Mississippi Board of Nursing by telephone. 6. On [DATE] at 1:19 PM, the DON submitted a report to the Mississippi Attorney General Web Submission by email. 7. On [DATE] at 2:55 PM, the DON submitted the final report to the Mississippi Board of Nursing by fax. 8. On [DATE] at 3:37 PM, the DON submitted the final report to the Mississippi Attorney General Office by fax. 9. On [DATE] at 3:54 PM, the DON submitted the final report to the MSDH by fax. 10. To identify other residents that have the potential to be affected by the deficient practice, a 100% chart review of all residents was performed by the Medical Records Nurse and the MDS (Minimum Data Set) Nurse on [DATE]. Those residents having had a fall with neurological checks since [DATE] were reviewed. The review revealed that 11 of 11 residents with falls requiring neurological checks did not have the neurological checks performed every 30 minutes x 4 as per the facility policy. 11. On [DATE] at 1:00 PM the DON in-serviced all RNs and LPNs on neurological checks . This in-service review of the Neurological Checks included that the neurological checks are to be performed every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 4 hours x 4 and every 8 hours x 3. The findings should be documented on the Neurological Assessment Flow Sheet by the nurse that performed the neurological check. 12. On [DATE] at 4:30 PM an emergency Quality Assurance meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topics discussed were the Accidents and Incidents, Neurological Checks, Falls, Physician Notification of Change in Condition or Status, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies. These policies were reviewed and action plans were put in place. 13. Beginning [DATE], at 9:00 AM, all falls resulting in neurological checks being performed will be reviewed 7 days a week by the DON, or designee, to ensure compliance with the facility policy for neurological checks. ? Incidents and documentation will be reviewed by the Quality Assurance/Performance Improvement Committee monthly. This committee will be responsible for any needed action to ensure the effectiveness of the monitoring process for residents who fall and require neurological checks. This committee will monitor the policies: Neurological Checks, Notification of MD Regarding Change in Condition or Status, Accidents and Incidents, Falls, [MEDICATION NAME] therapy, Care Plans, Charting and Documentation Guidelines and Abuse, Neglect and Misappropriation of Property to ensure they are being followed. 14. 0n [DATE] at 11:00 AM, an in-service was initiated by the DON for "Abuse and Neglect and Misappropriation of Property" to include all RN's, LPN's and Certified Nursing Assistants (CNA's), Housekeeping, Dietary and Maintenance. The inservice review of the Abuse, Neglect and Misappropriation of Property policy included the definitions of Abuse, Neglect and Misappropriation, examples of what constitute abuse and neglect and the consequences. 15. On [DATE] at 6:30 PM, an in-service was initiated by the Nurse Consultant for the Administrator and the Medical Director to review the duties of each role. The roles include oversight of the facility to ensure that the facility is in compliance with current rules, regulations, and guidelines, and to monitor the implementation of policy and procedures. **No staff will be allowed to work until attending required in-services. 16. On [DATE] at 10:45 AM a second emergency QA meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topic discussed was the Abuse and Neglect and Misappropriation of Property policy. This policy was reviewed and an action plan was put in place. The facility alleged the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on [DATE] across all disciplines beginning at 1:30 PM through 4:04PM. These interviews included LPNs, RNs, CNAs, Social Services, Activities, Dietary Staff, Housekeeping Staff, Maintenance Staff, Business Office Manager, Director of Nurses and the Administrator. The content of the in-services held on [DATE] through [DATE] were verified during each interview. Two (2) Registered Nurses and five (5) Licensed Practical Nurses (LPNs) verified being in-services on the facility's policy/procedures for Abuse and Neglect, Care Plans, Neuro Checks, Accidents and Incidents, Falls, Medical Doctor notification of change in resident condition and status, [MEDICATION NAME] Therapy and Charting and Documentation guidelines. Five (5) Certified Nurses Aides (CNAs), Two (2) Dietary Staff, Two (2) Therapy Department Staff, Three (3) Housekeeping Staff, One (1) Maintenance Staff, the Business Office Manager, One (1) Activity Staff, and One (1) Social Services Staff were interviewed and verified being in-serviced on the facility's policy and procedure on Abuse and Neglect. The Administrator verified being in-serviced on the facility's Abuse and Neglect policy, Neuro Check Policy, Care Plan Policy, Medical Doctor notification in Resident Changes and Status policy, Falls, [MEDICATION NAME] Therapy and Charting and Documentation guidelines by the Company's Consultant. Record review to verify the acceptable credible Allegation of Compliance revealed a 100 % audit of Resident medical records to review falls and neurochecks performed since [DATE]. Record review of Licensed Practical Nurse (LPN) #1's personnel file confirmed termination of employment from the facility following the completion of the facility's investigation. Review of the Quality Assurance meetings dated [DATE] and [DATE] confirmed the meetings consisted of covering the facility's Neuro Check policy, Notification of the Medical Doctor with changes in Resident condition and status and the incident involving Resident #1, and other topics included Accidents and Incidents, Falls, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies.

Based on interview, record review and policy review, the facility's Medical Director failed to direct the coordination of medical policies in the facility and to ensure that the facility's established policy for Neurological checks was implemented by the nursing staff for five (5) of seven (7) residents reviewed. (Residents #1, #2, #4, #5 and #7). The facility's nursing staff failed to perform neurological checks at the proper frequency/time frame. The practice of not coordinating medical policies and not ensuring the facility's established policy for Neurological checks were followed by the nursing staff placed residents, who required neurological checks due to signs/symptoms of head injury related to falls, in a situation that was likely to cause serious injury, impairment, harm, or death. This situation resulted in an Immediate Jeopardy that began on 02/24/14, after Resident #1 fell and sustained a head injury which lead to an [MEDICAL CONDITION] and death. The State Survey Agency determined the Immediate Jeopardy was removed on 02/28/14 prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75(i) (F-501), was lowered to an "E", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled "Medical Director", dated June 1, 2000, revealed "It is the policy of this facility that physician services are under the supervision of the medical director". "PROCEDURE: 2. The Medical Director is a licensed physician in the state and is responsible for: a. The standards, coordination, surveillance, and planning for improvement of medical care in this facility; d. Assuring that the resident receive adequate services appropriate to meet their needs; e. Assuring that the medical regimen is incorporated with the resident care plan; i. Assuring that physician services are in compliance with current rules, regulations, and guidelines concerning long-term care." Review of the facility's policy and procedure entitled "Neurological Checks", dated April 18, 2011, revealed "Policy: It is the policy of this facility to conduct and document a Neurological checks when the resident's condition warrants". The "Purpose: To conduct a 5 point neurological check to identify gross neurological deficits in the event of a head, neck, or face injury, a suspected neurological event, or for unwitnessed, unexplained events involving an observed change in the resident's position (ex. Observed on the floor even if there is no injury obvious at the time of the event)". "Special Observations: Observe for and document any pertinent observations. (i.e. the presence of [MEDICAL CONDITION], vomiting, paralysis)". "TIMING of NEUROLOGICAL CHECKS: If the resident remains in the facility, neuro checks are to be done as follows until 72 hours are completed or as ordered by the physician". Every 15 minutes X 4 Every 30 minutes X 4 Every 1 hour X 4 Every 4 hours X 4 Every 8 hours X 3 There was no documentation to indicate that this policy of April 18, 2011, had been reviewed and approved by the Medical Director. Interview with the Medical Director (MD) at 3:00 PM on 02/26/14 revealed, "The way I usually have neuro checks done are 1 X q hour X 4 instead of q 30 minutes X 4". On 02/27/14 at 10:25 AM, the Medical Director brought to the surveyor a policy used at another facility he directed and said he thought this facility's neuro check policy was like the other facility. He was shown a copy of this facility's neuro check policy at this time. On 2/27/14 at 10:25 AM, interview with the Medical Director revealed "I'm not aware of the neuro check policy at this facility. I didn't know it was different". On 2/28/14, the Medical Director presented the surveyors with a signed written statement on his letterhead about neuro checks: "I have served as the Medical Director of the (Name of Facility) (formally known as the (prior name of this facility) to 2011) since its inception. Since the beginning of this facility, from time to time, it was necessary to order neuro checks for a suspected head injury. The nurse on duty would immediately access the resident for need for further evaluation. The time frame for this neurological exam from the beginning of the nursing home was a neurological exam every 15 minutes for one hour, then every hour for 4 hours, then every 4 hours for 24 hours, and then once a shift for one day. This is also the same policy that is currently in place at the (Name of local Nursing home) of which I am also the Medical Director and several other nursing homes in this area. When this facility became (Name of this facility) under the auspices of (name of company), apparently they had a document with a different time frame for neurological checks. However, I have no recollection of ever being presented that new policy and was not aware that it was in place". Resident #1 - Review of the facility's incident report, nurse notes, and neurological assessment flow sheet revealed Resident #1 had a fall with a head injury on 02/24/14 and neuro checks were initiated but were not completed per policy for the at 30 minute intervals times four (4). Resident #2 - Record review of incident and medical records revealed that Resident #2 experienced falls with documented neuro checks on 12/30/13, 01/04/14, 02/14/14, and 02/23/14. Review of the Neurological Assessment Flow Sheet revealed neuro checks were not completed per facility policy. Resident #4 - Record review of incident and medical records revealed that Resident #4 experienced falls with documented neuro checks on 11/27/13, 12/27/13, 01/17/14 and 01/31/14. Review of the Neurological Assessment Flow Sheet revealed neuro checks were not completed per facility policy. Resident #5 - Record review of incident and medical record revealed Resident #5 experienced falls requiring neuro checks on 11/20/13, 11/26/13, 12/11/13, 12/31/13, 01/03/14, 01/26/14, 01/28/14, and 01/31/14. Review of the Neurological Assessment Flow Sheet revealed neuro checks were not completed per facility policy. Resident #7 - Review of the incident and medical record revealed Resident #7 experienced falls requiring neuro checks on 11/19/13, 12/06/13, 12/09/13, and 01/22/14. Review of the Neurological Assessment Flow Sheet revealed neuro checks were not completed per facility policy. The facility submitted an acceptable credible Allegation of Compliance on 2/28/14 for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy : 1. On 02/24/14 at 1:00 PM the Director Of Nursing (DON) initiated in-services with the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the following policies: "Accidents and Incidents", "Falls", "Physician Notification of Change in Condition or Status", "[MEDICATION NAME] Therapy", "Care Plans" and "Charting and Documentation Guidelines". The in-service review of the Accidents and Incidents policy included that any incident involving a resident should be immediately reported to the physician and the responsible party. Documentation in the medical record should reflect that these actions have been carried out and should include the time and date of notifications by nursing staff. The in-service review of the Physician Notification of Change in Condition or Status included notifying the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. The in-service review of the Falls Policy included to initiate a fall assessment on admission, quarterly, with each fall and to update the fall Care Plan with an intervention after each fall. The in-service review of the [MEDICATION NAME] Therapy policy included that the DON must be notified as soon as possible for any resident who takes blood thinners and has a fall. The notification should be done immediately after initial treatment is provided to the resident. The in-service review of the Care Plan policy included that the Care Plan is to be updated with an intervention with each fall. The Care Plan should be followed as written. The in-service review of the Charting and Documentation Guidelines included that documentation in the medical record should include the date and time of the MD and the Responsible Party (RP) notifications with all incidents. The documentation should be concise, accurate and complete. 2. An investigation of Resident #1's incident was initiated on 02/24/14 at 3:20 PM by the Administrator and the DON. 3. On 2/24/14 at 4:10 PM, the Administrator and the DON met with LPN #1 which resulted in the termination of LPN #1 due to the falsification of Resident #1's medical record which falsely indicated the MD had been notified of the fall. 4. On 02/24/14 at 4:30 PM, the DON notified the MSDH (Mississippi State Department of Health) by voicemail. 5. On 02/25/14 at 12:00 PM, the DON notified the Mississippi Board of Nursing by telephone. 6. On 02/25/14 at 1:19 PM, the DON submitted a report to the Mississippi Attorney General Web Submission by email. 7. On 02/25/14 at 2:55 PM, the DON submitted the final report to the Mississippi Board of Nursing by fax. 8. On 02/25/14 at 3:37 PM, the DON submitted the final report to the Mississippi Attorney General Office by fax. 9. On 02/25/14 at 3:54 PM, the DON submitted the final report to the MSDH by fax. 10. To identify other residents that have the potential to be affected by the deficient practice, a 100% chart review of all residents was performed by the Medical Records Nurse and the MDS (Minimum Data Set) Nurse on 02/26/14. Those residents having had a fall with neurological checks since 11/1/13 were reviewed. The review revealed that 11 of 11 residents with falls requiring neurological checks did not have the neurological checks performed every 30 minutes x 4 as per the facility policy. 11. On 02/26/14 at 1:00 PM the DON in-serviced all RNs and LPNs on neurological checks . This in-service review of the Neurological Checks included that the neurological checks are to be performed every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 4 hours x 4 and every 8 hours x 3. The findings should be documented on the Neurological Assessment Flow Sheet by the nurse that performed the neurological check. 12. On 02/26/14 at 4:30 PM an emergency Quality Assurance (QA) meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topics discussed were the Accidents and Incidents, Neurological Checks, Falls, Physician Notification of Change in Condition or Status, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies. These policies were reviewed and action plans were put in place. 13. Beginning 02/27/14, at 9:00 AM, all falls resulting in neurological checks being performed will be reviewed 7 days a week by the DON, or designee, to ensure compliance with the facility policy for neurological checks. ? Incidents and documentation will be reviewed by the Quality Assurance/Performance Improvement Committee monthly. This committee will be responsible for any needed action to ensure the effectiveness of the monitoring process for residents who fall and require neurological checks. This committee will monitor the policies: Neurological Checks, Notification of MD Regarding Change in Condition or Status, Accidents and Incidents, Falls, [MEDICATION NAME] therapy, Care Plans, Charting and Documentation Guidelines and Abuse, Neglect and Misappropriation of Property to ensure they are being followed. 14. 0n 02/27/14 at 11:00 AM, an in-service was initiated by the DON for "Abuse and Neglect and Misappropriation of Property" to include all RNs, LPNs and Certified Nursing Assistants (CNAs), Housekeeping, Dietary and Maintenance. The in-service review of the Abuse, Neglect and Misappropriation of Property policy included the definitions of Abuse, Neglect and Misappropriation, examples of what constitute abuse and neglect and the consequences. 15. On 2/27/14 at 6:30 PM, an in-service was initiated by the Nurse Consultant for the Administrator and the Medical Director to review the duties of each role. The roles include oversight of the facility to ensure that the facility is in compliance with current rules, regulations, and guidelines, and to monitor the implementation of policy and procedures. **No staff will be allowed to work until attending required in-services. 16. On 2/27/14 at 10:45 AM a second emergency QA meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topic discussed was the Abuse and Neglect and Misappropriation of Property policy. This policy was reviewed and an action plan was put in place. The facility alleged the Immediate Jeopardy was removed on 2/27/14. On 02/28/14, the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on 2/28/14 across all disciplines beginning at 1:30 PM through 4:04PM. These interviews included LPNs, RNs, CNAs, Social Services, Activities, Dietary Staff, Housekeeping Staff, Maintenance Staff, Business Office Manager, Director of Nurses and the Administrator. The content of the in-services held on 02/24/14 through 02/27/14 were verified during each interview. Two (2) Registered Nurses and five (5) Licensed Practical Nurses (LPNs) verified being in-services on the facility's policy/procedures for Abuse and Neglect, Care Plans, Neuro Checks, Accidents and Incidents, Falls, Medical Doctor notification of change in resident condition and status, [MEDICATION NAME] Therapy and Charting and Documentation guidelines. Five (5) Certified Nurses Aides (CNAs), Two (2) Dietary Staff, Two (2) Therapy Department Staff, Three (3) Housekeeping Staff, One (1) Maintenance Staff, the Business Office Manager, One (1) Activity Staff, and One (1) Social Services Staff were interviewed and verified being in-serviced on the facility's policy and procedure on Abuse and Neglect. The Administrator verified being in-serviced on the facility's Abuse and Neglect policy, Neuro Check Policy, Care Plan Policy, Medical Doctor notification in Resident Changes and Status policy, Falls, [MEDICATION NAME] Therapy and Charting and Documentation guidelines by the Company's Consultant. Record review to verify the acceptable credible Allegation of Compliance revealed a 100 % audit of Resident medical records to review falls and neuro checks performed since 11/01/2013. Record review of Licensed Practical Nurse (LPN) #1's personnel file confirmed termination of employment from the facility following the completion of the facility's investigation. Review of the Quality Assurance meetings dated 02/26/14 and 02/27/14 confirmed the meetings consisted of covering the facility's Neuro Check policy, Notification of the Medical Doctor with changes in Resident condition and status and the incident involving Resident #1, and other topics included Accidents and Incidents, Falls, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies.

