Every finding on record at Capri Health and Rehabilitation Center

Based on record review, interview, and observation, the facility failed to implement policies and procedures to investigate allegations of abuse and neglect for 1 of 2 (#1) residents sampled. The findings included: A policy on Abuse, Neglect, Exploitation, Mistreatment, and Injury of Unknown Origin (ANEMMI) last revised on 1/24 which stated that the Center will seek and accept concerns, complaints, or grievances from residents, resident families and staff without reprisal. The right to report a concern or incident is not limited to a formal, written grievance process, but includes any verbalized complaint to any facility staff member. Any resident event that is reported to any staff by resident, family, or their staff or any other person will be considered as possible ANEMMI if it meets any of the following criteria: A. Any resident or family complaint of physical harm, pain or mental anguish resulting from willful infliction from others. Any and all staff observing or hearing about such events must report the event immediately to the Administrator, Immediate Supervisor and one of the following, the Director of Nursing (DON), ANNEMI Prevention Coordinator, or Risk Manager, so that appropriate reporting and investigation procedures take place immediately. B. Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being to include toileting issues. Resident #1 is a vulnerable adult who was admitted to the facility on [DATE]. She is diagnosed with Parkinson's disease, vascular dementia, anxiety disorder, muscle weakness, dysphagia, and cognitive communication deficit. Resident #1 was last assessed as cognitively intact on 1/29/25 by scoring a 13 on the Brief Interview of Mental Status (BIMS), a test for potential cognitive impairment. The resident was receiving Speech Therapy for her aphasia (language disorder which affects a person's ability to communicate) until 4/22/24. The resident is not currently receiving speech therapy for her difficulty with voice volume and phonation (ability to produce sound), she was last seen 4/22/24. A Social Service Assessment was performed on 2/24/25 which showed that the resident had a negative trauma screen and was documented as usually understood. On 3/26/25 at 10:00 a.m., during an interview Resident #1 said, a man laid in bed with me when asked about the incident. There was an allegation of someone coming into her room. The resident was asked, How did that make you feel? The resident said, scared and can't sleep. When asked was it a staff member or a resident? She replied, A resident. The resident then began using repetitive words, and it became difficult to continue the interview. On 3/26/25 at 10:26 a.m., direct observation of Resident #1 sitting in a wheelchair in her room with a mesh banner across her doorway that said STOP. On 3/26/25 at 10:30 a.m., during an interview the Director of Nursing (DON) said that she did not interview the resident when she became aware of the allegation. The DON verified she did not contact the resident's daughter, did not interview other residents on the unit, and did not notify the Administrator of the allegation. The DON didn't believe that any of the male residents on that floor could transfer from a wheelchair to a bed without assistance. The DON said she believed that the STOP banner was sufficient to make the resident feel safe and that the event was likely a matter of another resident wandering into her room by mistake. On 3/26/25 at 11:19 a.m., during an interview Resident #1 said that yes the uninvited resident put his hands in the bed, and yes that she believed he was trying to get into bed with her. The resident was then observed to draw both of her hands under her chin and her eyes became wide. The resident appeared tense and the interview was stopped. On 3/27/25 at 9:34 a.m., during a phone interview the Hospice Director said that Resident #1's daughter notified Hospice via a phone call to report that her mother had a man come into her room and get in bed with her. We were told that she reported the incident to the DON at the facility. On 3/27/25 at 11:44 a.m., during an interview the Administrator stated, it is possible that someone getting into bed with another resident could be an incident that needs to be reported, depending on the situation. On 3/27/25 at 3:28 p.m., during an interview Staff A Licensed Practical Nurse (LPN) stated that the night shift staff knows who can walk but was not aware of a list of residents who wandered.

Based on observation and interview, the facility failed to ensure housekeeping and maintenance services to maintain a safe, functional, sanitary and comfortable environment for residents, staff and the public on the first and second floor of the facility. The findings included: During a tour of the facility on 9/24/24 at 5:00 p.m., the following environmental observations were made: A black substance was observed on the ceiling vents and surrounding ceiling tiles of the Capri reading room, the first floor hallway near the elevator, and the Social Service Office on the second floor 2nd floor. Photographic evidence obtained. The floor and cove base of the first floor hallway near the nourishment room, the first floor hallway near the central bath, the memory care near the speech therapy room, and near room [ROOM NUMBER] were in poor repair, cracked and separating. Photographic evidence obtained. The wallpaper was peeling from wall with orange discoloration coming through the paper in the memory care near the speech therapy room and the second floor hallway near the elevators Photographic evidence obtained. Black biogrowth was observed on the walls and/or ceiling of the second floor wall across from the elevator and the ceiling tiles of the second floor storage room. Photographic evidence obtained. On 9/25/24 at 9:13 a.m., in an interview the Administrator said they had received quotes for roof replacement which had been sent to corporate for review. The Administrator agreed areas of the building were getting old and could use some attention. She said they had begun working on the walls and wallpaper, but due to the impending hurricane staff had been sent to sister facilities. She said at this time there was no definitive end date for the repairs but was working on getting a plan in place.

Based on observation, interview, and record review, the facility failed to develop a resident centered care plan to meet the needs of 1 (Resident #45) of 3 residents reviewed with impaired hearing. The findings included: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included mixed conductive and sensorineural hearing loss, and cochlear implant (Surgically implanted device that helps people with severe to profound hearing loss perceive sound) status. Review of the Significant Change in Status Assessment with a target date of 8/26/24 revealed Resident #45's hearing was highly impaired with absence of useful hearing. Resident #45's cognition was moderately impaired with a Brief Interview for Mental Status score of 09. The care plan initiated on 10/16/23 and revised on 10/26/23 noted Resident #45 had a communication problem related to hearing deficit. Per the resident's family, the cochlear implant has stopped working. The care plan initiated on 10/9/23 noted Resident #45 was able to make leisure needs and preferences known. The resident preferred a balance of social and independent leisure activities. The goal was for the resident to express satisfaction with leisure routine. The interventions included to encourage in-room leisure time such as television. On 9/23/24 at 5:27 a.m., Resident #45 was observed in the bedroom with eyes closed. The resident did not respond to interview questions. On 9/23/24 at 11:50 a.m., in an interview the resident's spouse said Resident #45 was 100% deaf. She told staff numerous times it was important for them to turn on the closed captioning (text that reflects an audio track and can be read while watching visual content) when he watched television since he could not hear. She said Resident #45 was not able to turn on the closed captioning himself. Resident #45's spouse said it should be a simple thing to do but the staff don't turn it on. She said every time she visits, she has to turn it on herself, including when she arrived today. On 9/24/24 at 9:51 a.m., Resident #45 was observed in a wheelchair facing the television set. The closed captioning was not turned on. No text was displayed on the television screen. The television remote control was observed on the nightstand on the opposite side of the bed and was not within reach of the resident. On 9/25/24 at 9:18 a.m., Resident #45 was observed in his room. The television was on but the closed captioning was not turned on. No text was displayed on the television screen. Licensed Practical Nurse (LPN) Staff Y verified the closed caption function was not turned on. In an interview LPN Staff Y said she knew Resident #45's hearing was impaired. She acknowledged there was no care plan interventions to remind staff to turn on the closed caption when Resident #45 was watching television. On 9/25/24 at 9:26 a.m., the Minimum Data Set (MDS) coordinator said she was responsible to ensure care plan interventions were individualized to meet the needs of each resident. The MDS coordinator verified Resident #45's care plan included to encourage in-room leisure time such as television but did not direct staff to turn on the closed caption since the resident's hearing was highly impaired.

Based on observation, review of the clinical record, review of facility policy, resident and staff interviews, the facility failed to consistently apply a physician ordered orthotic device to prevent the decline in range of motion for 1 (Resident #32) of 1 resident reviewed with contractures (rigidity of joint). The findings included: The facility policy Standards and Guidelines : Physician Orders documented Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. Physician should be notified and the responsible party if indicated. Review of the clinical record revealed Resident #32 had an admitted [DATE] with diagnoses including Parkinson's disease, anxiety and muscle weakness. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 9/7/24 documented Resident #32 was dependent on staff for activities of daily living. The MDS noted Resident #32's cognitive skills for daily decision making were moderately impaired. The Physician orders dated 6/28/24 included for the resident to use bilateral palm guards during the day shift. Remove as needed during hygiene care and during meals. Review of the Certified Nursing Assistant (CNA) care Kardex ( provides instruction for resident care) instructed to use bilateral hand palm guards during the day shift. Remove as needed during hygiene care and during meals. Check skin integrity. On 9/23/24 at 5:47 a.m., and at 3:45 p.m., Resident # 32 was observed in his bed. The resident's hands were contracted. Resident #32 was not wearing the splinting device as ordered. Two hand splints were observed on the nightstand. On 9/24/24 at 10:23 a.m., Resident #32 was observed in bed without the physician's ordered splints to his hands. The splints were observed on the nightstand. On 9/24/24 at 10:30 a.m., CNA Staff A said she was not aware the resident had hands splints. Staff A said she had not observed the resident using the hand splints in a while. On 9/24/24 at 2:53 p.m., Resident #32 was observed in his room in bed without the splints to his hands. In an interview Resident #32 said he did not know why he did not have the hand splints on, and he did not refuse to wear them. On 9/24/24 at 3:00 p.m., during a joint observation with Licensed Practical Nurse Staff D confirmed Resident #32 was not wearing the palm protectors (splints) to his hands as ordered. Resident #32 told the nurse he did not know where his palm protectors were and said no one applied the splints for him. On 9/24/24 at 3:37 p.m., in an interview Occupational Therapist Staff E said Resident #32 was to wear the palm guards daily.

Based on observation, review of facility policy and procedures, record review, staff and resident interviews, the facility failed to provide the necessary care and services to meet the needs for 3 (Resident #999, #875 and #900) of 5 residents reviewed for activities of daily living (ADLs). The findings included: The facility policy Standards and Guidelines : ADL Care and Services issued 4/2020 (revised 1/2024) documented :Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition grooming and personal and oral hygiene . Residents will be provided with care treatment and services to ensure that their activities of daily living are met . Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene bathing dressing grooming nail care and oral care . The resident has the right to refuse any and all ADL care the refusal of care will be documented in the resident's medical record with the appropriate notification including the physician and resident representative. 1. Review of the clinical record revealed Resident #999 had an admitted [DATE] with diagnoses including stage 4 pressure ulcer to the sacral region, protein calorie malnutrition and muscle weakness. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 5/9/24 documented the resident was dependent on 1-2 staff for bathing. The MDS noted Resident #999's cognitive skills for daily decision making were moderately impaired. Review of the Certified Nursing Assistant (CNA) documentation for May 2024 revealed the resident refused showers on 5/13/24, 5/20/24, 523/24. On 5/30/24 there was no documentation that a shower was provided. The CNA documentation for June showed N/A [not applicable] on 6/3/24 and 6/17/24. There was no documentation in the clinical record the resident had refused care. On 6/6/24 and 6/13/24 the documentation revealed the resident refused showers. There was no documentation in the clinical record indicating the staff attempted to encourage bathing. On 6/24/24 at 10:30 a.m., Resident #999 was observed in bed, her hair was uncombed, and she looked unkempt. In an interview, the resident said she had not received a shower for a while now. She said, I have asked but all I get is a bed bath once a week. 2. Review of the clinical record revealed Resident #875 had an admitted [DATE] with diagnoses including muscle weakness, repeated falls, and compression fracture of the first lumbar vertebrae. The Admission Minimum Data Set with an assessment reference date of 6/17/24 documented Resident #875 required substantial to maximum assistance for bathing and partial to moderate assistance for personal hygiene. The MDS noted Resident #875's cognitive skills for daily decision making were moderately impaired. On 6/24/24 at 10:45 a.m., in an interview Resident #875 said staff did not assist her with showers. She said, They give me bed baths. I want a shower, but they said it is easier for them to do a sponge bath, so I just gave up. Resident #875 was observed in her bed. Her hair was greasy and uncombed. She had long fingernails, extending approximately 1/4 inch with a brown substance under several nails. Review of the CNA task list failed to show documentation the resident was scheduled for showers or had received any showers since her admission. On 6/24/24 at 12:00 p.m., in an interview Licensed Practical Nurse (LPN) Staff D said she did not know why the resident did not receive any shower since admission. She said all the residents are scheduled for a shower twice a week. LPN Staff D said, I know the CNA will make three attempts to encourage the resident to shower and then the nurse will try. 3. Review of the clinical record revealed Resident #900 had an admitted [DATE] with diagnoses including hemiplegia and hemiparesis affecting the left side, contracture of the left hand and right and left foot drop. The plan of care identified Resident #900 had an ADL self-care deficit and indicated the resident was dependent on 2 staff members for bathing. On 6/24/24 at 2:25 p.m., in an interview Resident #900 said, I don't get showers because they come in all rude and throw the towels on the foot of the bed and say it's time for your shower. I don't know who they are because they have changed staff so much. They don't introduce themselves. Resident #900 said, I do take showers sometimes, if the staff are polite. Resident #900 was in bed during the interview. She appeared unkempt. Her hair was uncombed and severely matted. Her bedding was in disarray and soiled with food crumbs. The resident was completely nude in the bed with a soiled bath towel covering her upper torso. The resident was noted to have contractures of the left shoulder, hand and arm. Review of the care plan initiated 10/30/23 documented Resident #900 is resistive to care/refusing care (heel protectors/boots, showers, medications, treatment, getting out of bed etc. The interventions included: Educate resident/family of the possible outcomes of not complying with treatment of care. Give clear explanation of all care activities as they occur during each contact. Provide consistency within care to promote comfort with ADL's. Review of the CNA documentation for May 2024 documented N/A on 5/4/24 and 5/14/24. The resident refused a shower on 5/23/24 and 5/29/24. Review of the CNA documentation for June 2024 revealed the resident refused scheduled showers on 6/1/24, 6/5/24, 6/8/24, 6/22/24. On 6/26/24 at 2:00 p.m., in a telephone interview Resident #900's son said his mother was very lucid and makes decisions for herself. The son said as a family they expressed concerns related to the care of his mother at the quarterly care plan meeting. He said even though his mother was set in her ways, and it is painful for her but they don't even try to get her out of bed. They even hold care plan meetings in her room. The management staff told him it was easier than getting her out of bed. The resident's son said no one from the facility discussed her personal hygiene or refusal of showers with him. He said he thought his mother received a shower at least weekly. On 6/25/24 at 11:40 a.m., in an interview the Director of Nursing (DON) said when a resident refuses a shower, three attempts are made. If the resident still refuses, the CNA alerts the nurse and it is documented. The DON said the nurse is responsible to document the refusal in the electronic record. The DON said the staff will notify the family and ask them to speak with the resident to see if they can encourage the resident. We call the family as well and let them know their loved one has refused bathing or any other care. The DON said Resident #900 was alert and oriented and had the right to refuse care. She said, It is in her care plan as well. On 6/25/24 at 12:53 p.m., in an interview CNA Staff G said, the policy is to try three different times during the shift to offer a shower. If the resident continues to refuse, she notifies the nurse. The nurse will speak with the resident. If the resident continues to refuse the shower, the nurse documents the refusal. CNA Staff G said she will then offer a bed bath to the resident. On 6/25/24 at 2:53 p.m., in an interview Unit Manager Staff H said the CNA is to make three attempts to shower the resident then notify the nurse if the resident still refuses. She or the nurse would then try and encourage the resident to shower. If the resident still refuses, the nurse will document the refusal. The Unit Manager said she did not know until 6/24/24 Resident #900 had been refusing showers multiple times. She said Resident #900 was set in her ways and, if she doesn't want it, she doesn't want it. Staff H said it was the resident's right to refuse to shower but she had not collaborated or discussed with staff the reason for the refusal and how they could encourage the resident to accept her showers. On 6/26/24 at 3:08 p.m., in an interview the Medical Director, he said he was not aware Resident #900 was refusing showers. The Medical Director said, The memory changes and someone can be fully demented and still refuse care. We can't physically drag a patient into the shower and force them to shower.