Based on record review, interview and policy review, the facility's nursing staff failed to promptly notify the physician for one (1) of seven (7) residents reviewed when the resident fell . (Resident #1). Resident #1, who received [MEDICATION NAME] (blood thinner) therapy, experienced an unwitnessed fall at 5:40 AM on [DATE]. The facility's nursing staff did not notify Resident #1's physician until 9:40 AM on [DATE] of the resident's fall and change in condition. Resident #1 was subsequently later transferred via helicopter to a trauma center and admitted with a [DIAGNOSES REDACTED]. Resident #1 expired on [DATE] at 2:43 PM. The facility's failure to promptly notify the physician when Resident #1 fell and experienced a change in condition resulting in a [DIAGNOSES REDACTED]. This situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. An acceptable credible Allegation of Compliance was received on [DATE] in which the facility alleged the Immediate Jeopardy was removed on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.10 (F-157), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy and procedure entitled "Physician Notification of Change in Condition or Status", revised [DATE], revealed: "Policy Statement: It is the policy of this facility to provide a mechanism for informing the resident, the resident's physician, the legal representative or an interested family member of changes that affect the resident." "Procedure: 1. The resident, the resident's attending physician, the legal representative or an interested family member will be notified when there is: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention; b. A significant change in the resident's physical, mental or psychological status (i.e. a deterioration in health, mental or psychological status in either life-threatening conditions or clinical complications)". Resident #1 Record review of the facility's incident investigation revealed Resident #1, who was receiving [MEDICATION NAME] therapy, was found on the floor of her room on [DATE] @ 5:40 AM by Certified Nurse Aide (CNA) #1. Resident #1 later became unresponsive to verbal and tactile stimuli and was transferred to a trauma center. Resident #1 was admitted with a [DIAGNOSES REDACTED]. Record review of the facility's incident investigation revealed a note by the Director of Nurses (DON), dated [DATE], which read "I received a phone call from (Name of MD) at approximately 3:15 PM. He notified me that he had not been notified of (Name of Resident #1)'s fall this morning during the time surrounding the incident. He assured me that he had checked the messages and call logs on both his home and personal cell phone to ensure no message had been left." Interview with the resident's physician at 3:00 PM on [DATE], confirmed "No, I was not called after her (Resident #1) fall and that is highly unusual for that facility. I was first contacted by the nurse at the facility when they were about to fly her out by helicopter. She was letting me know of the transfer." A second interview with the resident's physician at 10:25 AM on [DATE], revealed he found out about Resident #1's fall when the resident was needing to be transferred after being found unresponsive. The physician stated, "I called to double check to see if I missed a call from the nurse. I had not missed a call. There wasn't one. I was at the hospital when I was finally called. I checked with the hospital operator to check and see if I missed a call from the nurse. She had not called for me at the hospital after the fall." Record review of a written witness statement from LPN #1, dated [DATE], revealed "After (Name of Resident #1) fell , I put her on Neurochecks (Neurological Checks/Assessment). She was AAOX3 (alert and oriented to person, place, and time) with clear speech. All the paperwork was filled out per protocol. I notified the second contact because I didn't get an answer with the first. I thought I had notified the MD but apparently I didn't". Record review also revealed a nurses note dated [DATE] at 7:05 AM related to notification of the responsible party which documented "MD aware". Interview with LPN #1 on [DATE] at 12:45 PM, revealed "I thought I called the doctor, but apparently I didn't. I couldn't get her first contact but did get her second. I did write the 7:05 AM note. I thought I had called him (MD). I could have swore I did. I don't remember talking to him. I was busy with everything. I have been terminated for falsifying documentation. I really thought I had called the doctor." Record review of Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) of 15 indicating resident was independent in decision making. The MDS documented the resident was independent with transfers and ambulation. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy : 1. On [DATE] at 1:00 PM the Director Of Nursing (DON) initiated in-services with the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the following policies: "Accidents and Incidents", "Falls", "Physician Notification of Change in Condition or Status", "[MEDICATION NAME] Therapy", "Care Plans" and "Charting and Documentation Guidelines". The in-service review of the Accidents and Incidents policy included that any incident involving a resident should be immediately reported to the physician and the responsible party. Documentation in the medical record should reflect that these actions have been carried out and should include the time and date of notifications by nursing staff. The in-service review of the Physician Notification of Change in Condition or Status included notifying the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. The in-service review of the Falls Policy included to initiate a fall assessment on admission, quarterly, with each fall and to update the fall Care Plan with an intervention after each fall. The in-service review of the [MEDICATION NAME] Therapy policy included that the DON must be notified as soon as possible for any resident who takes blood thinners and has a fall. The notification should be done immediately after initial treatment is provided to the resident. The in-service review of the Care Plan policy included that the Care Plan is to be updated with an intervention with each fall. The Care Plan should be followed as written. The in-service review of the Charting and Documentation Guidelines included that documentation in the medical record should include the date and time of the physician, and the Responsible Party (RP) notifications with all incidents. The documentation should be concise, accurate and complete. 2. An investigation of Resident #1's incident was initiated on [DATE] at 3:20 PM by the Administrator and the DON. 3. On [DATE] at 4:10 PM, the Administrator and the DON met with LPN #1 which resulted in the termination of LPN #1 due to the falsification of Resident #1's medical record which falsely indicated the MD had been notified of the fall. 4. On [DATE] at 4:30 PM, the DON notified the MSDH (Mississippi State Department of Health) by voicemail. 5. On [DATE] at 12:00 PM, the DON notified the Mississippi Board of Nursing by telephone. 6. On [DATE] at 1:19 PM, the DON submitted a report to the Mississippi Attorney General Web Submission by email. 7. On [DATE] at 2:55 PM, the DON submitted the final report to the Mississippi Board of Nursing by fax. 8. On [DATE] at 3:37 PM, the DON submitted the final report to the Mississippi Attorney General Office by fax. 9. On [DATE] at 3:54 PM, the DON submitted the final report to the MSDH by fax. 10. To identify other residents that have the potential to be affected by the deficient practice, a 100% chart review of all residents was performed by the Medical Records Nurse and the MDS (Minimum Data Set) Nurse on [DATE]. Those residents having had a fall with neurological checks since [DATE] were reviewed. The review revealed that 11 of 11 residents with falls requiring neurological checks did not have the neurological checks performed every 30 minutes x 4 as per the facility policy. 11. On [DATE] at 1:00 PM the DON in-serviced all RNs and LPNs on neurological checks . This in-service review of the Neurological Checks included that the neurological checks are to be performed every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 4 hours x 4 and every 8 hours x 3. The findings should be documented on the Neurological Assessment Flow Sheet by the nurse that performed the neurological check. 12. On [DATE] at 4:30 PM an emergency Quality Assurance meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topics discussed were the Accidents and Incidents, Neurological Checks, Falls, Physician Notification of Change in Condition or Status, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies. These policies were reviewed and action plans were put in place. 13. Beginning [DATE], at 9:00 AM, all falls resulting in neurological checks being performed will be reviewed 7 days a week by the DON, or designee, to ensure compliance with the facility policy for neurological checks. ? Incidents and documentation will be reviewed by the Quality Assurance/Performance Improvement Committee monthly. This committee will be responsible for any needed action to ensure the effectiveness of the monitoring process for residents who fall and require neurological checks. This committee will monitor the policies: Neurological Checks, Notification of MD Regarding Change in Condition or Status, Accidents and Incidents, Falls, [MEDICATION NAME] therapy, Care Plans, Charting and Documentation Guidelines and Abuse, Neglect and Misappropriation of Property to ensure they are being followed. 14. 0n [DATE] at 11:00 AM, an in-service was initiated by the DON for "Abuse and Neglect and Misappropriation of Property" to include all RNs, LPNs and Certified Nursing Assistants (CNAs), Housekeeping, Dietary and Maintenance. The in-service review of the Abuse, Neglect and Misappropriation of Property policy included the definitions of Abuse, Neglect and Misappropriation, examples of what constitute abuse and neglect and the consequences. 15. On [DATE] at 6:30 PM, an in-service was initiated by the Nurse Consultant for the Administrator and the Medical Director to review the duties of each role. The roles include oversight of the facility to ensure that the facility is in compliance with current rules, regulations, and guidelines, and to monitor the implementation of policy and procedures. **No staff will be allowed to work until attending required in-services. 16. On [DATE] at 10:45 AM a second emergency QA meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topic discussed was the Abuse and Neglect and Misappropriation of Property policy. This policy was reviewed and an action plan was put in place. The facility alleged the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on [DATE] across all disciplines beginning at 1:30 PM through 4:04PM. These interviews included LPNs, RNs, CNAs, Social Services Staff , Activities Staff, Dietary Staff, Housekeeping Staff, Maintenance Staff, Business Office Manager, Director of Nurses and the Administrator. The content of the in-services held on [DATE] through [DATE] were verified during each interview. Two (2) Registered Nurses and five (5) Licensed Practical Nurses (LPNs) verified being in-services on the facility's policy/procedures for Abuse and Neglect, Care Plans, Neuro Checks, Accidents and Incidents, Falls, Medical Doctor notification of change in resident condition and status, [MEDICATION NAME] Therapy and Charting and Documentation guidelines. Five (5) Certified Nurses Aides (CNAs), Two (2) Dietary Staff, Two (2) Therapy Department Staff, Three (3) Housekeeping Staff, One (1) Maintenance Staff, the Business Office Manager, One (1) Activity Staff, and One (1) Social Services Staff were interviewed and verified being in-serviced on the facility's policy and procedure on Abuse and Neglect. The Administrator verified being in-serviced on the facility's Abuse and Neglect policy, Neuro Check Policy, Care Plan Policy, Medical Doctor notification in Resident Changes and Status policy, Falls, [MEDICATION NAME] Therapy and Charting and Documentation guidelines, by the Company's Consultant. Record review to verify the Allegation of Compliance revealed a 100 % audit of Resident medical records to review falls and neurochecks performed since [DATE]. Record review of Licensed Practical Nurse (LPN) #1's personnel file confirmed termination of employment from the facility following the completion of the facility's investigation. Review of the Quality Assurance meetings dated [DATE] and [DATE] confirmed the meetings consisted of covering the facility's Neuro Check policy, Notification of the Medical Doctor with changes in Resident condition and status and the incident involving Resident #1, and other topics included Accidents and Incidents, Falls, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies.