Based on record review, review of facility policy and procedures and resident and staff interviews the facility failed to ensure pain medications were provided in accordance with professional standards of practice and physician orders for 2 (Resident #99 and #399) of 3 residents reviewed for pain management. The findings included: The facility policy Medication Administration issued 10/2020 (revised 1/2024) specified: medications are ordered and administered safely and as prescribed. The director of nursing services directs all personnel who administer medications and or have related functions. Medications are administered in accordance with prescribed orders, including any required time limit. If a drug is withheld, refused, or given at a time other than the schedule time, the individual administering the medication shall document the rationale in the residence medical record and notify the physician and responsible party if indicated. 1. Review of the clinical record revealed Resident #99 had an admitted [DATE] with diagnoses including colon cancer, rheumatoid arthritis and major depressive disorder. On 6/25/24 at 8:25 a.m., in an interview Resident #99 said she was not consistently receiving her pain medications and was informed by the nurse that the pharmacy did not send it. The resident said she was to receive scheduled Oxycodone 5 milligrams (mg) at 6:00 a.m., and 12:00 p.m. Resident #99 said, the medication was scheduled and after that I have to ask for it. I can have it every six hours as needed. Every month they run out and no one can tell me why. I have reported it to the nurse, the Social Worker, and the Unit Manager. No one can tell me why they keep running out and there is always a two-to-three-day gap before I get my medication. I usually take a total of three pain pills per day. My pain is in my back, abdomen and left leg as it swells up. Sometimes I cry because it hurts so bad the pain gets to a 10/10. By that time my whole body is hurting. Review of the physician's orders revealed an order dated 4/19/24 to administer Oxycodone 5 mg two times a day, to be given at 6:00 a.m., and 12:00 p.m. The physician's orders dated 4/19/24 included to administer Oxycodone 5 mg every 6 hours as needed for pain after the routine 12:00 p.m. dose. Review of the June 2024 Medication Administration Record (MAR) lacked documentation the routine Oxycodone 5 mg was administered on 6/2/24 (6:00 a.m., and 12:00 p.m.), on 6/3/24 at 6:00 a.m., on 6/17/24 at 12:00 p.m., and on 6/23/24 at 12:00 p.m. On 6/2/24 at 5:16 a.m., the nurse documented on a progress note the Oxycodone was on order. On 6/2/24 at 1:42 p.m., the nurse documented the Oxycodone was not available. On 6/3/24 at 6:09 a.m., the nurse documented awaiting delivery On 6/23/24 at 12:13 p.m., the nurse documented the Oxycodone 5 mg was not available. On 6/25/24 at 12:02 p.m., in an interview Licensed Practical Nurse (LPN) Staff E said she has been employed at the facility less than two months. Staff E said sometimes the medications are not available. Staff E said, I don't know why but sometimes the pharmacy does not bring the medications. You need to call the pharmacy and ask them to send the medication. 2. Review of the clinical record revealed Resident #399 had an admitted [DATE] with diagnoses including, right hip fracture, end stage renal disease and anxiety. On 6/26/24 at 9:00 a.m., in an interview Resident #399 said she had a fall at another facility and broke her right hip. I am getting my pain medication most of the time. The nurse gives it to me. I can have it so many times a day and then I have to ask for it. Sometimes my hip hurts so bad 10 out of 10. I ask for a pain pill and they don't give it to me. Review of the Physician's order dated 5/21/24 documented to administer Oxycodone HCl oral tablet 5 mg one tablet by mouth three times a day for pain. Review of the MAR for May 2024 failed to reveal documentation the resident received the scheduled dose of Oxycodone on 5/21/24 at 6:00 a.m., 5/26/24 at 6:00 a.m., 5/31/24 at 2:00 p.m., 6/2/24 at 6:00 a.m., 6/4/24 at 10:00 a.m., 6/6/24 at 10:00 a.m., and 2:00 p.m Review of the nursing progress notes failed to show documentation of the reason why the Oxycodone 5 mg was not administered as ordered. On 6/25/24 at 12:30 p.m., in an interview the Director of Nursing (DON) said, if a medication was unavailable the nurse can get it from the Pyxis (emergency medication dispensing machine) and contact the pharmacy for delivery. The DON said, Resident #99 confabulates things and it is in her care plan. On 6/25/24 at 1:05 p.m., in an interview the DON said he checked the Pyxis and on 6/2/24 the last Oxycodone 5 mg was removed. The quantity delivered by the pharmacy was 20 Oxycodone 5 mg tablets in the Pyxis. The same thing occurred on 6/22/24, the last Oxycodone 5 mg tablet was removed so it would be empty on 6/23/24. The DON said, I do know we have been having issues with the pharmacy and the delivery of medications this month, I don't know why. I will contact them and increase the par for the Oxycodone 5 mg in the Pyxis. The DON said he did not know when the pharmacy delivers the medications or restocks the Pyxis. The DON said he was not aware Resident #99 had missed several doses of the scheduled pain medication. On 6/26/24 at 9:45 a.m., in an interview Unit Manager Registered Nurse Staff H said when medications are needed they text the physician. They call the pharmacy when they are running low on medications, and if the medication is not at the facility. Staff H said they also check the computer system to see when the medication was reordered and call the pharmacy. She said she was aware Resident #99 ran out of her pain medication twice but she was not in pain when the medication was not available as documented on the MAR. Staff H said Resident #99 also receives Tylenol, Gabapentin and Ibuprofen for pain. On 6/25/24 at 10:00 a.m., review of the Pyxis medication log with the DON showed one Oxycodone 5 mg remaining with a PAR (Periodic Automatic Replacement) level of 10 tablets of Oxycodone. The DON said, You tell me what to do when the pharmacy is not delivering the medications. What do we do? The DON said he did not have weekly or monthly interdisciplinary team (IDT) meetings with the staff to review residents with repeat issues/concerns/care needs. The DON said they have a monthly staff meeting and there is a care plan meeting. On 6/26/24 at 3:08 p.m., in an interview the Medical Director said he was not notified Resident #99 and #399 had missed doses of scheduled pain medication and said he knew there were issues with the pharmacy, the facility was working on that.

Based on observation, review of facility policy and procedures and staff interview, the facility failed to provide a clean, safe and sanitary environment for residents in 6 (Rooms 110, 113, 114, 116, 118 and 119) of 17 rooms observed on the Memory Care Unit. The findings included: On 6/24/24 at 9:30 a.m., during an initial tour on the Memory Care Unit the following was observed: 1. room [ROOM NUMBER]. In the bathroom there was a bed pan on the floor next to the toilet, a wash basin wedged between the toilet and the wall. There was a container of disinfecting wipes behind the toilet on the floor with a soiled washcloth. Photographic evidence obtained. 2. room [ROOM NUMBER]. The bathroom had cracks in the tiles, brown and black grime on the tiles surrounding the base of the toilet. Photographic evidence obtained. 3. room [ROOM NUMBER] A. Multiple bottle of lotion, cream and sprays were stored in two wash basins on the nightstand. Photographic evidence obtained. 4. room [ROOM NUMBER] B. Bottle of body lotion, shampoo and body wash were stored in a caddy. Photographic evidence obtained. 5. room [ROOM NUMBER]. A wash basin was stored on the floor under the sink, and another one was stored on the floor next to the toilet. Photographic evidence obtained. 6. room [ROOM NUMBER]. A wash basin was stored on the bathroom floor behind the toilet. The tile surrounding the base of the toilet had a black substance on the tiles. Photographic evidence obtained. 7. room [ROOM NUMBER]. A wash basin was stored on the floor in the bathroom near the toilet. Two packs of incontinent wipes, a soiled washcloth, a bottle of lotion and a bottle of foaming wash were stored on the toilet tank. Photographic evidence obtained. 8. room [ROOM NUMBER] A. A tube of antifungal cream was stored unsecured on the nightstand. A nebulizer (machine used to deliver medication into the lungs) mask was observed uncovered on the machine. Photographic evidence obtained. On 6/24/24 at 11:30 a.m., in an interview the Director of Nursing (DON) was informed of the concerns and findings on the Memory care unit. The DON said he had not toured the unit. On 6/24/24 at 11:40 a.m., Certified Nursing Assistant (CNA) Staff C was observed coming down the Memory Care Unit hallway with bags of wash basins and bed pans. Staff C said the DON had called the unit and said to remove them from the bathroom floors. CNA Staff C said resident personal care items should be stored in the resident's bedside dresser along with the wash basins. On 6/24/24 at 11:49 a.m., Licensed Practical Nurse Staff A verified the items left in the bathroom on the floors and said, I know, the wash basins should not be on the bathroom floor. The personal care items can be left out. On 6/24/24 at 12:30 p.m., in an interview the Regional Nurse Consultant (RNC) verified the residents' personal items were left unsecured in the dementia unit, including bottles of shampoo, lotion, sprays and disinfecting wiped. He said the residents on that unit wander. He said, I can't guarantee that a resident won't eat or drink it but like I said, it is not a psych ward. The RNC said he did not know what the policy was for keeping personal items on the Memory Care Unit.

Based on review of facility policy and procedures, record review, staff and resident interviews, the facility failed to provide the necessary care and services to ensure each resident who is incontinent of urine is identified, assessed and provided appropriate incontinent care for 2(Resident #999 and #900) of 3 residents reviewed with incontinence. The findings included: The facility policy Standards and Guidelines : ADL Care and Services issued 4/2020 (revised 1/2024) documented :Residents who are unable to carry out activities of daily living (ADLs)independently will receive the services necessary to maintain good nutrition grooming and personal and oral hygiene. Residents will be provided with care treatment and services to ensure that their activities of daily living are met. Appropriate care and services will be provided for residents who are unable to carry out ADL's (activities of daily living) independently, with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with hygiene and elimination(toileting). 1.Review of the clinical record revealed Resident #999 had an admitted [DATE] with diagnoses including stage 4 pressure ulcer to the sacral region, protein calorie malnutrition and muscle weakness. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with a date of 5/9/24 documented the resident was frequently incontinent of bladder and always incontinent of bowel. The MDS noted Resident #999's cognitive skills for daily decision making were moderately impaired. The care plan identified Resident #999 required assistance with ADLs including toileting. The interventions specified The resident is not able to participate in the task at all and will need staff to move, clean, and dress them. This may require the dependent assistance of two people to be done thoroughly and safely. On 6/24/24 at 10:30 a.m., during an interview Resident #999 said I am left in bed and not always assisted out of bed. I use a lift and I can't use the bathroom. When I wet on myself, they don't come or they tell me they will be back with help to change me, but they do not come back. I lay here wet, and I don't like it. The resident said I have a wound on by backside and it is not good for me to be wet. 2. Review of the clinical record revealed Resident #900 had an admitted [DATE] with diagnoses including hemiplegia and hemiparesis affecting the left side, contracture of the left hand and right and left foot drop. The plan of care identified Resident #900 had was at risk for complications related in bowel or bladder incontinence. The care plan interventions specified, Toileting: The resident is not able to participate in the task at all and will need staff to move, clean, and dress them. This may require the dependent assistance of two people to be done thoroughly and safely. Provide incontinence care with each incontinent episode as tolerated. On 6/24/24 at 2:25 p.m., in an interview Resident #900 said the staff say they change us every two hours but it is more like every four hours. I put the light on to be changed and they turn it off and don't return. I have to have two people because I fell out of bed two years ago when one CNA was changing me. They can never seem to find another person to help. Being wet is not pleasant, I want to be changed. On 6/24/24 at 11:40 a.m., Certified Nursing Assistant (CNA) Staff C said we try and toilet the resident whenever they ask. Every couple of hours if they are incontinent, we clean the resident and change them. On 6/25/24 at 12:02 p.m., in an interview Licensed Practical Nurse (LPN) Staff E said I think the CNA's are to toilet/change residents every 2-3 hours and when they request it. On 6/25/24 at 9:30 a.m., in an interview CNA Staff F said in my opinion the emergency light should be answered immediately or within 1 minute. I try to think if it were me that is what I would want. I don't know if the facility has a toileting program and I can only speak for myself, but I try and toilet or change residents every 2 hours. Most of the residents will let you know if they have to use the toilet or they need to be changed. On 6/25/24 at 12:53 p.m., in an interview CNA Staff G said, we toilet the residents every few hours, there isn't a schedule, you just do. 6/25/24 at 8:50 a.m., in an interview the Director of Nursing (DON) said the facility did not have a toileting program. When asked what the expectation was for staff providing assistance for continent and incontinent residents, the DON replied the same as it would be at any other place.

Based on observation, review of facility policy and procedures, review of clinical records and staff and resident interview, the facility failed to secure all medications in a locked storage compartment and failed to ensure 1 medication cart (East wing) of 5 medication carts was secured and locked when out of the direct supervision of the nurse. The findings included: The facility policy Medication Storage and Labeling issued 3/2021 (revised 01/2024) specified The facility stores all drugs and biological's in a safe, secure, and orderly manner. Drugs and biological's used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 1. On 6/24/24 at 2:25 p.m., during an observation on the second floor, the medication cart on the East Wing was observed unlocked, and unattended. Two nurses were observed standing in the East hallway talking. The medication cart was not under direct observation of the nurses. One resident was observed in a wheelchair going past the unsecured medication cart. Photographic evidence obtained. On 6/24/24 at 2:27 p.m., Licensed Practical Nurse (LPN) Staff K quickly came up the hall to the cart and said, I know it was unlocked. I had an emergency. I had to go and I ran and I forgot to lock it. 2. On 6/25/24 at 9:40 a.m., a large bottle of antacid was observed on Resident #800's bedside table. Photographic evidence obtained. In an interview during the observation Resident #800 said, I keep them here and take them when I have heartburn. Resident #800 opened the bottle, placed two antacid tablets in his mouth, chewed and swallowed them. On 6/25/24 at approximately 9:45 a.m., LPN Staff E went in the resident's room and confirmed the observation of the bottle of antacid stored on the resident's bedside table. LPN Staff E said she did not know if it was permitted to self-administer and store medications at the bedside. Review of the clinical record for Resident #800 revealed a physician order dated 7/21/23 to give two tablets of (brand name) chewable antacid every six hours as needed for heartburn. The clinical record did not show an assessment verifying Resident #800 was able to safely self-administer the antacid, and was able to safely, and securely store the antacid. On 6/25/24 at 11:20 a.m., in an interview the Director of Nursing (DON) said he was not aware Resident #800 kept the bottle of antacid at the bedside. He confirmed Resident #800 was not assessed to determine if he was able to safely self-administer the antacid, and his ability to ensure the antacid is stored safely and securely.

Based on observation, clinical record review, policy and procedures review, staff and resident interviews the facility failed to protect residents' rights to be free from verbal and physical abuse for 3 (Residents #700, #650, and #800) of 3 sampled residents. The findings included: The facility policy Abuse, Neglect, Exploitation, Mistreatment and Injury of Unknown Origin issued 8/22 (revised 10/22) documented Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment . Patients with needs and behaviors that might lead to conflict with staff or other residents will be identified by the Interdisciplinary Care Planning Team, with interventions and follow through designed to minimize the risk of conflict . Review of the clinical record revealed Resident #999 was admitted on [DATE]. Diagnoses included Dementia and Major Depressive Disorder. On 12/23/23 the diagnosis list was updated to include adjustment disorder and dementia with behavioral disturbance. The Admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/21/23 documented Resident #999 had behaviors of wandering occurring one to three days in the last seven days. The MDS noted the resident was rarely/never understood. On 11/1/23 at 12:02 p.m., the nurse's progress note documented, Husband/family alerted this nurse to concerns of increased agitation and sadness/hopelessness. Resident assessed for suicidal ideation by 2 nurses, none noted, resident denied thoughts or plans. The physician was notified and ordered Citalopram (antidepressant) 10 milligrams (mg) a day and a Psychiatry consult. Review of the Psychiatric APRN (Advanced Practice Registered Nurse) note dated 12/1/23 documented, Chief complaint . nursing also reports resident (#999) is having behaviors . Nursing reports resident is having behaviors of being verbally inappropriate, combative towards family and hard to redirect . Recommendation: Resident observed today walking around the unit, alert, confused, uncooperative, hard to redirect . Nurse reports resident is having behaviors to be in [sic] combative towards family, verbally inappropriate and hard to redirect. Resident is unstable. Symptoms are occurring due to exasperated mood disorder, the symptoms are occurring daily and causing severe distress . Psych (psychiatry) started Depakote sprinkles 250 mg (milligrams) by mouth twice daily diagnosis of mood disorder . Staff to continue to monitor and document behaviors . On 12/21/23 at 1:59 p.m., a nursing progress note documented, It was reported to this writer that the resident is showing increased aggression, cussing at fell ow residents, throwing a cookie at a fell ow resident. Notified MD (Physician), psych (Psychiatry) notified she will be in Friday. Will redirect resident. On 12/22/23 at 1:33 p.m., a nursing progress note documented Resident #999 had, Agitation and aggressive behaviors reported to psych Advanced Registered Nurse Practitioner (ARNP). On 12/22/23 the Psychiatric APRN documented, Resident being seen for follow-up psych evaluation due to recent medication change. Nursing reports resident having aggressive behaviors, hard to redirect, throwing things, difficult with her care. Patient observed on unit alert confused, no behaviors noted at time of interview . Psych feels the symptoms are occurring due to exacerbation of underlying MOOD Disorder. The symptoms are occurring daily and causing severe distress . Therefore psych decided to increase Depakote sprinkles to 500 mg by mouth twice daily . Staff to monitor and document behaviors . On 12/22/23 at 1:46 p.m., a nursing progress note documented, Resident had violent outburst wrapped a cord around her husbands [sic] throat and attempted to throw monitor at him, hit him in the face and pulled his hair. Yelled for help and nurses were able to intervene and separate. No violence toward any staff or any other resident noted. She did yell at her husband obscenities. The Psych ARNP was notified and new order for Seroquel 25 mg (Antipsychotic) two times a day for 14 days, increase observation, and any other signs of violence notify primary immediately and send to the emergency room for evaluation and treatment for altered mental status. On 12/29/23 the Psychiatric APRN documented, Nursing reports resident's behaviors appear to be slowly resolving since starting Seroquel . Patient behaviors appear to be stable at this time . Psych recommends decrease Depakote Sprinkles to 250 mg by mouth twice daily X3 (for three) days, then 125 mg by mouth twice daily X2 (for two) days, then discontinue . On 1/2/24 the APRN documented seeing the resident for a follow up visit after Resident #999 fell on [DATE], was sent to the emergency room and returned to the facility that evening. The APRN noted Resident #999 was on multiple psychotropic medications with aggressive behavior with her dementia and psychiatry has been working with her medications. The APRN documented the resident was pleasant and cooperative. She spoke with the resident's husband and deferred discussion of her behaviors to Unit Manager. The APRN documented, Will discontinue seroquel for now. On 1/13/24 at 10:15 p.m., the progress note documented Residents #999 and #800 were in their room. Resident #999 started raising her voice stating that Resident #800 was not to be in her room, shouted get out. Resident #999 started throwing salt and sugar packets and individualized snack packets at Resident #800 saying while throwing things, this is my room. Certified Nursing Assistant (CNA) Staff A witnessed Resident #999 pick up a plastic plate cover and toss it at her roommate striking her in the head above left eye. CNA Staff A immediately called for the nurse. Resident #999 was assigned to one to one (1-1) supervision with a CNA and moved to another room. On 1/13/24 at 10:47 p.m., an incident description noted Resident #800 was found sitting on the side of the bed and verbally informed the staff that her roommate (Resident #999) hit her. Resident #999 was seen picking up a broken plate off the floor. When asked how the plate broke Resident #800 said, She went crazy, look at my head. Resident #800 had a lump above her left eye, with a small laceration. Resident #800 stated her roommate became angry and kept telling her this is her room and that she needed to leave, Her roommate turned evil and became so strong and hit her with the lid of the dinner cover. On 1/13/24 at 10:00 p.m., a nursing progress note documented, notified family of incident, husband states It was no surprise for him, then asked why patient was not moved to memory care. The facility's investigation into the abuse allegation noted a Certified Nursing Assistant (CNA) witnessed Resident #999 pick up a plastic plate cover and toss it at her roommate striking her in the head above the left eye. The CNA immediately called for the nurse to come to the room. The nurse arrived and the residents were immediately separated. Resident #999 was moved to a different room and all potential harmful objects were removed from her room. The facility's investigative findings on 1/18/24 noted, The facility unsubstantiate the allegation of abuse related to the residents being adquately supervised and staff responding immediately. The care plan was updated on 1/15/24 noting Resident #999 had a history of exhibiting the following behaviors: Chronic/frequent refusal of care and/or services, impulsivity, Physical and verbal aggression. The goal was for Resident #999 to have fewer episodes of the identified behavior. The interventions as of 1/15/24 included to administer medications as ordered. Monitor/document for side effects and effectiveness; encourage resident to interact with staff members as tolerated; explain procedures to the resident before starting and allow the resident time to adjust to changes as needed; minimize potential for teh resident's disruptive behaviors by offereing tasks with divert attention/redirect behavior as indicated; one on one with staff as needed. On 2/16/24 the facility added non-pharmacological interventions utilized as needed to redirect resident behavior: offering lower stimulus environment, speaking calming, allowing resident to choose care options as they are able or offer activities to divert resident's attention. The Certified Nursing Assistant (CNA) visual/bedside Kardex (Provides instructions for care) did not list Resident #999's verbal and physical aggressive behaviors. The kardex noted to minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention/redirect behavior as indicated. On 1/16/24 at 4:24 p.m., a nursing progress note documented, Resident continues 1-1 observation due to physically aggressive behavior towards other residents. Administered medication as ordered. Resident complained of having too much medication and stated, It will be their fault if I do something to someone because of all the medication. On 1/19/24 the Psychiatric APRN documented, Resident seen today per nursing request as resident had behaviors of being aggressive including a recent incident with her previous roommate. Pt (Patient) alert with confusion, noted agitation, flat mood, and affect, uncooperative at times during interview. On 2/6/24 the Psychiatric APRN documented Resident #999 reportedly made a comment that her roommate was noisy, and she was going to slit her throat if she was not more quiet. On 2/6/24 Unit Manager Registered Nurse Staff B documented, Resident recent aggressive behaviors and statements demonstrate possible further aggressive events, MD, Psychology, husband, sister, and management notified. Resident will remain in a room without a roommate for safety and possible placement at another facility to better suit her needs. On 2/10/24 at 6:18 p.m., the Assistant Director of Nursing documented, This nurse received notification from day shift and evening nurse, other residents and other residents family member that (Resident #999) is being extremely aggressive. She is using vulgar language, using racial slurs, refusing to leave other resident's rooms . On 2/25/24 a nursing progress note documented Resident #999 was moved in a room with Resident #650. On 2/29/24 at 9:45 a.m., in an interview the Administrator said Resident #999 came to them without a psychiatric background and only dementia as a diagnosis. Resident #999's first roommate Resident #800 was hit in the head with a plate/tray. We removed Resident #800. Resident #999 stayed in the two person room alone for several weeks, but we could not keep her in a double room alone forever. Resident #999 was placed in a room with Resident #700. Resident #999 said she was going to slit her new roommate's throat and made racial slurs to her and her family who were visiting. We moved the roommate out of the room. Both residents reside on the same floor but in different halls. The Administrator said resident #999 was very distant, easily upset and on one occasion she attempted to strangle her spouse with a cord, we had to get staff to get her off of him and still she is here. Right now, Resident #999 is in a room with a friend, another resident who is alert and oriented and kind of looks out for her and can handle her. They agreed to be roommates. On 2/29/24 at 10:15 a.m., Resident #999 was observed ambulating with a rolling walker past other residents in the hallway. She walked up and down the hallway and to the nurse's desk unsupervised by staff. On 2/29/24 at 11:15 a.m., in an interview Registered Nurse (RN) Staff B said Resident #999 had memory problems and behavior issues. During a care plan meeting she had threatened to Jump out of the window. She is very territorial. One day her family member brought in candy for her to share with her friends at the dining room table and when the other ladies asked for a piece of candy, she threw the candy at them. She is very negative and aggressive. On 2/29/24 at 12:00 p.m., Resident #999 was observed ambulating with a rolling walker in the hallway unsupervised. She ambulated to the small seating room and declined to sit. Licensed Practical Nurse (LPN) Staff C approached and explained to Resident #999 that she had a visitor who wanted to speak with her. Resident #999 made an angry face and said what do you want?. She was noted to have a mask like face with angry expressions. She was not able to recall any incidents of abuse toward her spouse or other residents. She became easily agitated when asked questions and walked away. On 2/29/24 at 1:15 p.m., an attempt was made to interview Resident #700. She did not respond appropriately to interview questions. She continues to reside on the same unit as Resident #999. On 2/29/24 at 2:20 p.m., in a telephone interview Resident #999's Primary Care Physician said she knew the resident had some behaviors prior to her admission but she was doing okay, All of a sudden, she began displaying aggression. I know psych was involved and they were adjusting her medications. I became more involved when the family requested to meet with me because they felt the psych medications she was on were not effective and they wanted to try medications she had used in the past. I said let's try it then because whatever they were trying was not working. On 2/29/24 at 3:05 p.m., in an interview Certified Nursing Assistant (CNA) Staff D said if Resident #999 was having behaviors, she would call for help if she could not calm her. She would offer her something to eat, take her to activities or talk with her. She said she had not seen her hit anyone but, She walks all the time. She can be mean; she yells at you and does not want you to touch her for care. On 2/29/24 at 4:22 p.m., in a telephone interview the Psychiatric APRN said she was initially asked to see Resident #999 for aggressive behavior. She had aggressive behavior, difficult to redirect and she was refusing care. She said,I don't think a skilled nursing facility is appropriate for her, she needs a psychiatric facility that can manage her behaviors and adjust her medications as needed. This is just my opinion. On 2/29/24 at 5:07 p.m., in an interview Licensed Practical Nurse (LPN) Staff C said they monitor Resident #999 by observation, charting, documentation, and report one shift to the next. She is unpredictable so I guide her and try to be positive with her, so she feels more comfortable. I give her lots of encouragement. I have not seen her physically aggressive but verbally yes. She refuses care, and you must approach her slow, and calm, she startles easily. I have seen her refuse care and refuse redirection. The new room change has been a challenge for her. She walks a lot, and she does not stay in her room. She wanders a lot and most of the time you can redirect her. For her safety and everyone involved with the recent room change we tried to ease her into it. Redirection is difficult sometimes. Observation is a big thing for her, you must know where she is at all times, I encourage activities. I have never seen her verbally aggressive with other residents. When she can't be redirected, we let her walk and calm down. We work as a team. We let her express herself in a safe manner. On 3/4/24 at 10:18 a.m., in an interview CNA Staff E, said she has observed Resident #999 be aggressive with other residents, She yells at them, curses at them and will throw things at them. She tries to pick a fight. On 3/4/24 at 10:45 a.m., in an interview Resident #800, said she remembered the incident with Resident #999. It was in the evening and the curtain was pulled between us. I was in bed and had just eaten. She came over to my side and she was angry, her face was mad and she told me you better not take anything of mine. She started to shake the bedside table and my dinner tray was still on it. She threw the whole thing at me, and the plate warmer fell at the foot of the bed. It was dome shaped. She picked it up and hit me with it, she did not throw it, she hit me. I was yelling and a CNA came in and then two more came in. My left eye was black, black as could be after that. On 3/4/24 at 12:22 p.m., in an interview the Medical Director said he was not the primary care physician for Resident #999 but has discussed the resident because, We have been discussing the risks, so she was always being discussed and managed. She has a psych history of her behaviors. Her primary care physician was not in agreement with psych medications, and he was in constant communication with the family and the facility was in constant communication. We felt this was not the facility for her, but the family wanted her to remain here. They did one to one care, she was not aggressive, so it was discontinued. She was deemed safe and not a danger to herself and others. The family wants the resident to remain here. The staff are constantly monitoring her. Her history of psych behaviors are aggression. Aggression with her own husband, she had hostile behavior with the husband. We are constantly monitoring but not doing one to one, that is what we have in place and monitoring her medications. She becomes more hostile when you try to do something with her. She did not want to be on one to one. The staff are always asking the roommate if there are any problems. I am not her doctor, but I know all about her. On 3/4/24 at 9:20 a.m., in an interview Resident #650, current roommate of Resident #999, said she makes me uneasy. She stands at the foot of my bed staring at me and cursing under her breath. I don't know her, but I know of her behaviors. She comes in and out of the room and walks to the foot of my bed, stares at me and curses. I have asked to see the Director of Nursing twice, but he has not come. I don't feel 100% safe, that's for sure. On 3/4/24 at 1:00 p.m., in an interview the Medical Director said, Resident #999 was not a threat to others. When informed of Resident #650's interview complaining about Resident #999 staring at her, cursing, and not feeling safe, the Medical Director said, Well, that's not threatening, she is just looking at her.