Based on interview, record review and policy review, the facility failed to maintain accurate and completely documented medical records for one (1) of seven (7) residents reviewed as evidenced by failure to document a head injury and false documentation of notification to the physician for a fall with a head injury. (Resident #1) The facility's failure to accurately document notification to the physician in the medical record after Resident #1 fell and experienced a change in condition, which resulted in a [DIAGNOSES REDACTED]. This situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The facility's Administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. An acceptable Allegation of Compliance was received on [DATE] in which the facility alleged the Immediate Jeopardy was removed on [DATE]. The State Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (l)(1)(F514), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy and procedure entitled "Neurological Checks", dated [DATE], revealed, "Documentation: Document findings on the Neurological Assessment Flow Sheet (located in the Forms and Guidelines Manual). The Neurological Assessment Flow Sheet may be placed in the (Medication Administration Record) MAR until completion, and then it is placed in the active medical record. Document notification of the physician and the responsible party in the nurse's notes as needed". Resident #1 Record review of the facility's incident investigation revealed Resident #1, who was receiving [MEDICATION NAME] therapy, was found on the floor of her room on [DATE] @ 5:40 AM by Certified Nurse Aide (CNA) #1. On [DATE] at 9:40 AM, Resident #1 was found in bed, unresponsive to verbal and physical stimuli with the following vital signs documented ,[DATE] millimeters/mercury (mm/Hg)-blood pressure; 55 beats/minutes-pulse; 32-breaths/minute - respirations. Resident #1 was transferred by helicopter to the closest trauma unit where she expired at 2:43 PM later that day. Record review of Resident #1's nurse's note by Licensed Practical Nurse (LPN) #1, regarding physician notification dated [DATE] at 7:05 AM, revealed "MD (Medical Doctor - Physician) aware". However, interview with the Resident #1's physician at 3:00 PM on [DATE], revealed he was first contacted by Registered Nurse (RN) #1 on the day of the fall to inform him of the transfer of the resident by helicopter. Record review of a witness statement from LPN #1 dated [DATE], revealed "After (Name of Resident #1) fell , I put her on neuro checks. She was AAOX3 (Alert and Oriented to person, place, and time) with clear speech. All the paperwork was filled out per protocol. I notified the 2nd contact because I didn't get an answer with the first. I thought I had notified the MD but apparently I didn't". Interview with LPN #1 on [DATE] at 12:45 PM, revealed LPN #1 wrote the 7:05 AM nurse's note and thought she had called the Medical Doctor. LPN #1 confirmed she had been terminated for falsifying documentation. Review of LPN's #1 written statement, dated [DATE], revealed Resident #1 reported to LPN #1 that she (Resident #1) hit her head when she fell . Review of a Nurse's Note dated [DATE] at 5:40 AM, revealed that nursing staff failed to document in the medical record, the resident's report of hitting her head. Review of the facility's incident report completed by LPN #1, dated [DATE], revealed "Site of Injury: Finger Right index" and "Toe right 3rd". Review of the Incident report dated [DATE] failed to document the resident hit her head. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy : 1. On [DATE] at 1:00 PM the Director Of Nursing (DON) initiated in-services with the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the following policies: "Accidents and Incidents", "Falls", "Physician Notification of Change in Condition or Status", "[MEDICATION NAME] Therapy", "Care Plans" and "Charting and Documentation Guidelines". The in-service review of the Accidents and Incidents policy included that any incident involving a resident should be immediately reported to the physician and the responsible party. Documentation in the medical record should reflect that these actions have been carried out and should include the time and date of notifications by nursing staff. The in-service review of the Physician Notification of Change in Condition or Status included notifying the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. The in-service review of the Falls Policy included to initiate a fall assessment on admission, quarterly, with each fall and to update the fall Care Plan with an intervention after each fall. The in-service review of the [MEDICATION NAME] Therapy policy included that the DON must be notified as soon as possible for any resident who takes blood thinners and has a fall. The notification should be done immediately after initial treatment is provided to the resident. The in-service review of the Care Plan policy included that the Care Plan is to be updated with an intervention with each fall. The Care Plan should be followed as written. The in-service review of the Charting and Documentation Guidelines included that documentation in the medical record should include the date and time of the MD and the RP notifications with all incidents. The documentation should be concise, accurate and complete. 2. An investigation of Resident #1's incident was initiated on [DATE] at 3:20 PM by the Administrator and the DON. 3. On [DATE] at 4:10 PM, the Administrator and the DON met with LPN #1 which resulted in the termination of LPN #1 due to the falsification of Resident #1's medical record which falsely indicated the MD had been notified of the fall. 4. On [DATE] at 4:30 PM, the DON notified the MSDH (Mississippi State Department of Health) by voicemail. 5. On [DATE] at 12:00 PM, the DON notified the Mississippi Board of Nursing by telephone. 6. On [DATE] at 1:19 PM, the DON submitted a report to the Mississippi Attorney General Web Submission by email. 7. On [DATE] at 2:55 PM, the DON submitted the final report to the Mississippi Board of Nursing by fax. 8. On [DATE] at 3:37 PM, the DON submitted the final report to the Mississippi Attorney General Office by fax. 9. On [DATE] at 3:54 PM, the DON submitted the final report to the MSDH by fax. 10. To identify other residents that have the potential to be affected by the deficient practice, a 100% chart review of all residents was performed by the Medical Records Nurse and the MDS (Minimum Data Set) Nurse on [DATE]. Those residents having had a fall with neurological checks since [DATE] were reviewed. The review revealed that 11 of 11 residents with falls requiring neurological checks did not have the neurological checks performed every 30 minutes x 4 as per the facility policy. 11. On [DATE] at 1:00 PM the DON in-serviced all RNs and LPNs on neurological checks . This in-service review of the Neurological Checks included that the neurological checks are to be performed every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 4 hours x 4 and every 8 hours x 3. The findings should be documented on the Neurological Assessment Flow Sheet by the nurse that performed the neurological check. 12. On [DATE] at 4:30 PM an emergency Quality Assurance (QA) meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topics discussed were the Accidents and Incidents, Neurological Checks, Falls, Physician Notification of Change in Condition or Status, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies. These policies were reviewed and action plans were put in place. 13. Beginning [DATE], at 9:00 AM, all falls resulting in neurological checks being performed will be reviewed 7 days a week by the DON, or designee, to ensure compliance with the facility policy for neurological checks. ? Incidents and documentation will be reviewed by the Quality Assurance/Performance Improvement Committee monthly. This committee will be responsible for any needed action to ensure the effectiveness of the monitoring process for residents who fall and require neurological checks. This committee will monitor the policies: Neurological Checks, Notification of MD Regarding Change in Condition or Status, Accidents and Incidents, Falls, [MEDICATION NAME] therapy, Care Plans, Charting and Documentation Guidelines and Abuse, Neglect and Misappropriation of Property to ensure they are being followed. 14. On [DATE] at 11:00 AM, an in-service was initiated by the DON for "Abuse and Neglect and Misappropriation of Property" to include all RNs, LPNs and Certified Nursing Assistants (CNAs), Housekeeping, Dietary and Maintenance. The in-service review of the Abuse, Neglect and Misappropriation of Property policy included the definitions of Abuse, Neglect and Misappropriation, examples of what constitute abuse and neglect and the consequences. 15. On [DATE] at 6:30 PM, an in-service was initiated by the Nurse Consultant for the Administrator and the Medical Director to review the duties of each role. The roles include oversight of the facility to ensure that the facility is in compliance with current rules, regulations, and guidelines, and to monitor the implementation of policy and procedures. **No staff will be allowed to work until attending required in-services. 16. On [DATE] at 10:45 AM a second emergency QA meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topic discussed was the Abuse and Neglect and Misappropriation of Property policy. This policy was reviewed and an action plan was put in place. The facility alleged the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable credible Allegation of Compliance was verified by staff interviews and record review of in-services on [DATE] across all disciplines beginning at 1:30 PM through 4:04PM. These interviews included LPNs, RNs, CNAs, Social Services, Activities, Dietary Staff, Housekeeping Staff, Maintenance Staff, Business Office Manager, Director of Nurses and the Administrator. The content of the in-services held on [DATE] through [DATE] were verified during each interview. Two (2) Registered Nurses and five (5) Licensed Practical Nurses (LPNs) verified being in-services on the facility's policy/procedures for Abuse and Neglect, Care Plans, Neuro Checks, Accidents and Incidents, Falls, Medical Doctor notification of change in resident condition and status, [MEDICATION NAME] Therapy and Charting and Documentation guidelines. Five (5) Certified Nurses Aides (CNAs), Two (2) Dietary Staff, Two (2) Therapy Department Staff, Three (3) Housekeeping Staff, One (1) Maintenance Staff, the Business Office Manager, One (1) Activity Staff, and One (1) Social Services Staff were interviewed and verified being in-serviced on the facility's policy and procedure on Abuse and Neglect. The Administrator verified being in-serviced on the facility's Abuse and Neglect policy, Neuro Check Policy, Care Plan Policy, Medical Doctor notification in Resident Changes and Status policy, Falls, [MEDICATION NAME] Therapy and Charting and Documentation guidelines by the Company's Consultant. Record review to verify the acceptable credible Allegation of Compliance revealed a 100 % audit of Resident medical records to review falls and neuro checks performed since [DATE]. Record review of Licensed Practical Nurse (LPN) #1's personnel file confirmed termination of employment from the facility following the completion of the facility's investigation. Review of the Quality Assurance meetings dated [DATE] and [DATE] confirmed the meetings consisted of covering the facility's Neuro Check policy, Notification of the Medical Doctor with changes in Resident condition and status and the incident involving Resident #1, and other topics included Accidents and Incidents, Falls, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies.

Based on record review, staff interview, and policy review, the facility's nursing staff failed to follow the care plan intervention to notify the physician of any falls, as needed, for one (1) of seven (7) residents (Resident #1). Resident #1, who received [MEDICATION NAME] (blood thinner) therapy, experienced an unwitnessed fall at 5:40 AM on [DATE], and hit her head. The facility's nursing staff did not notify Resident #1's physician. per care plan intervention, until 9:40 AM on [DATE] of the resident's fall and change in condition. Resident #1 became unresponsive, and was transferred to the nearest trauma center via helicopter. Resident #1 was diagnosed as having [MEDICAL CONDITION] (bleeding within the skull) following the injury. Resident #1 expired at the hospital on [DATE] at 2:23 PM. The facility's nursing staff's failure to follow the care plan intervention when Resident #1 fell and hit her head requiring physician intervention, resulted in a [DIAGNOSES REDACTED]. This situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The facility's administrator was notified of the Immediate Jeopardy and Substandard Quality of Care (SQC) on [DATE]. An acceptable Allegation of Compliance was received on [DATE] in which the facility alleged the Immediate Jeopardy was removed on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] prior to exit. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.20 (F-282), was lowered to a "D", while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy for care plans entitled "Goals and Objectives", dated [DATE], revealed "It is the policy of this facility that care plan incorporate goals and objectives which lead to the resident's highest obtainable level of independence". "Procedures: 1. Goals and objectives are defined as the desired outcome for a specific resident problem. 2. Goals and objectives are: a. Resident oriented; b. Behaviorally stated; c. Measurable; and d. Within a specified time frame". Resident #1 Record review of Resident #1's Fall Risk Care Plan with a target date of ",[DATE]" and a problem onset date [DATE] revealed an approach to "Notify MD/RP (Responsible Party) for any falls PRN (as needed)". Review of Resident #1's undated care plan titled "Anticoagulant Therapy" ([MEDICATION NAME] therapy), revealed a problem with potential for bleeding related to anticoagulation therapy and approaches to notify MD/RP of s/s (signs and symptons) bleeding PRN (as needed) and to monitor for s/s bleeding, bruising, black tarry stools PRN. An interview with the resident's physician (Medical Doctor (MD)) on [DATE] at 3:00 PM and on [DATE] at 10:25 AM, confirmed he had not been notified of Resident #1's fall at the time of the occurrence. The physician stated, "I was first contacted by the nurse at the facility when they were about to fly her (the resident) out by helicopter. She was letting me know of the transfer." Record review of LPN #1's written statement dated [DATE] revealed "After (Name of Resident #1) fell , I put her on Neurochecks (Neurological Checks). She was AAOX3 (alert and oriented to person, place, and time) with clear speech. All the paperwork was filled out per protocol. I notified the 2nd contact because I didn't get an answer with the first. I thought I had notified the MD but apparently I didn't". Interview with the Director of Nurses (DON) on [DATE] at 12:50 PM, revealed "Nurses are supposed to review care plans in the charts. There is no set schedule. The Minimum Data Set (MDS) nurse updates care plans quarterly. The nurses check (care plans) quarterly to make sure care plans are present on the chart and accurate. Floor nurses are supposed to update care plans with new interventions with incidents. In stand up, if there are incidents we review to make sure there are new interventions and we check to make sure they are appropriate. If I know a care plan has changed, I put a note at the nurse's desk letting floor nurses know there is a change". Record review of Resident #1 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) of 15 indicating resident was independent in decision making. This MDS documented the resident was independent with transfers and ambulation. The facility submitted an acceptable credible Allegation of Compliance on [DATE] for the Immediate Jeopardy. Review of the facility's acceptable credible Allegation of Compliance (AoC) revealed the facility took the following actions to remove the Immediate Jeopardy : 1. On [DATE] at 1:00 PM the Director Of Nursing (DON) initiated in-services with the Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) on the following policies: "Accidents and Incidents", "Falls", "Physician Notification of Change in Condition or Status", "[MEDICATION NAME] Therapy", "Care Plans" and "Charting and Documentation Guidelines". The in-service review of the Accidents and Incidents policy included that any incident involving a resident should be immediately reported to the physician and the responsible party. Documentation in the medical record should reflect that these actions have been carried out and should include the time and date of notifications by nursing staff. The in-service review of the Physician Notification of Change in Condition or Status included notifying the physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. The in-service review of the Falls Policy included to initiate a fall assessment on admission, quarterly, with each fall and to update the fall Care Plan with an intervention after each fall. The in-service review of the [MEDICATION NAME] Therapy policy included that the DON must be notified as soon as possible for any resident who takes blood thinners and has a fall. The notification should be done immediately after initial treatment is provided to the resident. The in-service review of the Care Plan policy included that the Care Plan is to be updated with an intervention with each fall. The Care Plan should be followed as written. The in-service review of the Charting and Documentation Guidelines included that documentation in the medical record should include the date and time of the MD and the RP notifications with all incidents. The documentation should be concise, accurate and complete. 2. An investigation of Resident #1's incident was initiated on [DATE] at 3:20 PM by the Administrator and the DON. 3. On [DATE] at 4:10 PM, the Administrator and the DON met with LPN #1 which resulted in the termination of LPN #1 due to the falsification of Resident #1's medical record which falsely indicated the MD had been notified of the fall. 4. On [DATE] at 4:30 PM, the DON notified the MSDH (Mississippi State Department of Health) by voicemail. 5. On [DATE] at 12:00 PM, the DON notified the Mississippi Board of Nursing by telephone. 6. On [DATE] at 1:19 PM, the DON submitted a report to the Mississippi Attorney General Web Submission by email. 7. On [DATE] at 2:55 PM, the DON submitted the final report to the Mississippi Board of Nursing by fax. 8. On [DATE] at 3:37 PM, the DON submitted the final report to the Mississippi Attorney General Office by fax. 9. On [DATE] at 3:54 PM, the DON submitted the final report to the MSDH by fax. 10. To identify other residents that have the potential to be affected by the deficient practice, a 100% chart review of all residents was performed by the Medical Records Nurse and the MDS (Minimum Data Set) Nurse on [DATE]. Those residents having had a fall with neurological checks since [DATE] were reviewed. The review revealed that 11 of 11 residents with falls requiring neurological checks did not have the neurological checks performed every 30 minutes x 4 as per the facility policy. 11. On [DATE] at 1:00 PM the DON in-serviced all RNs and LPNs on neurological checks . This in-service review of the Neurological Checks included that the neurological checks are to be performed every 15 minutes x 4, every 30 minutes x 4, every hour x 4, every 4 hours x 4 and every 8 hours x 3. The findings should be documented on the Neurological Assessment Flow Sheet by the nurse that performed the neurological check. 12. On [DATE] at 4:30 PM an emergency Quality Assurance meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topics discussed were the Accidents and Incidents, Neurological Checks, Falls, Physician Notification of Change in Condition or Status, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies. These policies were reviewed and action plans were put in place. 13. Beginning [DATE], at 9:00 AM, all falls resulting in neurological checks being performed will be reviewed 7 days a week by the DON, or designee, to ensure compliance with the facility policy for neurological checks. ? Incidents and documentation will be reviewed by the Quality Assurance/Performance Improvement Committee monthly. This committee will be responsible for any needed action to ensure the effectiveness of the monitoring process for residents who fall and require neurological checks. This committee will monitor the policies: Neurological Checks, Notification of MD Regarding Change in Condition or Status, Accidents and Incidents, Falls, [MEDICATION NAME] therapy, Care Plans, Charting and Documentation Guidelines and Abuse, Neglect and Misappropriation of Property to ensure they are being followed. 14. On [DATE] at 11:00 AM, an in-service was initiated by the DON for "Abuse and Neglect and Misappropriation of Property" to include all RNs, LPNs and Certified Nursing Assistants (CNAs), Housekeeping, Dietary and Maintenance. The inservice review of the Abuse, Neglect and Misappropriation of Property policy included the definitions of Abuse, Neglect and Misappropriation, examples of what constitute abuse and neglect and the consequences. 15. On [DATE] at 6:30 PM, an in-service was initiated by the Nurse Consultant for the Administrator and the Medical Director to review the duties of each role. The roles include oversight of the facility to ensure that the facility is in compliance with current rules, regulations, and guidelines, and to monitor the implementation of policy and procedures. **No staff will be allowed to work until attending required in-services. 16. On [DATE] at 10:45 AM a second emergency QA meeting was conducted by phone with the Medical Director, Administrator, Director of Nursing, Medical Records Director, Business Office Manager and the MDS (Minimum Data Set) Nurse. The topic discussed was the Abuse and Neglect and Misappropriation of Property policy. This policy was reviewed and an action plan was put in place. The facility alleged the Immediate Jeopardy was removed on [DATE]. On [DATE], the State Survey Agency surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable Credible Allegation of Compliance was verified by staff interviews and record review of in-services on [DATE] across all disciplines beginning at 1:30 PM through 4:04 PM. These interviews included LPNs, RNs, CNAs, Social Services, Activities, Dietary Staff, Housekeeping Staff, Maintenance Staff, Business Office Manager, Director of Nurses and the Administrator. The content of the in-services held on [DATE] through [DATE] were verified during each interview. Two (2) Registered Nurses and five (5) Licensed Practical Nurses (LPNs) verified being in-services on the facility's policy/procedures for Abuse and Neglect, Care Plans, Neuro Checks, Accidents and Incidents, Falls, Medical Doctor notification of change in resident condition and status, [MEDICATION NAME] Therapy and Charting and Documentation guidelines. Five (5) Certified Nurses Aides (CNAs), Two (2) Dietary Staff, Two (2) Therapy Department Staff, Three (3) Housekeeping Staff, One (1) Maintenance Staff, the Business Office Manager, One (1) Activity Staff, and One (1) Social Services Staff were interviewed and verified being in-serviced on the facility's policy and procedure on Abuse and Neglect. The Administrator verified being in-serviced on the facility's Abuse and Neglect policy, Neuro Check Policy, Care Plan Policy, Medical Doctor notification in Resident Changes and Status policy, Falls, [MEDICATION NAME] Therapy and Charting and Documentation guidelines by the Company's Consultant. Record review to verify the acceptable Credible Allegation of Compliance revealed a 100 % audit of Resident medical records to review falls and neurochecks performed since [DATE]. Record review of Licensed Practical Nurse (LPN) #1's personnel file confirmed termination of employment from the facility following the completion of the facility's investigation. Review of the Quality Assurance meetings dated [DATE] and [DATE] confirmed the meetings consisted of covering the facility's Neuro Check policy, Notification of the Medical Doctor with changes in Resident condition and status and the incident involving Resident #1, and other topics included Accidents and Incidents, Falls, Care Plans, Charting and Documentation Guidelines and [MEDICATION NAME] Therapy policies.