Based on record review, and interview the facility failed to report significant changes in behaviors to the appropriate state agencies for a level II Preadmission Screening and Resident Review (PASRR) for 1 (Resident #999) of 3 residents reviewed with newly diagnosed psychiatric disorder. The findings included: Review of the clinical record revealed Resident #999 was admitted to the facility on [DATE] with diagnoses including Dementia and Major Depressive Disorder. A level I PASRR screen form dated 10/13/23 documented No diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. On 11/1/23 at 12:02 p.m., the nurse's progress note documented Husband/family alerted this nurse to concerns of increased agitation and sadness/hopelessness. Resident assessed for suicidal ideation by 2 nurses, none noted, resident denied thoughts or plans. The physician was notified and ordered Citalopram (Antidepressant) 10 milligrams (mg) a day and a Psychiatric consult. Review of the Psychiatric APRN (Advanced Practice Registered Nurse) note dated 12/1/23 documented, Chief complaint . nursing also reports resident (#999) is having behaviors . Nursing reports resident is having behaviors of being verbally inappropriate, combative towards family and hard to redirect . Recommendation: Resident observed today walking around the unit, alert, confused, uncooperative, hard to redirect . Nurse reports resident is having behaviors to be in [sic] combative towards family, verbally inappropriate and hard to redirect. Resident is unstable. Symptoms are occurring due to exasperated mood disorder, the symptoms are occurring daily and causing severe distress . Psych (psychiatry) started Depakote sprinkles 250 mg (milligrams) by mouth twice daily diagnosis of mood disorder . Staff to continue to monitor and document behaviors . On 12/21/23 at 1:59 p.m., a nursing progress note documented, It was reported to this writer that the resident is showing increased aggression, cussing at fell ow residents, throwing a cookie at a fell ow resident. Notified MD, psych notified she will be in Friday. Will redirect resident. On 12/22/23 at 1:33 p.m., the progress note documented Resident #999 had Agitation and aggressive behaviors reported to psych Advanced Registered Nurse Practitioner (ARNP). On 12/22/23 at 1:46 p.m., the progress note documented, Resident had violent outburst wrapped a cord around her husband's throat and attempted to throw monitor at him, hit him in the face and pulled his hair. Yelled for help and nurses were able to intervene and separate. No violence toward any staff or any other resident noted. She did yell at her husband obscenities. The Psych ARNP was notified and new order for Seroquel 25 mg two times a day for 14 days, increase observation, and any other signs of violence notify primary immediately and send to emergency room (ER) for eval and treatment for altered mental status (AMS). On 12/23/23 the diagnosis list was updated to include adjustment disorder and dementia with behavioral disturbance. On 1/13/24 at 10:15 p.m., the progress note documented Residents #999 and #800 were in their room. Resident #999 started raising her voice stating that Resident #800 was not to be in her room, shouted get out. Resident #999 started throwing salt and sugar packets and individualized snack packets at Resident #800 saying while throwing things, this is my room. Certified Nursing Assistant (CNA) Staff A witnessed Resident #999 pick up a plastic plate cover and toss it at her roommate striking her in the head above left eye. CNA Staff A immediately called for the nurse. Resident #999 was assigned to 1-1 with a CNA and moved to another room. On 1/14/24 the diagnosis list was updated to include psychotic disorder. On 1/19/24 the Psychiatric ARNP documented Resident seen today per nursing request as resident had behaviors of being aggressive including a recent incident with her previous roommate. Pt alert with confusion, noted agitation, flat mood, and affect, uncooperative at times during interview. On 2/6/24 the Psychiatric ARNP documented Resident #999 reportedly made a comment that her roommate was noisy, and she was going to slit her throat if she was not more quiet. On 2/6/24 Unit Manager Registered Nurse Staff B documented, Resident recent aggressive behaviors and statements demonstrate possible further aggressive events, MD, Psychology, husband, sister, and management notified. Resident will remain in a room without a roommate for safety and possible placement at another facility to better suit her needs. On 2/29/24 at 9:45 a.m., in an interview the Administrator said Resident #999 came to us without a psychiatric background and only dementia as a diagnosis. Resident #999's first roommate Resident #800 was hit in the head with a plate/tray. We removed Resident #800. Resident #999 stayed in the 2-person room alone for several weeks, but we could not keep her in a double room alone forever. Resident #999 was placed in a room with Resident #700. Resident #999 said she was going to slit her new roommate's throat and made racial slurs to her and her family who were visiting. The Administrator said resident #999 was very distant, easily upset and on one occasion she attempted to strangle her spouse with a cord, we had to get staff to get her off of him and still she is here. Right now, Resident #999 is in a room with a friend, another resident who is alert and oriented and kind of looks out for her and can handle her. They agreed to be roommates. On 2/29/24 at 11:15 a.m., in an interview RN Staff B said Resident #999 had memory problems and behavior issues. During a care plan meeting she had threatened to Jump out of the window. She is very territorial. One day her family member brought in candy for her to share with her friends at the dining room table and when the other ladies asked for a piece of candy, she threw the candy at them. She is very negative and aggressive. On 2/29/24 at 4:22 p.m., in a phone interview the Psych ARNP said she was initially asked to see Resident #999 for aggressive behavior. She had aggressive behavior, difficult to redirect and she was refusing care. I don't think a skilled nursing facility is appropriate for her, she needs a psychiatric facility that can manage her behaviors and adjust her medications as needed. This is just my opinion. On 3/4/24 at 9:20 a.m., in an interview Resident #650, current roommate of Resident #999, said she makes me uneasy. She stands at the foot of my bed staring at me and cursing under her breath. I don't know her, but I know of her behaviors. She comes in and out of the room and walks to the foot of my bed, stares at me and curses. I have asked to see the Director of Nursing twice, but he has not come. I don't feel 100% safe, that's for sure. On 2/29/24 at 5:45 p.m., a record review revealed a level II PASRR was not completed. In an interview, the Administrator said a Level II screening was not completed because she did not know a Level II screen was necessary.