Based on observations, record reviews, resident interviews, staff interviews, Responsible Party (RP) interviews, Medical Director (MD) interview, and policy and procedure reviews, the facility failed to implement effective interventions to aid in the prevention of falls and/or revise care plans as needed for three (3) of 10 Resident ' s reviewed with falls. This is for Resident #2, Resident #4, and Resident #9. Resident #2 had an un-witnessed fall on 6/18/11 with no injuries; and on 9/2/11, Resident #2 had a un-witnessed fall and sustained a hip fracture. Resident # 4 had an un-witnessed fall on 3/26/11 and sustained a skin tear to the right arm. On 7/14/11, Resident #4 had an un-witnessed fall and sustained a laceration to the elbow requiring an emergency room visit and pain medications. On 12/22/11, Resident #4 had an un-witnessed fall and sustained a one-half inch laceration above the right eye. Resident #9 had an un-witnessed fall on 3/5/11 and complained of soreness to the right thigh. On 9/5/11, Resident #9 had an un-witnessed fall and sustained a skin tear to the right upper arm. On 9/6/11, Resident #9 sustained an un-witnessed fall and sustained a dime size abrasion to the head. On 11/18/11, Resident #9 sustained an un-witnessed fall and complained of right shoulder pain. On 11/29/11, Resident #9 had an un-witnessed fall and complained of pain to the left hip and left thumb. On 1/30/12, Resident #9 had an un-witnessed fall with no injuries. On 4/6/12, during the survey process, Resident #9 had an un-witnessed fall. Findings Include: Resident #2 Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) OF 4/29/11 revealed that the Brief Interview for Mental Status (BIMS) Score was "11" out of a possible "15" indicating that Resident #2 was cognitively intact. Resident #2 required only supervision with regards to ADL's. Resident #2 required limited assistance of one (1) person to physically assist with bathing. Resident #2 was identified as always continent of bowels but occasionally incontinent of bladder. Observations and Interview with Resident #2 on 4/4/12 at 12:05 p.m. and 4:55 p.m. revealed that Resident #2 was seated in a wheelchair and was unable to get out of wheelchair independently. Interview on 4/6/12 at 11:32 a.m. with Resident #2 ' s Responsible Party revealed that Resident #2 fell on [DATE] and broke her hip. She stated that Resident #2's life changed dramatically after the fall. The RP stated that Resident #2 was not able to care for herself, as much as she used to; and that she was less social that she was prior to the fall with fracture. Review of the facility " Incident Report " dated 6/18/11, revealed that Resident #2 was found sitting on the floor next to the night stand. " Stated " fell down. " The intervention stated: " Remind to use walker or call for assistance when needed. " There was no " Fall Risk Assessment " completed after the fall on 6/18/11. There was no change in the Care Plan to address the fall on 6/18/11. Review of the facility incident report revealed that Resident #2 fell in her room on 9/12/11. " Resident stated that she got up from her recliner and tripped over something and fell . Res (Resident) noted in floor on r (right) side complaining of hip pain. " The intervention on the " Supervisor ' s Investigation Report " stated " Res (resident) room should be made as barrier free as possible to avoid falls. " Resident was transported by ambulance to the hospital and admitted . Resident #2 stayed in the hospital until 9/16/11 for treatment of [REDACTED]. " Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) OF 9/23/11 revealed that the Brief Interview for Mental Status (BIMS) Score had decreased to 10 out of a possible 15. Resident #2 required supervision and setup help with regards to eating. Resident #2 had declined with regards to other ADL Activities to the point that she required extensive assistance for transfers (2+ person), dressing (2+ person), hygiene (1 person), bathing (2+ person), toileting (2+ person). Resident #2 now required total dependence (1 person) for ambulation on the unit and no longer could ambulate in the room or corridor - the activity was no longer occurring at this point. Resident #2 was now always incontinent with regards to bowel and always Incontinent with regards to bladder. Review of the facility ' s " Incident Report " revealed that Resident #2 fell in her room on 2/2/12. Resident #2 was found on the floor in her room lying on her back. Resident #2 sustained an abrasion on her left lower back. There were no changes in the care plan to address the fall. The " Supervisor ' s Investigation Report " revealed an intervention of " encourage resident to call for assistance when needed and encourage resident not to get up unassisted. " Resident #4 Record review revealed that Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview on 4/4/12 at 5:30 p.m. revealed that Resident #4's speech was slurred and slow and her answers were short and difficult to understand. Review of the Minimum Data Set (MDS) with an ARD of 03/09/2012 revealed that Resident #4 had mild impairments with daily decision making. Resident #4 required extensive assistance with transfers, locomotion, dressing, bathing, personal hygiene and two (2) plus assistance with assist with ADL's. The MDS dated [DATE] documented that Resident #4 was not continent of bowel and bladder. The record review revealed that Resident #4 had three (3) un-witnessed falls with injury as follows: 1- 3/26/11-Unwitnessed fall -The accident and incident report documented that Resident #4 was found supine on the floor, between the bathroom door and the cabinet. A 0.5x 0.1 cm (centimeter) skin tear noted to right arm. "Denies pain no immediate signs and symptoms of injury noted ... From resident's description of the accident, and the fact that the wheelchair was on its side, she apparently stumbled backwards and sat on the arm of the chair, causing it to tip over." The care plan was not revised with a new intervention after the fall on 3/26/11 and no new interventions to prevent further falls. There was no falls assessment completed on Resident #4 after the fall of 3/26/11. The facility did not document how they would attempt to prevent future falls of Resident #4. 2- 7/14/2011-Un-witnessed fall of Resident #4 in her room resulting in a laceration to the elbow and a trip to the emergency room (ER). Resident #4 received sutures to her right elbow area and a physician's orders [REDACTED]. The facility's accident and incident report stated: "Resident stated she lost her balance while transferring off toilet, and sat in the floor. Struck a shower hose hook, and received a 10 cm x 6 cm x 4 cm laceration to back of right arm." Resident was transferred via ambulance to the (ER). The care plan was not revised with new interventions after the fall of 7/14/11 to possibly prevent further falls. There was no falls assessment completed and documented after the fall of 7/14/11. There were no pain assessments completed after the fall on 7/14/11 for Resident #4. 3- 12/22/11-Un-witnessed fall with severe head laceration over right eye. The facility's accident and incident report stated: "Resident stated she was standing at her sink going to brush her teeth and lost her balance and fell ? inch cut noted above right eye." Neurological assessments were documented for each 15 minutes after the fall and Resident #4 was transported to the (ER) for evaluation via ambulance. Resident received steri-strips to right forehead above her right eye. The facility revised the care plan with a new intervention of a personal chair alarm. Record review revealed that Resident #4 had a decline in her cognitive functioning from the MDS dated [DATE] and the MDS dated [DATE] (after the falls). Resident #4 had an ADL decline between the MDS of 12/18/11 and the MDS dated [DATE]. Interview on 4/5/12 at 3:15 p.m. with Licensed Practical Nurse (LPN #1) confirmed that the care plans for Resident #4 had not been revised after each of the falls with injury on 3/26/11 and 7/14/11. LPN #1 stated that there were no falls assessments completed after the falls with injury on 3/26/11 and 7/14/11. Interview on 4/5/12 at 4:50 p.m. with Nurse Consultant confirmed that the facility had not completed a falls assessment and had not revised the care plan with new interventions after the falls with injury on 3/26/11 and 7/14/11. Nurse Consultant confirmed that Resident #4 had a fall with a head injury on 12/22/11. Interview on 4/5/12 at 5:15 p.m. with the Director of Nursing (DON) confirmed that there were no falls and pain assessments after the falls