Based on record review and staff interview the facility failed to ensure clinical records contained complete and accurate documentation of care provided for 2 (Residents #1 and #3) of 3 residents reviewed for accuracy of clinical records. The findings included: 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/2/23 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 00. The MDS noted Resident #1 was severely cognitively impaired with a Brief Interview of Mental Status score of 0. Resident #1 used a manual wheelchair for mobility, was frequently incontinent of urine and always incontinent of bowel. The current physician orders included to assist the resident with all meals. No assistance with meals was documented in the clinical record on 1/3/24, 1/7/24, 1/16/24, 1/17/24, 1/21/24 or 1/24/24. The physician's orders also included to encourage and assist resident with turning and repositioning when in bed and as needed for skin care. No assistance with turning and repositioning was documented for the day shift from 7:00 a.m., to 3:00 p.m., on 1/3/24, 1/7/24, 1/16/24, 1/17/24 or 1/21/24. No assistance with turning and repositioning was documented for the evening shift from 3:00 p.m., to 11:00 p.m., on 1/17/24, 1/21/24 or 1/24/24. No assistance with turning and repositioning was documented for the night shift from 11:00 p.m., to 7:00 a.m., on 1/6/24 or 1/20/24. The Certified Nursing Assistant (CNA) task form did not reflect Turning and Repositioning was done on Day shift from 1/2/24 through 1/8/23, 1/11/24, 1/14/24 through 1/19/24, 1/21/24 through 1/25/24. The Certified Nursing Assistant task form did not reflect turning and Repositioning was done on the evening shift on 1/2/24, 1/4/24, 1/7/24, 1/8/24, 1/11/24 through 1/18/24, 1/22/24 through 1/24/24. The Certified Nursing Assistant task form did not reflect turning and Repositioning was done on the evening shift on 1/2/24, 1/3/24, 1/5/24, 1/7/24, 1/11/24 through 1/13/24, 1/18/24 through 1/24/24. The Certified Nursing Assistant task form did not reflect documentation of breakfast eaten on 1/3/24 through 1/7/24, 1/11/24, 1/16/24, 1/17/24, 1/18/24, 1/20/24 through 1/23/24. The Certified Nursing Assistant task form did not reflect documentation of lunch eaten on 1/1/24, 1/3/24, 1/4/24, 1/5/24 through 1/8/24, 1/11/24, 1/14/24, 1/16/24, 1/17/24, 1/18/24, 1/20/24 through 1/24/24. The Certified Nursing Assistant task form did not reflect documentation of dinner eaten on 1/4/24, 1/7/24, 1/8/24, 1/11/24, 1/12/24, 1/16/24 through 1/18/24, 1/22/24 through 1/24/24. 2. Clinical record review showed Resident #3 was admitted to the facility on [DATE]. Admission diagnoses listed on the resident face sheet included fracture of left femur, spinal stenosis, fibromyalgia, and repeated falls. The current physician's orders included: Turn and reposition when in bed and as needed. Weigh resident daily for three days, weekly for four weeks, and monthly effective 1/7/24. The clinical record contained one weight obtained on 1/7/24. No other weight was documented. The care plan noted Resident #3 was at risk for skin impairment related to fragile skin, weakness, decreased mobility, incontinence, and risk for malnutrition. The interventions include to encourage and assist the resident to turn and reposition as tolerated. The CNA Kardex (provides instructions for care) noted to encourage and assist resident to turn and reposition as tolerated, turning and repositioning. The clinical record lacked documentation of turning and repositioning for Resident #3 on: 1/16/24, 1/17/24, 1/21/24 and 1/29/24 for the day shift, 1/9/24, 1/17/24, 1/21/24,1/24/24 for the evening shift, 1/20/24 for the night shift. On 1/31/24 at 2:33 p.m., CNA Staff A said the care provided should be documented and if a resident refuses care, the nurse should be notified. On 1/31/24 at 2:45 p.m., CNA staff B said the residents are checked every two hours and the care provided should be charted at least twice during the shift. On 1/31/24 at 5:03 p.m., Licensed Practical Nurse (LPN) Staff C said CNAs should check all of their residents every two hours and document in the electronic health record. On 1/31/24 at 5:10 p.m., CNA Staff D said she makes rounds every two hours and documents every two hours on the computer. She said all meals are also documented on the computer. On 2/1/24 at 6:40 a.m., CNA staff F said, We are supposed to check and change our residents every two hours, and document within the hour if possible but by definitely by the end of the shift. On 2/1/24 at 11:57 a.m., CNA staff I said everyone has to be turned, and repositioned. Weights are ordered by the physician and everything is documented in PCC (electronic health record). On 2/1/24 at 12:15 p.m., in an interview the Director of nursing (DON) verified the documentation of the care provided was incomplete for Residents #1 and #3. She also verified the lack of documentation Resident #3's weight was obtained as ordered. On 2/1/24 at 2:10 p.m., in an interview the Regional Nurse Consultant said documentation was a challenge with CNAs and agency staff, and physicians orders should be followed.

Based on review of the clinical record, review of facility policy and procedures and staff and family interviews, the facility failed to protect the resident's right to be free from neglect. The facility failed to provide the necessary services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. They failed to provide the correct diet and required assistance for one (Resident #43) of 3 sampled residents with dysphagia (difficulty swallowing). Resident #43 had a physician's order for a soft and bite sized diet, and required extensive assistance with meals. On [DATE] Resident #43 did not receive the necessary assistance during meals. Staff was not aware Resident #43 required extensive assistance with meals. The SLP (Speech-Language Patholigist) changed the resident's diet from a soft, small bites diet to a regular diet without an assessment and physician's order. The resident was served a regular diet. Resident #43 was found unresponsive. Staff performed CPR (Cardiopulmonary Resuscitation) called 911 and suctioned a whole Brussels sprout out of the resident's throat. EMS (Emergency medical services) took over CPR. CPR was not successful and Resident #43 was pronounced dead on [DATE] at approximately 8:50 p.m. The ME (Medical Examiner) advised the facility medical director that the cause of the resident's death was accidental death by choking. The facility's failure to provide the services necessary to prevent neglect placed other residents with similar conditions at a likelihood of serious illness and/or death. On [DATE] it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on [DATE] at 8:30 a.m. Immediate Jeopardy was identified on [DATE]. It began on [DATE] and was removed on [DATE]. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of [DATE] and verified by interview, observation and record review on [DATE]. Cross reference to F609, F689 and F692. The findings included: The facility policy Patient Protection, Abuse, Neglect, Mistreatment, and Misappropriation Prevention (dated,d+[DATE]) defined neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the clinical record revealed Resident #43 had an admitted [DATE] with diagnoses including dementia, anxiety, and oropharyngeal dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) v.1.17.2 with an assessment reference date (ARD) of [DATE] documented Resident #43 required supervision with eating meals. The MDS noted Resident #65's cognitive skills for daily decision making were intact. A Significant Change MDS v.1.17.2 with an ARD of [DATE] documented Resident #43 required extensive assistance of 1 person with eating her meals. The MDS noted Resident #43's cognitive skills were mildly impaired. Review of the Speech Language Pathologist (SLP) note dated [DATE] documented skilled interventions addressing swallowing dysfunction included therapeutic trial feedings with soft and bite sized consistency to increase safety. Patient with significant improvement with soft and bite sized consistency. Review of the clinical record showed the diet communication form dated [DATE] documented a soft and bite sized diet. On [DATE] the SLP wrote on a posted note to change Resident #43's diet to a regular diet and gave the posted note to the Certified Dietary Manager (CDM). On [DATE] the CDM changed Resident #43's diet from soft and bite sized to a regular textured diet without a physician order. On [DATE] at 6:30 p.m., Certified Nursing Assistant (CNA) Staff A delivered the evening meal to Resident #43 who was in her bed. The meal served was chicken and dumplings with whole Brussels sprouts. The CNA set up the meal tray and left Resident #43 unattended. On [DATE] at 7:45 p.m., CNA Staff A went to Resident #43's room to pick up her meal tray. The CNA reported Resident #43 was sitting upright in bed with the meal tray in front of her on the over the bed table. The CNA asked the resident if she was finished eating and the resident nodded her head yes. The CNA removed the tray and exited the room. On [DATE] between 8:15 p.m., and 8:20 p.m., CNA Staff A returned to Resident #43's room to assist the resident to get ready for bed and found her unresponsive. Licensed Practical Nurse (LPN) Staff B was notified and assessed the resident who was pulseless and not breathing. The LPN initiated CPR and contacted 911. EMS arrived and pronounced Resident #43 dead at 8:51 p.m. On [DATE] at 10:03 a.m., in an interview the SLP said Resident #43 was on a regular diet and it took a very long time for her to eat meals, up to 3 hours at each meal. She was safe, she would chew her food for a while, and she had no dentures. The SLP worked with Resident #43 because she was losing weight and changed her diet to soft with bite sized small pieces on [DATE]. The family requested regular food so she told the kitchen she could have the regular diet on [DATE]. She did not write a doctor's order, she wrote the diet change on a sticky note and gave it to the CDM. The SLP confirmed she did not evaluate Resident #43 before changing her diet to a regular diet. The SLP said I made a lot of mistakes. She said she should have assessed the resident, and should have obtained a physician order. I did not follow the policy for upgrading the diet. On [DATE] at 4:10 p.m., in an interview, CNA Staff A said Resident #43 was a total care resident with everything but could feed herself. Staff A said on [DATE] she set the food tray up and put her in a sitting position in bed for the meal. I put the tray on the table and put the table in front of her. She had regular food and I helped her to cut it. CNA Staff A said I don't know when the diet was changed, she was always on a regular diet. No one at the facility spoke with me about her or how much help she needed. I left the room after I gave her the food at 6:30 p.m. I checked on her at 7:45 p.m., because she eats slow. I gave her time to eat. Resident #43 was not eating, and Staff A asked her if she was done. She shook her head yes and I took the tray from her. I don't know if she had food in her mouth, I did not look. Staff A said Resident #43 never told me if she had any problem chewing or swallowing. The nurse will tell you if something is new, they will let you know. No one told me the diet was changed and the resident needed assistance to eat. CNA Staff A said she went back to Resident #43's room to get her ready for bed between 8:25 p.m., and 8:30 p.m. I laid her head down and she looked like she was not breathing. I called my coworker, and she said no she is not breathing, and she called the nurse. The nurse came right away, and called a Code Blue, then started CPR. The nurse checked the mouth, nothing was in there, but she was not breathing so they started CPR. The Respiratory Therapist (RT) came and suctioned her and the Brussels sprout came out. On [DATE] at 2:06 p.m., in an interview, the Respiratory Therapist said I was four rooms down and heard the page for Code Blue and responded. They were bringing the code cart in and the nurse was doing chest compressions. I was getting the Ambu bag (a handheld device used to provide pressure ventilation to patients who are not breathing). I noticed when I used it, she was not ventilating, I saw no chest rise. I noticed something green at the back of her mouth, it appeared to be a Brussels sprout and it was whole. I used the suction machine to remove the Brussels sprout, it was bigger than a marble but smaller than a golf ball. Resident #43 did not cough when the food was removed. I was ventilating her when EMS arrived. Resident #43 was unresponsive when I arrived. No one attempted to do the Heimlich maneuver on her, nursing was doing chest compressions. The Brussels sprout was right there at the back of her throat. She did not cough or anything when I removed the food. On [DATE] at 8:45 a.m., in an interview, the MDS Coordinator Registered Nurse Staff C said Resident #43 had a weight loss and a decline in her activities of daily living (ADL's). I reviewed the CNA documentation and noticed Resident #43 had a change in her ADL's. Resident #43 went from supervision with meals to different levels of assistance documented in the CNA charting. I initiated a significant change MDS on [DATE]. I did not observe Resident #43, and I did not speak with the CNA's regarding her care needs. The management team was notified by email there was a change with Resident #43. The MDS Coordinator said extensive assist means the CNA's are actually feeding the resident. Staff #43 said she did not speak with the resident or the CNA's. I don't know how the information is passed on to the CNA's when there is a change in the resident's status. On [DATE] at 11:08 a.m., in an interview, LPN Staff B said she was familiar with Resident #43. She ate really slow in bed and kept the tray for hours and would not let us take it. She had some dementia and was resistive at times. We made sure the head of the bed was up. She just needed her containers opened for her. She had finger food, and did not use utensils. I was not aware she had dysphagia until I checked her diet. LPN Staff B said Resident #43's diet was regular texture, there were whole Brussels sprouts served. LPN Staff B said she was not aware Resident #43 required extensive, or any assistance with meals. The LPN said if a resident was on an altered diet, there must be someone with them and if they have dysphagia, someone needs to be at the meals. I supervised that night to the point that I walked past the room and looked in at her. LPN Staff B said I know what a small bite sized diet looks like. It looks like toddler food. It is cut and chopped but the Brussels sprouts she had that night were whole. She said she checked her mouth and saw she had food in the back of her throat. The RT suctioned her and removed a whole Brussels sprout. No one told me Resident #43 required assistance with meals. It was not communicated. On [DATE] at 3:14 p.m., in an interview, the Director of Nursing (DON) said he received a phone call from LPN Staff B on [DATE]. LPN Staff B said Resident #43 had coded and 911 was at the facility. CPR was provided. I interviewed the staff and had them make witness statements. The DON said I don't know why the significant change MDS was done. We talk about things in the daily morning Eagle Room meeting, but I don't recall what the change was. I know the spouse wanted Resident #43 on regular foods and I think that is why SLP wrote the note. I guess she felt the resident was safe. Resident #43 could feed herself. She required no assistance from staff, I was not aware the MDS said otherwise. She took a long time to eat. The diet was changed by the SLP who is no longer employed at the facility. The SLP put the change for the diet on a sticky note. The previous CDM made the change in the computer, that is not process. A physician order is necessary to change the diet. The SLP gave the sticky note to the kitchen and the CDM made the changes. The policy is a recommendation for a diet change goes to the Registered Nurse Practitioner or Physician for an order for diet change, then it is changed in the computer system. The CDM should not have made the change based on what was written on the sticky note. Resident #43 was never assessed for swallowing difficulty per the SLP. I did not look at the speech therapy notes, I only went by what the SLP told me. The DON said he determined the root cause of Resident #43's death. At the time, we thought she just passed. I had no knowledge of the Medical Examiner (ME) taking the case. They did not tell us they were going to do that. The Medical Director called the ME's office and was informed Resident #43 died from accidental death by choking. On [DATE] at 10:47 a.m., in an interview, the Administrator said Resident #43's diet was changed to a regular diet on [DATE] because of the information on a sticky note the SLP provided to the CDM. The root cause after the investigation was the SLP did not complete an evaluation, and did not receive an order from the physician to upgrade the diet. The Administrator said there was no diet order to change Resident #43's diet to a regular diet. On [DATE] at 10:00 a.m., in an interview, the spouse of Resident #43 said he received a phone call from the facility. They said she was not breathing and they were doing CPR. I got to the facility, and I was with her. I never asked for her diet to be changed, and they never asked me if I wanted it changed. In my opinion, they left her alone and did not check on her for over an hour, that is what happened. The facility told me she passed, they did not say she choked. The medical examiner called me and told me about her choking, I guess that is why he took the case. I always cut her food up in real small pieces for her. I was there every day except the days she had physician appointments outside of the facility. She had gone to an appointment on that day . The food was always regular, and must cut up into tiny pieces, I did that for her. The facility did not check on her for a long period of time when she was eating that night, that is what I and my family think. She would fall asleep during meals. She was always so tired. The facility knew she was falling asleep at meals and that is why it took her so long to eat. I think they did not check on her, she fell asleep with food in her mouth and choked. Like I told the facility, I think she fell asleep and choked. I wish they would have checked on her, maybe she would be here. That is the concern for myself and my family, why did they not check on her? The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of [DATE] and verified by interview, observation, and record review on [DATE] included the following: On [DATE] all resident diet orders in the electronic medical record (EMR) were compared to the tray card, the most recent orders and speech therapy evaluations. On [DATE] all residents with dyshagia or on a mechanically altered diet were ordered Speech Therapy evaluations. On [DATE] all resident care plans and kardex's were audited for diet orders. On [DATE] licensed and unlicensed clinical staff re-educated on the use of the Kardex. On [DATE] all therapy staff were educated on the process of rehabilitation screening and evaluations. On [DATE] dietary staff were educated on the proper process when receiving or changing diet orders. On [DATE] through [DATE] all staff received education on abuse, neglect.