with injury on 3/26/11 and 7/14/11. The DON stated that Resident #4 had greatly declined prior to 12/18/11 and was no longer continent of bowel and bladder and was no longer able to transfer independently. The DON stated that as of 2/22/12, the facility had new policies and new procedures for assessments of falls and for revising of the care plans after each fall. The DON stated that Resident #4 had received injuries after the falls on 3/26/11; 7/14/11; and 12/22/11. Interview on 4/6/12 at 10:00 a.m. with the Medical Director (MD) confirmed that he was very aware of Resident #4. MD stated that Resident #4 had declined due to the natural causes of the disease process and advanced age. MD stated that the facility had recently changed their policies and procedures to more aggressively document interventions that have been made by the facility to prevent future falls and injuries. The MD stated that he had attended Quality Assurance (QA) meetings and the falls with injuries of Resident #4 had been discussed. Interview on 4/6/12 at 11:30 a.m. with the Responsible Party (RP) revealed that Resident #4 had greatly declined after having pneumonia in January 2011. The RP stated that after the pneumonia, Resident #4 had become weaker and weaker physically and was more dependent upon others for her needs. RP stated that Resident #4 was unable to clearly speak due to a decline in her condition but that her mind was as sharp as it had always been. RP stated that Resident #4 has become dependent upon the staff for all her physical needs and that Resident #4 knows now that she must call for assistance. RP stated that Resident #4 has learned that she may fall without assistance. Resident #9: Observation on 4/16/12 at 2:10 p.m. revealed that Resident #9 was sitting in a small low wheelchair in the dayroom at an activity with a group of other residents and staff. Record review revealed that Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 had MDS resident assessment dated [DATE] that documented that Resident #9 had a BIMS score of " 7 " which indicated moderate cognitive deficits. Resident #9 was identified to have some long and short term memory problems. Review of the facility ' s " Accident and Incident Reports " revealed: 1- 5/5/11-Un-witnessed fall. Resident #9 was found in her room after she was heard yelling out for help. Upon entering the room Resident #9 was found on the floor. She stated that she missed the chair and sat in the floor. "Stated she did not hit her head. C/O (complained of) some soreness to the right outer thigh and the area is tender to the touch. MD aware. RP aware." The pain assessment dated [DATE] stated: "Yells out when area touched." The un-witnessed fall with injury and pain was not care planned with possible new interventions after the fall with injury of 5/5/11. 2- 9/5/11-Un-witnessed fall with some complaints of soreness. " Nurse walking down the hall and heard call for help. Found Resident #9 in the floor next to her bed. " Resident #9 stated that she was trying to sit on the bed and slid off to the floor. Resident was assessed and a skin tear was noted to her upper right arm and treatment was initiated. The care plan was not revised with new interventions after the un-witnessed fall with a skin tear on 9/5/11. The facility did not complete a falls assessment after Resident #9 ' s un-witnessed fall with a skin tear of 9/5/11. There was no pain assessment for the un-witnessed fall with a skin tear and a complaint of soreness from the fall on 9/5/11. 3- 9/16/11-Un-witnessed fall with a dime size abrasion to the left side of her head. The incident report read: "Resident yelling out when entering room resident was found on the floor. Resident stated she lost her balance trying to pick her pencil up out the floor. Resident has a dime size abrasion to left side of head. Instructed resident to use call light for assistance and side rails up x 2. Ask staff to pick up objects off floor instead of bending over." The record review revealed that there was no fall assessment completed after the fall with injury on 9/16/11. There was no documentation of an evaluation of Resident #9's head injury after the fall. The care plan was not updated with new interventions to aid in the prevention of falls. The care plan had a notation on 10/12/11 stating: " multiple interventions for falls discussed with family states that they want Resident to have maximum independence and no interventions be implemented at this time." 4- 11/18/11-Un-witnessed fall with complaints of pain to right shoulder. The incident report stated: "Yelling head at nursing station. "Help" Resident observed sitting on floor. Resident said "slipped off" of the bed. Resident C/O (complained of) right shoulder pain. Administered pain med as ordered. Resident moves all extremities freely at this time. MD made aware and N.O (new order) received. Resident stated that she did not hit head. Moves all extremities upon assessment. X-ray of Right wrist and shoulder in the a.m." The care plan was not revised with new interventions after the fall with injury on 11/18/11. Resident #9 was injured and pain medications were administered. The out-come of the injuries were not documented in the incident report and were not care planned. 5-1/29/12-Un-witnessed fall with complaints of pain to left hip and left thumb. Review of incident reports for Resident #9 revealed: "She stated she stood up to go to B.R. (bathroom) and sat in floor. C/O (complaints of) pain to left hip and left thumb. Both hit the floor when she sat down. Resident instructed not to get up unassisted. To always call staff for assistance with ADL (Activities of Daily Living). Call light within reach." There was no revision of the care plan after the fall. 6-1/30/12-Un-witnessed fall. The incident report stated: "Called to room per (Name of Activity Staff). Resident noted to be sitting on buttocks in front of bed." The care plan was not revised with new interventions after the un-witnessed fall of 1/30/12. 7-4/6/12-Fall. The incident report was in progress note for a fall of Resident #9 on 4/6/12. Interview on 4/6/12 at 2:15 p.m. with Licensed Practical Nurse (LPN #2) revealed that Resident #9 had fallen again on 4/6/12 and had received no injuries. LPN #2 stated that Resident #9 could walk very short distances in her bedroom only with the assistance of a walker but that she must use a wheelchair for longer distances. LPN #2 stated that Resident #9 had to be reminded to use the walker. LPN #2 stated that the facility was still investigating the fall that occurred on 4/6/12 and were documenting the incident. Interview on 4/6/12 at 2:55 p.m. with the DON confirmed that the facility had not revised the 2011 care plan after each fall and that a falls assessment was not completed after each fall. The DON confirmed that the falls on 9/5/11 and 9/16/11 had no falls assessments completed after the falls were sustained. The DON confirmed that the care plans were not revised with new appropriate interventions after the falls of 5/5/11; 9/5/11; 9/16/11; and 11/18/11. The DON stated that as of 2/22/12, the facility had a new policy and procedure and were revising care plans with new interventions after each fall. The facility policy and procedure dated 7/1/2000 entitled "Amending Resident Assessments" read: "It is the policy of the facility to allow the interdisciplinary team to amend the resident's initial admission assessment ...There has been a significant change in the resident's condition. A significant change means any of the following: 1. Deterioration in two (2) or more activities of daily living, communication, and/or cognitive abilities that appear permanent ..." The facility did devise a significant change assessment after Resident #4 had two (2) changes in ADL's and in her cognitive status. " The facility policy and procedure dated 6/1/2000 entitled " Comprehensive Care Plan " read: "Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly." The facility did not revise the care plans after each fall to document the new interventions that the facility put in to place after each fall of Resident #2; #4 and #9. The facility policy and procedure dated 8/22/2005 entitled " Falls Potential and Prevention Protocol " (dated 8/22/2005) read: "4. A Fall Risk Assessment will be completed after each fall (as well as pain assessment and neurological exam is applicable) and updated at least quarterly. The care plan and C.N.A. Information Sheet will also be updated to reflect changes ..." The falls and pain assessments were not completed after each of the falls and injuries of Resident #2; #4; and #9.