Based on record review, facility policy and procedures, and staff and family interviews, the facility failed to implement processes to communicate a change in condition and ensure adequate supervision and assistance to prevent the choking death for one (Resident #43) of 3 residents reviewed with dysphagia (difficulty swallowing). On [DATE] it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on [DATE] at 8:30 a.m. Immediate Jeopardy was identified on [DATE]. It began on [DATE] and was removed on [DATE]. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of [DATE] and verified by interview, observation and record review on [DATE]. Cross reference F600, F609, and F692 The findings included: Review of the clinical record revealed Resident #43 had an admitted [DATE] with diagnoses including dementia, anxiety, and dysphagia (difficulty swallowing). Review of the Physician orders documented resident #43 was on a regular textured diet. A Significant Change Minimum Data Set (MDS) with an ARD of [DATE] documented Resident #43 required extensive assistance of one person with eating her meals. Review of the Speech Language Pathologist (SLP) note dated [DATE] documented skilled interventions addressing swallowing dysfunction included therapeutic trial feedings with soft and bite sized consistency to increase safety. Patient with significant improvement with soft and bite sized consistency regular diet (normal food cut into smaller pieces). Review of the clinical record showed the diet communication form dated [DATE] documented a soft and bite sized diet. On [DATE] the SLP wrote on a posted note to change Resident #43's diet to a regular diet without a physician order, and gave the posted note to the Certified Dietary Manager (CDM). On [DATE] the CDM changed Resident #43's diet from soft and bite sized to a regular textured diet without a physician order. On [DATE] at 6:30 p.m., Certified Nursing Assistant (CNA) Staff A delivered the evening meal to Resident #43 who was in her bed. The meal served was chicken and dumplings and whole Brussels sprouts. The CNA set up the meal tray and left Resident #43 unattended. On [DATE] at 7:45 p.m., CNA Staff A went to Resident #43's room to pick up her meal tray. The CNA reported Resident #43 was sitting upright in bed with the meal tray in front of her on the over the bed table. The CNA asked the resident if she was finished eating and the resident nodded her head yes. The CNA removed the tray and exited the room. On [DATE] between 8:15 p.m., and 8:20 p.m., CNA Staff A said she returned to Resident #43's room to assist the resident to get ready for bed and found her unresponsive. Licensed Practical Nurse (LPN) Staff B was notified and assessed the resident who was pulseless and not breathing. The LPN initiated CPR and contacted 911. EMS arrived and pronounced Resident #43 dead at 8:51 p.m. On [DATE] at 10:03 a.m., in an interview the SLP said Resident #43 was on a regular diet and it took up to 3 hours for her to eat meals. I worked with Resident #43 because she was losing weight. I changed her diet to soft with bite sized small pieces on [DATE]. The family requested regular food so I told the kitchen she could have the regular diet on [DATE]. I did not write a doctor's order, I wrote the diet change on a sticky note and gave it to the CDM. The SLP confirmed she did not evaluate Resident #43 before changing her diet to a regular diet. The SLP said I made a lot of mistakes. I should have assessed the resident and should have written the physician order. I did not follow the policy for upgrading the diet. On [DATE] at 4:10 p.m., in an interview CNA Staff A said, Resident #43 could feed herself. On [DATE] I set the food tray up and put her in a sitting position in bed for the meal. She had regular food and I helped her to cut it. CNA Staff A said I don't know when the diet was changed. She was always on a regular diet, I never saw anything but a regular diet for her. No one at the facility told me how much help she needed. Once I gave her the food at 6:30 p.m., I left the room. At 7:45 p.m., I checked on her because she eats slow. I gave her time to eat. Resident #43 was not eating, I asked her if she was done, and she shook her head yes and I took the tray from her. I never noticed any food in her mouth, I did not look. Resident #43 never told me if she had any problem chewing or swallowing. The nurse will tell you if something is new, they will let you know. No one told me the diet was changed, and the resident now needed assistance to eat. CNA Staff A said she went back to Resident #43's room between 8:25 p.m., and 8:30 p.m., to get her ready for bed. I laid her head down and she looked like she was not breathing. I called my coworker, and she said no she is not breathing, and she called the nurse. The nurse came right away, called a Code Blue, and she started CPR. The nurse checked the mouth, and nothing was in there but she was not breathing, so they started CPR. The Respiratory Therapist (RT) came and suctioned her and the BrusselS sprout came out, it looked like a green ball. On [DATE] at 2:06 p.m., in an interview the Respiratory Therapist (RT) said I heard the page for Code Blue and responded. Resident #43 was unresponsive when I arrived. Staff were bringing the code cart in and the nurse was doing chest compressions. I noticed when I used the Ambu bag (a handheld device used to provide pressure ventilation to patients who are not breathing) she was not ventilating, I saw no chest rise. I noticed something green at the back of her mouth. I used the suction machine to remove a Brussels sprout. It was bigger than a marble but smaller than a golf ball. Resident #43 did not cough when the food was removed. I was ventilating her when EMS arrived. No one attempted to do the Heimlich maneuver on her, nursing was doing chest compressions. The Brussels sprout was right there at the back of her throat. On [DATE] at 8:45 a.m., in an interview the MDS Coordinator Registered Nurse Staff C said Resident #43 had a weight loss and a decline in her activities of daily living (ADL's). I reviewed the CNA documentation and noticed Resident #43 had a change in her ADL's. I reviewed the CNA documentation and noticed she had days when she required more assistance than others. I initiated a significant change MDS on [DATE]. I did not observe Resident #43, and I did not speak with the CNA's regarding her need for assistance with meals. The management team was notified by e mail there was a change. The MSD Coordinator said extensive assist means the CNA's are actually feeding the resident. I don't know how the information is passed on to the CNA's when there is a change in the resident's status. On [DATE] at 11:08 a.m., in an interview, LPN Staff B said she was familiar with Resident #43. She just needed her containers opened for her. She had finger food and did not use utensils. LPN Staff B said she was not aware that Resident #43 required extensive assistance with meals. Staff B said if a resident was on an altered diet, there must be someone with them. If they have dysphagia, someone needs to be with them during meals. I supervised that night to the point that I walked past the room and looked in at her. LPN Staff B said I know what a small bite sized diet looks like it looks like toddler food, it is cut and chopped. The Brussels sprouts she had that night were whole. I checked her mouth and I said she had food in the back of her throat, they brought the suction machine. The RT suctioned her and removed a whole Brussesl sprout. The CNA never told me Resident #43 required assistance with meals. It was not communicated when she went from a regular diet to bite sized soft diet, and back to a regular diet. I wish the unit managers would tell us if there any changes. On [DATE] at 3:14 p.m., in an interview the Director of Nursing (DON) said I received a phone call from LPN Staff B on [DATE]. She said the Resident #43 had coded and 911 was at the facility, CPR was provided. I interviewed the staff and had them write witness statements. I don't know why the significant change MDS was done for resident #43. We talk about things in the daily morning Eagle Room meeting, but I don't recall what the change was. I know the spouse wanted Resident #43 on regular foods and I think that is why SLP wrote the note. I guess she felt the resident was safe. Resident #43 required no assistance from staff, I was not aware the MDS said otherwise. The SLP put the change for the diet on a sticky note. The previous CDM made the change in the computer, that is not process. A physician order is necessary to change the diet. The SLP gave the sticky note to the kitchen and the CDM made the changes. The policy is the recommendation for a diet change goes to the Registered Nurse Practitioner or Physician for a diet change order, and then it is changed in the computer system. Resident #43 was never seen for swallowing difficulty per the SLP. I did not look at the therapy notes, I only went by what the SLP told me. The DON said he determined the root cause of Resident #43's death was she just passed. The Medical Director called the Medical Examiners office and was informed Resident #43 died from accidental death by choking. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of [DATE] and verified by interview, observation, and record review on [DATE] included the following: On [DATE] all resident diet orders in the electronic medical record (EMR) were compared to the tray card, the most recent orders and speech therapy evaluations. On [DATE] all residents with dyshagia or on a mechanically altered diet were ordered Speech Therapy evaluations. On [DATE] all resident care plans and kardex's were audited for diet orders. On [DATE] licensed and unlicensed clinical staff re-educated on the use of the Kardex. On [DATE] all therapy staff were educated on the process of rehabilitation screening and evaluations. On [DATE] dietary staff were educated on the proper process when receiving or changing diet orders. On [DATE] all staff were re-educated on how to communicate a change in the resident's condition. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of [DATE] and verified by interview, observation and record review on [DATE].

Based on record review, facility policy and procedures, and staff and family interviews, the facility ensure residents receive a therapeudic diet when there is a nutritional problem. The facility failed to provide food in the appropriate texture, and size to prevent accidental choking death for one (Resident #43) of 3 residents reviewed with dysphagia (difficulty swallowing). On 4/6/23 it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on 4/6/23 at 8:30 a.m. Immediate Jeopardy was identified on 4/6/23. It began on 3/20/23 and was removed on 4/7/23. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of 4/6/23 and verified by interview, observation and record review on 4/7/23. Cross reference F600, and F689. The findings included: The facility policy Participation in Treatment Decisions Related to Diet Orders initiated 4/2022, specified The facility is responsible to inform the patient of the right to participate in their treatment. It is also the facility's responsibility to talk with the patient or patients decision maker and provide information pertaining to the risks and benefits of choice.In most cases involving diet restrictions where the consistency or texture of food and drinks is altered, recommendations are preceded by an evaluation by the rehab professional that identifies or demonstrates swallowing difficulties. The patient's physician is ultimately responsible to provide orders for diet consistencies or nutritional restrictions to the diet as well as educating and having discussions with the patient and patient decision-maker and documenting conversations in the medical record. The physician then issues orders as appropriate. The facility policy Soft and Bite Sized Diet specified, The diet consists of foods that are soft, tender and moist with pieces no bigger than 15 millimeters (mm) with no thin liquids leaking or dripping from the food. Vegetables are cooked soft and chopped into pieces no bigger than 15 mm x 15 mm. Review of the clinical record revealed Resident #43 had an admitted [DATE] with diagnoses including dementia, anxiety, and oropharyngeal dysphagia (difficulty swallowing). Review of the Physician orders documented Resident #43 was on a regular textured diet. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) v.1.17.1 with an assessment reference date (ARD) of 12/8/22 documented Resident #43 required supervision with eating meals. A Significant Change MDS v.1.17.1 with an ARD of 3/10/23 documented Resident #43 required extensive assistance of one person with eating her meals. Review of the Speech Language Pathologist (SLP) note dated 2/17/23 documented skilled interventions addressing swallow dysfunction included therapeutic trial feedings with soft and bite sized consistency to increase safety. Patient with significant improvement with soft and bite sized consistency. Review of the clinical record showed the diet communication form dated 2/16/23 documented a soft and bite sized diet was ordered by the physician. On 3/20/23 the SLP wrote on a posted note to change Resident #43's diet to a regular diet and gave the posted note to the Certified Dietary Manager (CDM). On 3/20/23 the CDM changed Resident #43's diet from soft and bite sized to a regular textured diet without a physician order. On 4/4/23 at 10:03 a.m., in an interview the SLP said Resident #43 was on a regular diet and it took a very long time for her to eat meals. I worked with Resident #43 because she was losing weight and I changed her diet to soft with bite sized small pieces on 2/14/23. The family requested regular food so I told the kitchen she could have the regular diet on 3/20/23. I did not write a doctor's order, I wrote the diet change on a sticky note and gave it to the CDM. A soft and bite sized diet was a regular diet, it would be normal food cut into smaller pieces. The SLP confirmed she did not evaluate Resident #43 before changing her diet to a regular diet. The SLP said I made a lot of mistakes, I should have assessed the resident and should have received a physician order. I did not follow the policy for upgrading the diet. On 4/5/23 at 10:47 a.m., in an interview the Administrator said Resident #43's diet was changed to regular on 3/20/23 because of the sticky note the SLP provided to the CDM. The root cause after the investigation was the SLP, did not complete an evaluation and did not receive an order from the physician to upgrade the diet. The Administrator said there was no diet order to change Resident #43's diet to a regular diet. On 4/6/23 it was determined the findings of the survey posed Immediate Jeopardy to the health and safety of the residents in the facility. The Administrator was informed of the Immediate Jeopardy on 4/6/23 at 8:30 a.m. Immediate Jeopardy was identified on 4/6/23. It began on 3/20/23 and was removed on 4/7/23. The scope and severity was decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of 4/6/23 and verified by interview, observation and record review on 4/7/23. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of 4/6/23 and verified by interview, observation, and record review on 4/7/23 included the following: On 3/26/23 all resident diet orders in the electronic medical record (EMR) were compared to the tray card, the most recent orders and speech therapy evaluations. On 3/26/23 all residents with dyshagia or on a mechanically altered diet were ordered Speech Therapy evaluations. On 4/6/23 all resident care plans and kardex's were audited for diet orders. On 4/6/23 licensed and unlicensed clinical staff re-educated on the use of the Kardex. On 3/30/23 all therapy staff were educated on the process of rehabilitation screening and evaluations. On 4/3/23 dietary staff were educated on the proper process when receiving or changing diet orders. On 4/6/23 all staff were re-educated on how to communicate a change in the resident's condition. The Immediate Jeopardy was removed as a result of the facility's corrective actions implemented as of 4/6/23 and verified by interview, observation and record review on 4/7/23.