CI MS #9883 Based on record review, staff interview and policy review, the facility failed to provide the necessary care and services for one (1) of three (3) residents reviewed, Resident #1. The facility failed to provide emergency care (oral suctioning) to clear the airway of Resident #1 who had vomited and aspirated. Resident #1 was noted unresponsive with gurgling respirations on [DATE], time unknown. EMS (Emergency Medical System) arrived at the facility on [DATE] at 10:57 p.m. and found Resident #1 sitting in a wheelchair (w/c) unattended by staff, with her head tilted back with shallow gurgling respirations. On [DATE] at 11:04 p.m., in route to the emergency room , Resident #1 went into cardiopulmonary arrest and expired on [DATE] at 11:40 p.m. in the emergency room . A discharge [DIAGNOSES REDACTED]." Findings Include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a closed record review. Resident #1 expired on [DATE] at 11:40 p.m. Review of the printed physician orders [REDACTED]. Review of a Speech Therapy screen, dated [DATE], revealed "Dysphagia managed with nectar liquids." Interview with the Director of Nursing (DON) on [DATE] at 9:30 a.m., revealed that she had fed Resident #1 her supper meal on the evening of [DATE]. The DON stated that Resident #1 received a mechanical soft diet with nectar thickened liquids. The DON stated that Resident #1 had no choking or swallowing problems and was not pocketing food that night. The DON stated that she spoke with the nurses on duty ([DATE]) the next day and was told that Resident #1 had vomited around 9:30 p.m. on [DATE] and they (nurses) had gotten Resident #1 up into her w/c and brought her to the nurses' station. The DON stated that the nurses told her that sometime before the change of shift (11:00 p.m.) they noted Resident #1 with gurgling respirations at the nurses' station and attempted to suction Resident #1 but was unsuccessful as she was biting on the tubing. The DON stated that there was no assessment or vital signs documented in Resident #1's medical record. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:30 a.m., revealed that she came on duty [DATE] around 10:45 p.m. for report. LPN #1 noted Resident #1 sitting in her w/c in front of the nurses' station with gurgling respirations. LPN #1 stated that LPN #2 said "we think she aspirated". LPN #1 stated that she tried to get an oxygen saturation level on Resident #1 but that it would not register a reading and that Resident #1 had a weak pulse of 42. LPN #1 stated that she instructed LPN #2 and Registered Nurse (RN) #1 to call the physician and EMS that Resident #1 had to "get out of here". LPN #1 stated that Resident #1's eyes were fixed. LPN #1 stated that she was upset as LPN #2 and RN #1 seemed as nothing was wrong. LPN #1 stated that no vital signs were taken and nothing was documented in the medical record. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 10:50 a.m., revealed that about 9:30 p.m. on [DATE] she was making rounds and noted Resident #1 with panting respirations. CNA #1 stated that she notified LPN #2 and RN #1. CNA #1 stated that Resident #1 was gotten up to her w/c and taken to the nurses' station. CNA #1 stated that RN #1 suctioned Resident #1, but that she did not see any vomit on Resident #1. CNA #1 stated that Resident #1 seemed better, rolled her w/c chair around a bit before shift change. CNA #1 stated that before shift change (time unknown) she was sitting with and talking to Resident #1 and suddenly Resident #1 went unresponsive. CNA #1 stated that LPN #1 was working with Resident #1 while LPN #2 and RN #1 were trying to get papers ready to send Resident #1 out to hospital. Interview with RN #1 on [DATE] at 12:15 p.m., revealed that she had worked the ,[DATE] shift on [DATE]. RN #1 stated (time unknown) that CNA #2 reported to her that Resident #1 was not "acting right". RN #1 stated that Resident #1 appeared like she was holding something in her mouth. RN #1 stated that she was a new RN and was not as familiar with Resident #1 as LPN #2 and CNA #2 were. RN #1 stated that she and LPN #2 tried to do a finger sweep of Resident #1's mouth and suction her mouth but only got back some "green mushy substance". RN #1 stated Resident #1 was not in any distress and was assisted out of bed to her w/c and brought to the nurses' station. RN #1 stated that before 11:00 p.m. LPN #2 noted that Resident #1 was congested. RN #1 stated that and a finger sweep of Resident #1's mouth was attempted with nothing obtained and the physician and EMS was called. RN #1 stated that nothing was documented concerning the care for Resident #1 but she thought that LPN #2 had documented the incident. Interview with CNA #2 on [DATE] at 2:10 p.m., revealed that worked the ,[DATE] shift on [DATE]. CNA #2 stated that between 9:15 p.m. and 9:30 p.m. Resident #1 was noted in bed making "throat noises". CNA #2 stated that when Resident #1 was sat up on the side of the bed Resident #1 started having "mucus secretions". Resident #1 was gotten up in the w/c and taken to the nurses' station and suctioned. CNA #2 stated that she did not see Resident #1 again as she went to the personal care side to finish her rounds. Interview with LPN #2 on [DATE] at 9:15 a.m., revealed that CNA #2 reported that Resident #1 needed to be checked (time unknown). LPN #2 stated that when she got to the room RN #1 and CNA #2 had Resident #1 sitting up on the side of the bed. LPN #2 stated that Resident #1 looked like she had "spit up" on her shirt. LPN #2 stated that Resident #1 was gotten up into her w/c and brought to the nurses' station and that Resident #1 seemed better as she rolled herself around in her w/c, this was around 9:30 p.m. LPN #2 stated that shortly before 11:00 p.m. LPN #1 noted that Resident #1 sitting in her w/c was not responding and her head was tilted back. LPN #2 stated that they (LPN #1, LPN #2 or RN #1) did not attempt to suction Resident #1 as there was no order to do so. LPN #2 further stated that no vital signs were taken, but that LPN #1 did try to get oxygen saturation on Resident #1. Interview with EMS #1 on [DATE] at 12:15 p.m., revealed that on arrival to the facility Resident #1 was noted slumped down in her w/c with her head tilted back against the back of the w/c with shallow gurgling respirations. EMS #1 stated that there were two (2) nurses behind the nurses' station and another doing something in the hall. EMS #1 asked the nurses (names unknown) if they had tried to suction Resident #1 and they stated "no". EMS #1 stated that he and his partner removed Resident #1 from the w/c to the stretcher and began suctioning food and fluid from Resident #1's mouth and throat. EMS #1 stated that one of the nurses's stated that Resident #1's oxygen saturation was "66". EMS #1 stated that Resident #1 was unresponsive and after loading Resident #1 into the ambulance Resident #1 went into Cardiopulmonary Arrest and CPR (cardiopulmonary resuscitation) was initiated. EMS #1 stated that Resident #1 had aspirated and was not attended by staff when they got there. Interview with LPN #1 on [DATE] at 3:00 p.m., revealed that when Resident #1 was noted gurgling near shift change no suctioning was done to clear the airway. LPN #1 stated that she did not know what they (LPN #2 and RN #1) had done for Resident #1 prior to her arrival, but Resident #1 was in distress when she found her at shift change. Review of the nurse's notes for [DATE] revealed the following: 11:00 p.m. "Pt (patient) lethargic; non-responsive MD notified; pt transferred to (name) ER per ambulance; attempted to notify family no answer; attempted to notify DON no answer left message to call facility. 11:50 p.m. (name) ER nurse called facility to notify Res. (resident) expired." Review of a hand written note, dated [DATE], by the DON, revealed "Spoke with (name) LPN #1 and (name) RN #1 d/t (due to) (name) Resident #1 being sent to hospital and death. (Name) RN #1 stated that she and (name) LPN #2 were notified by (name) CNA #2 that resident had vomited approx. (approximately) 9pm. Both nurses went to room and placed resident in w/c and took her to nurse's station. (Name) RN #1 stated that resident proceeded to wheel self up and down hall. (Name) LPN #1 came in and report was started when she looked and noticed that "something was not right" with (name) Resident #1. Both nurses's stated that she was breathing and had a pulse. Both nurses's stated they began procedure to get resident transferred out to ER." Review of the emergency room record, dated [DATE], revealed "11:34 p.m. upon arrival to ER pt pupils was fixed, no respiration, no pulse appreciated EKG (electrocardiogram) showed asystole at 11:40 p.m. pt was considered deceased . Clinical impression Cardiopulmonary arrest secondary to aspiration." Review of the EMS report, dated [DATE], revealed arrival to the facility at 10:57 p.m. "pt found sitting in w/c unattended, head tilted back gurgling O2 (oxygen) sat monitor on pt upon arrival EMS-N.H. (nursing home) staff states O2 sat "66"- EMS asked if N.H. staff had suctioned pt and they advised "no". Food particles on shirt near mouth. Unresponsive, pupil's clouded/sluggish, food/fluid in oropharynx, Bilat (bilateral) breath sounds: Rales/Rhonchi Bilat. With shallow gurgled respirations, suctioned copious amounts of fluid/food particles from mouth/oropharynx." Review of the facility's policy for Emergency Care, dated [DATE], revealed "Responsibility: Licensed Nurse Purpose To provide emergency care to a resident in need of urgent services. Procedure If resident's condition has changed, call attending physician and report changes and nursing observations. Provide emergency care as needed. Record details and exact time of condition changes of resident, initiation of emergency procedures and resident's response to emergency care. Documentation date, time, reason emergency care is required. Vital signs, assessment and all observations related to the resident's condition. Observation of the resident at regular intervals. Signature and title." Review of the facility's policy for Suctioning, dated [DATE], revealed "Purpose 1. To remove secretions from the mouth, oropharynx, nasopharynx. 2. To prevent airway obstruction. 3. To prevent aspiration of secretions from the mouth, oropharynx and nasopharynx. Documentation 1. Date, time, procedure. 2. Amount, color and consistency of material suctioned. 3. Condition of mouth, oropharynx, and nasopharynx. 4. Frequency of suctioning. 5. Notification of physician if condition changes. 6. Signature and title." Review of the facility's policy for Charting dated [DATE] revealed "It is the policy of this facility that all services provided to the resident or any changes in the resident's condition be recorded in the resident's medical record." There was no documented evidence of an assessment in the medical record for Resident #1 at 9:30 p.m. or shortly before 11:00 p.m. There was no documented evidence that any type of emergency care was provided to clear Resident #1's airway.