Based on record review, facility policy and procedure, and staff interviews, the facility failed to report the allegation of neglect within 24 hours to the State Agency. The facility also failed to report the results of the investigation to the State Agency within 5 days for one (Resident #43) of 3 reports reviewed. Cross reference to F600 The findings included: The facility policy Patient Protection, Abuse, Neglect, Mistreatment, and Misappropriation Prevention (dated ,d+[DATE]) defined neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Review of the clinical record revealed Resident #43 had an admitted [DATE] with diagnoses including dementia, anxiety, and dysphagia (difficulty swallowing). Review of the physician orders documented Resident #43 was on a regular textured diet. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) v.1.17.1 with an assessment reference date (ARD) of [DATE] documented Resident #43 required supervision with eating meals. The MDS noted Resident #65's cognitive skills for daily decision making were intact. A Significant Change MDS v.1.17.1 with an ARD of [DATE] documented Resident #43 required extensive assistance of one person with eating her meals. Review of the Speech Language Patholigist (SLP) note dated [DATE] documented skilled interventions addressing swallowing dysfunction included therapeutic trial feedings with soft and bite sized consistency to increase safety. Patient with significant improvement with soft and bite sized consistency. Review of the clinical record showed the diet communication form dated [DATE] documented a soft and bite sized diet. On [DATE] the SLP wrote on a posted note to change Resident #43's diet to a regular diet without a physician order and gave the posted note to the Certified Dietary Manager (CDM). On [DATE] the CDM changed Resident #43's diet from soft and bite sized to a regular textured diet without a physician order. On [DATE] at 6:30 p.m., Certified Nursing Assistant (CNA) Staff A delivered the evening meal to Resident #43 who was in her bed. The meal served was chicken and dumplings with whole Brussels sprouts. The CNA set up the meal tray and left Resident #43 unattended. On [DATE] at 7:45 p.m., CNA Staff A entered Resident #43's room to pick up her meal tray. The CNA reported Resident #43 was sitting upright in bed with the meal tray in front of her on the over the bed table. The CNA asked the resident if she was finished eating and the resident nodded her head yes. The CNA removed the tray and exited the room. On [DATE] between 8:15 p.m., and 8:20 p.m., CNA Staff A returned to Resident #43's room to assist the resident to get ready for bed and found her unresponsive. Licensed Practical Nurse (LPN) Staff B was notified and assessed the resident who was pulseless and not breathing. The LPN initiated CPR and contacted 911. EMS arrived and pronounced Resident #43 dead at 8:51 p.m. On [DATE] at 2:06 p.m., in an interview the Respiratory Therapist said I was four rooms down and heard the page for Code Blue and responded. They were bringing the code cart in and the nurse was doing chest compressions. I was getting the Ambu bag (a handheld device used to provide pressure ventilation to patients who are not breathing). I noticed when I used it, she was not ventilating, I saw no chest rise. I noticed something green at the back of her mouth, it appeared to be a Brussels sprout and it was whole. I used the suction machine to remove the Brussels sprout, it was bigger than a marble but smaller than a golf ball. I was ventilating her. EMS arrived and took over CPR. Resident #43 was unresponsive when I arrived. On [DATE] at 9:30 a.m., the Administrator confirmed she did not file a report with the State agency as required. At the time we did not know what had happened to Resident #43. We thought it was a heart attack or age-related death. We found out she had accidentally choked around [DATE] when we received the Medical Examiner report. It was not abuse, she choked. She was receiving the correct diet at the time. I did not know I was required to file both a state and federal report.

Based on record review, review of facility's policy and procedure, staff, and resident interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate interventions to prevent avoidable fall related serious injuries for 5 (Resident #20, #85, #193, #392, and #292) and 2 (Resident #27, and #192) with multiple falls, of 10 residents sampled with falls or fall related injuries. Resident #20 was admitted to the facility on [DATE] and was dependent on staff for repositioning. On 1/22/22 the resident rolled out of bed during care and sustained a nasal bone fracture. Resident #85 was admitted to the facility on [DATE] and was assessed to be at risk for falls. On 2/5/22 and 5/14/22 the resident sustained a fall resulting respectively in a [CONDITION(S)] and wrist and acute head injury. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained a fall resulting in a dislocation of the right hip prosthesis. Resident #292 was admitted to the facility on [DATE]. The resident was assessed to be at risk for falls. On 6/11/22 the resident was sent to an acute care hospital after he was found on the floor with a head wound actively bleeding, requiring staples. Resident #27 was admitted to the facility on [DATE]. Resident #27 was assessed to be at risk for falls. Resident #27 sustained 12 unwitnessed falls from 2/9/22 through 5/23/22. Resident #192 was admitted to the facility on [DATE] with a history of falls with injury. Resident #192 sustained eight unwitnessed falls, including four falls on 5/31/22. The facility's failure to implement systemic interventions to prevent avoidable falls and fall related serious injuries resulted in noncompliance at the Immediate Jeopardy level starting on 4/20/22. On 7/30/22 at 6:29 p.m., the Administrator was informed of the determination of ongoing Immediate Jeopardy and provided the Immediate Jeopardy templates. The findings included: Cross reference: F835 and F867. The facility's fall policy revised 2/18/22 noted the facility, perform a post fall assessment to determine the root cause of the fall. Gather assessment data from the patient, staff members, and any witnesses to the fall. Review the events that proceeded the fall and contributing factors. After a fall, complete a detailed incident report to help track the frequency of the patient's fall so that the facility can implement prevention measures with high-risk patients. 1. On 7/24/22 at 2:54 p.m., Review of the clinical record for Resident #85 showed an admitted [DATE] with diagnoses of [CONDITION(S)], and [CONDITION(S)]. Upon admission, Resident #85 was assessed to be at risk for falls and a care plan developed. The care plan for falls initiated on 10/31/20 noted the resident was at risk for falls due to history of falls, impaired balance, poor coordination, and unsteady gait. The goal was to minimize risk for falls. The interventions included to encourage to transfer and change positions slowly, have commonly used articles within easy reach, provide assistance to transfer, reinforce, re-educate and remind patient of the need to call for assistance and use call light. The Annual Minimum Data Set (MDS) assessment with a target date of 11/17/21 noted Resident #85 was cognitively intact. The discharge from therapy MDS with an assessment reference date of 11/26/21 noted Resident #85 required supervision or touching assistance (Helper provides verbal cues or touching/steadying assistance) for walking as resident completes activity. The progress note dated 1/28/22 at 11:36 a.m., noted, Staff reports that resident states that while reaching for a stuffed animal resident sat herself on the floor . The note did not describe the location of the fall. Review of the incident report created on 2/1/22 (4 days after the fall) at 11:18 a.m., showed on 1/28/22 at 11:00 a.m., Staff reports that resident states that she was reaching for a stuffed animal and sat herself on the floor. The investigation report did not contain any witness statements, or a review of the events that proceeded the fall and contributing factors. The incident investigation did not document if the fall interventions were in place at the time of the incident or interventions implemented to prevent recurrence. The progress note dated 2/5/22 at 4:19 p.m., noted, CNA went into residents [sic] room and noted that she was lying on the floor in front of the foot of the bed. When nurse went in she was sitting on her buttocks with knees slightly bent, on the floor at the foot of her bed . The nurse documented she assisted the resident to a standing position. Resident #85 could barely bear any weight on her left leg and complained of pain. The resident was sent to the hospital for evaluation and treatment. The incident and investigation report dated 2/5/22 at 3:57 p.m. did not document people interviewed during the investigation, a timeline of critical events, actions taken during the investigation, or a conclusion. The hospital record dated 2/5/22 noted Resident #85 said she came out of her room to walk down the hallway to check on someone who sounds like they were crying, she tripped and fell , she could not bear weight afterwards, and she hit her head. The resident was diagnosed with a left femoral neck fracture (part of the thigh bone), left wrist fracture, left facial abrasion and contusion. Resident #85 returned to the facility on [DATE]. Resident #85 received Physical, and Occupational Therapy. The care plan was not updated to include preventive measures to prevent recurrence of falls. The progress note dated 3/28/22 at 10:18 a.m., noted, Resident with a fall on 3/26/22. IDT (Interdisciplinary team) reviewed fall care plan and risk factors with interventions added. The incident report created on 3/28/22 at 8:36 a.m., (Two days after the fall) noted Date of incident: 3/26/22 2:00 PM. The housekeeper notified the nurse someone is on the floor. The writer observed the resident sitting on the floor in front of her wheelchair. On 3/28/22 at 10:55 a.m., the nurse documented, She [Resident #85] is able to tell the nurse she fell and how it happened. The note did not document the content of the interview with the resident. On 3/28/22 the care plan was updated to Provide resident with rest periods after meals/throughout the day as needed/desired. The investigative report dated 3/28/22 (two days after the fall of 3/26/22) was incomplete and did not document the content of the interview with the resident to determine the root cause of the incident and ensure the interventions listed on the care plan were appropriate to prevent recurrence of avoidable falls and fall related serious injuries. On 3/31/22 at 9:59 a.m. a progress note documented, Resident with a fall on 3/30/22. IDT reviewed fall care plan and risk factors with intervention added. The incident report created on 3/31/22 at 9:35 a.m. noted, Date of incident 3/30/22 at 12:00 p.m. Resident was observed sitting on floor in front of wheelchair. Resident stated she was attempting to get up on her own. Call light within reach and not activated, gripper socks [anti-skid socks] in place. Wheelchair locks engaged and bed in low position. On 3/31/22 the care plan was updated to assist and encourage resident to have her lunch meal in the Dining Room. The investigation report was not completed. It did not include a root cause analysis to determine if the intervention added to the care plan was appropriate to prevent further avoidable falls. On 5/14/22 at 10:20 a.m., an incident report noted Resident #85 was observed on the floor laying on her right side in front of the wheelchair and the air conditioner. The resident was awake and alert and stated, I slid off the w/c (wheelchair). The investigation report was not completed. The resident was sent to the hospital for evaluation and returned with a diagnosis of acute head injury. The care plan was updated on 5/16/22 (two days after the fall with serious injury) to include a Dycem (anti slip material) to the wheelchair seat. On 7/26/22 at 2:23 p.m., the Assistant Director of Nursing (ADON) said it is the facility process to complete a fall investigation. The ADON said Resident # 85 was independent prior to her fall of 2/5/22 and has not been able to ambulate on her own since sustaining those injuries. On 7/26/22 at 4:06 p.m., the Minimum Data Set (MDS) Registered Nurse Staff D said that prior to fall of 2/5/22, Resident #85 required supervision to independence with all functional status. As of last MDS assessment completed on 7/1/22, the resident has declined and requires extensive assistant with all functional mobility and is no longer ambulatory. RN Staff D said despite therapy, Resident #85 has not regained her prior level of function. On 7/26/22 at 2:54 p.m., the Rehabilitation Director said Resident #85 received therapy after her fall with major injuries on 2/5/22. The resident was discharged from therapy on 7/1/22 at a maximum assist to dependent with some functions. 2. Resident #292 was admitted to the facility on [DATE]. The Admission MDS assessment with a target date of 6/16/22 noted the resident had severe cognitive impairment. Resident #292 required extensive physical assistance of one person for bed mobility and extensive assistance of two persons for transfer (how resident moves to or from bed, chair, wheelchair, standing position). The diagnoses included traumatic brain injury. The resident's vision was highly impaired and did not wear corrective lenses. The care plan created on 6/13/22 noted the resident was at risk for falls due to a history of falls, recent falls with head injury, poor safety awareness, new environment, and weakness. On 6/11/22 the facility noted in an incident report, Resident observed lying on the floor with a head wound actively bleeding. He had been placed in w/c [wheelchair] 5 min (minutes) prior d/t (due to) climbing OOB (Out of bed). Resident #292 was sent out to the hospital and returned on 6/13/22 with staples to his head and a diagnosis of unspecified falls. The care plan updated on 6/13/22 noted to, assist with and encourage use of non-skid footwear, non-skid socks in and out of bed. The investigation report was not completed. It did not include a root cause analysis to determine if the intervention added to the care plan was appropriate to prevent further avoidable falls. On 6/14/22 at 12:40 p.m., the facility noted in an incident report, Pt [patient] fell next to bathroom door ambulating without assistive device. The nurse completing the incident report noted the resident sustained a skin tear to the right hand. The care plan was updated on 6/14/22 to assist the resident with toileting and/or provide incontinence care upon rising, before/after meals, at bedtime and as needed. One on one care/observation with staff as needed/indicated. The investigation report for the fall of 6/14/22 was not completed. It did not include an investigation, conclusion to determine the root cause of the incident to ensure the interventions were appropriate to prevent further avoidable falls. On 7/29/22 at 3:00 p.m., the Administrator and the Director of Nursing (DON) said the interdisciplinary team IDT reviewed the falls every morning and afternoon, Mondays through Fridays through the Eagle Room process. The Eagle Room process consists of a check list to ensure the following areas were completed after a fall: Neurological checks, Medication review, Notification of MD and family, electronic incident report, Investigation complete, reportable, fall evaluation completed, Pain evaluation completed, Referral or new intervention, Calcium and Vitamin D protocol, root cause (IDT) management document, care plan and task list (updated). The DON could not provide additional information indicating an investigation to determine root cause of the falls. 3. On 7/28/22 review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. The admission assessment dated [DATE] assessed Resident #27 to have a BIMS score of 11, a score between 8 to 12 means a person was assessed with moderately impaired cognition for daily decision making. Resident #27 admitting diagnoses included anxiety disorder, unspecified cerebral infarction, cognitive communication deficit, and a history of repeated falls. Further review of Resident #27's medical record revealed a fall care plan created on 2/4/2022 stating Resident #27 was at risk for falls due to weakness, confusion, poor safety awareness, resident placed himself on the floor and would slide out of bed and chair. The facility's goal for falls is the facility would minimize the risk of injury related to falls and decrease the number of falls, with a target date of 9/03/2022. The fall care plan interventions stated they would assist and encourage the resident to be up and out of bed and room daily for supervised activities and dining (4/25/2022), assist Resident #27 with toileting, and/or provide incontinence care upon rising, before/after meals and bedtime (3/11/2022), assist with and encourage the use of non-skid footwear (4/20/2022), bed in low position (2/14/2022), Dycem/anti-slip material to wheelchair seat (2/14/2022), encourage resident to be up in chair daily for breakfast (2/28/2022), encourage resident to attend supervised activity (4/08/2022), encourage to transfer and change position slowly (2/17/2022), follow-up with psychiatric Nurse Practitioner (NP) post 4/16/22 fall (4/18/2022), have commonly used articles within easy reach (2/04/2022), implement use of preventative devices for falls (5/24/2022), medication review with physician, NP and pharmacy consultant (4/18/22), monitor positioning while in bed to ensure safety and reposition as needed in bed (5/06/2022), provide assist to transfer and ambulate as needed (2/04/2022), provide stuffed animal while up in wheelchair and in bed for comfort and happiness (4/01/2022), psychiatric service consult related to sliding out of bed and chair behaviors (2/17/2022), reinforce need to call for assistance (2/04/2022), reinforce wheelchair safety as needed (2/27/2022), and the use of a STOP sign to help prompt/cue Resident #27 to call for assistance related to frequent falls (3/07/2022). A review of Resident #27's Incident Report and Investigation Report forms revealed Resident #27 from his admission on 2/04/2022 to 5/23/22 had 12 unwitnessed falls with no major injury. The incident Report created on 2/9/2022 stated Resident #27 was sitting on the floor in front of his wheelchair during lunchtime on 2/09/2022 at 1:00 p.m. with no injuries. The incident and investigation report dated 2/09/2022 said they took his vital signs, did a full assessment, and started neurological (neuro) checks. The incident and investigation report dated 2/09/2022 did not document the facility staff they interviewed during the investigation, timeline of critical events, actions taken during the investigation, or conclusion of their investigation. The incident Report created on 2/11/2022 stated Resident #27 was observed on the floor next to his bed on 2/10/2022 at 11:30 p.m. with no injuries. The incident and investigation report dated 2/11/2022 said they put Resident #17 back to bed, took his vital signs, and started neuro checks. The incident and investigation form did not document the name of the staff interviewed during the investigation, timeline of critical events, actions taken during the investigation, or conclusion of their investigation. The incident Report created on 2/16/2022 stated Resident #27 was observed next to his bed on 2/16/2022 at 6:15 p.m. with no injuries. The incident report stated Resident #27 told the nurse he rolled out of bed. The incident report investigation stated resident was wearing his non-skid socks, the bed was in a low position, the bedside table with fluid was in reach of Resident #27, and Resident #27 was last seen by nursing staff at 5:45 p.m. The incident and investigation report dated 2/16/2022 did not document the name of the staff interviewed during the investigation, the timeline of critical events, and the conclusion of their investigation. The incident report created on 2/23/2022 stated Resident #27 was observed on the floor next to his bed on 2/23/2022 at 6:32 a.m. with his pillow and blanket, with no injuries. The investigation revealed Resident #27's nurse said Resident #27 had yelled out multiple times during the shift, and when the nurse went into his room the resident was on the floor with his pillow and blanket covering him. Resident #27 told the nurse he placed himself on the floor. The investigation said the nurse did neuro checks, a full assessment, vital signs, and assisted the resident back into bed. The incident and investigation report dated 2/23/2022 did not document the name of the staff interviewed during the investigation, and the conclusion of their investigation. The incident report created on 2/27/2022 stated Resident #27 was observed on the floor next to his bed on 2/27/2022 at 5:45 a.m., with no injuries. The investigation stated Resident #27's nurse said they observed Resident #27 was on the floor next to his bed without injuries. She assisted Resident #27 back to bed, did a full assessment, and started five minutes neuro checks. She further said she had seen Resident #27 five minutes earlier in his bed resting quietly at 5:40 a.m. The incident and investigation report dated 2/27/2022 did not document the name of the staff interviewed during the investigation, and the conclusion of their investigation. The incident report created on 3/05/2022 stated Resident #27 was observed on the floor next to his bed on 3/05/2022 at 10:00 a.m., with no injuries. The investigation revealed Resident #27's nurse said she was notified by Resident #27's certified nursing assistant he was on the floor next to his bed without injuries. The resident was unable to state what happened but said he was not in pain. The nurse did a set of vital signs, initiated neuro checks, and put Resident #27 back to bed. The incident and investigation form did not document the staff interviewed during the investigation, the timeline of critical events, or the conclusion of their investigation. The incident report created on 3/10/2022 stated Resident #27 was observed on the floor during hourly rounds next to his bed on 3/10/2022 at 8:30 p.m., with no injuries. The investigation revealed Resident #27's certified nursing assistant said during her hourly rounds she found Resident #27 on the ground. Resident #27's nurse said they assisted Resident #27 back to bed, initiated neuro checks, started vital signs, and gave Resident #27 Tylenol for generalized pain. The investigation revealed Resident #27 had non-skid socks on, his call light was in reach, and the bedside table with fluids was in reach. The incident report said Resident #27 was unable to state what happened but said he was not in pain. The nurse did a set of vital signs and initiated neuro checks. The incident and investigation form did not document the name of the staff interviewed, the timeline of critical events, or the conclusion of their investigation. The incident report created on 4/01/2022 stated Resident #27 was observed next to his bed on the floor on 4/01/2022 at 5:00 a.m. with no injuries. The incident report stated Resident #27 said he did not know what happened when asked by the nurse. The investigation report said Resident #27's nurse started neuro checks, completed a full assessment of the resident, vital signs were completed, and Resident #27 was assisted back into bed. The incident and investigation report dated 4/01/2022 did not document the name of the staff interviewed during the investigation, and the conclusion of their investigation. The incident Report created on 4/08/2022 stated Resident #27 was observed on the floor next to his bed on 4/08/2022 at 10:56 a.m. with no injuries. The incident and investigation report dated 4/08/2022 said Resident #27 slid out of his bed onto the floor, and staff put him into his Geri chair (reclining chair). The nurse started vital signs and conducted a full assessment on Resident #27. The incident and investigation form did not document the name of the staff interviewed during the investigation, timeline of critical events, or conclusion of their investigation. The Incident report created on 4/16/2022 stated Resident #27 was observed sitting on the floor on 4/16/2022 at 7:31 a.m., with no injuries. The investigation revealed Resident #27's certified nursing assistant said they found Resident #27 on the ground next to his bed. Resident #27's nurse said she went to the room and asked the resident what happened, and he said he did not know. The incident report said Resident #27's nurse said his bed was in a low position, and he was sleeping when she did her rounds. The nurse did a set of vital signs and initiated neuro checks. The incident and investigation form did not document the name of the staff interviewed, the timeline of critical events, or the conclusion of their investigation. The incident report created on 5/05/2022 stated Resident #27 was observed on the floor next to his bed on 5/05/2022 at 8:00 p.m. with no injuries. The incident report investigation said Resident #27 was last seen by staff within fifteen minutes of the incident. The investigation said Resident #27's call light was within reach, beside table and fluids were within reach, he was wearing his gripper socks as required. The nurse started neuro checks, did a full assessment and staff assisted Resident #27 back to bed. The incident and investigation report dated 5/05/2022 did not document the name of the staff interviewed during the investigation, timeline of critical events, or conclusion of their investigation. The incident report created on 5/23/2022 stated Resident #27 was observed on the floor next to his bed on 5/23/2022 at 10:30 p.m. with no injuries. The incident report investigation said Resident #27's call light was within reach, the bed was in a low position, and the gripper socks were on. The nurse started neuro checks, did a full assessment and staff assisted Resident #27 back to bed. The incident and investigation report dated 5/23/2022 did not document the name of the staff interviewed during the investigation, the timeline of critical events, or the conclusion of their investigation. A review of Resident #27's twelve incident report investigations related to unwitnessed falls since his admission on 2/04/2022 to 5/23/2022 dated 2/9/2022, 2/11/2022, 2/16/2022, 2/23/2022, 2/27/2022, 3/5/2022, 3/10/2022, 4/01/2022, 4/08/2022, 4/16/2022, 5/05/2022 and 5/23/2022 were all started but did not contain all the required components to include a timeline of events related to the unwitnessed falls, staff interviewed related to the falls, actions taken during the investigation to ensure Resident #27 remained safe during the investigation, and a conclusion/summary of identified hazards and/or risks to Resident #27. 4. Clinical record review showed Resident #193 was admitted to the facility on [DATE] following a fall and fracture requiring right hip surgery. The Admission Minimum Data Set (MDS) assessment with a target date of 1/13/22 noted Resident #193 scored 13 on the brief interview for mental status indicative of intact cognition. Resident #193 required extensive physical assistance of one person for bed mobility, transfer, and walking. The care plan initiated on 1/7/22 noted Resident #193 was at risk for falls due to weakness, recent fall with fractures. The goal was to minimize the risk for falls. The interventions included to have commonly used articles within reach, provide assistance for transfer and ambulation as needed, reinforce the need to call for assistance. A care plan progress note dated 1/11/22 documented Resident #193 sustained a fall on 1/10/22. The interdisciplinary team reviewed the fall care plan and risk factors with interventions added. The incident report created on 1/11/22 noted Resident #193 sustained a fall on 1/10/22 at 10:21 p.m., Resident noted on floor, laying on right side, on her back. Right leg bent behind her and complaining of pain 10 (A pain score of 10 on a numerical pain scale from 0 to 10 indicates the worse possible pain). Resident #193 was sent to the hospital for evaluation and treatment. The incident report showed no documentation of an investigation date, no documents reviewed, people interviewed, timeline of critical events, or actions taken during or after the investigation. A fall assessment dated [DATE] at 9:10 p.m. showed Resident #193 had difficulty maintaining a standing position and had impaired balance. The fall assessment showed Resident #193 had joint pain and cognitive impairment. The fall assessments showed no environmental factors to the fall. The form showed a care plan was initiated or revised. There was no additional comments or observations documented on the form. A progress note dated 1/11/22 at 4:43 a.m. showed Resident #193 returned from the hospital with a dislocated right hip prosthesis. On 1/11/22 the Care Plan was updated for the resident to be encouraged to wear nonskid footwear and non-skid socks in and out of bed, and for the bed to be in a low position. There was no documentation as to why these interventions were put in place. On 7/27/22 at 4:29 p.m., the DON verified Resident #193 was interviewable. The DON said since there was no documentation of attempts to interview Resident #193 regarding the cause of the fall, he would not be able to determine the cause of the fall. 5. Resident #192 was admitted to the facility on [DATE] with history of falls with injury. The Admission MDS with a target date of 4/16/22 showed Resident #192's cognition was impaired. The resident required extensive physical assistance of two persons for bed mobility and transfers. A care plan initiated on 4/10/22 showed Resident #192 was a fall risk due to recent falls with fractures and surgery, weakness, cognitive impairment, and poor safety awareness. Review of incident report dated 4/29/22 at 11:10 a.m. for Resident #192 showed on 4/27/22 at 2:15 a.m., the nurse documented she was called to the resident's room by the Certified Nursing Assistant. The resident was observed lying on the floor besides the bed on the left side. The nurse documented she reminded the resident to use the call light and not get up unassisted. The fall evaluation dated 4/27/22 at 2:15 a.m., noted Resident #192 had impaired balance during transition, had impulsivity or poor safety awareness. The care plan for falls was updated to include to assist and encourage use of non-skid footwear, non-skid socks in and out of bed, bed in low position. There was no investigation to determine the root cause of the incident to ensure the interventions were appropriate to prevent further avoidable falls. Review of the incident report dated 5/3/22 showed on 5/3/22 at 11:10 a.m., Resident #192 was observed lying on the floor beside the bed. Bed was low to the floor upon discovery. The resident complained of severe back pain. The resident was sent out to the hospital via emergency medical services. The change in condition progress note dated 5/3/22 noted the resident returned from the hospital. A progress note created on 5/3/22 at 8:28 a.m. shows the MDS Coordinator documented Resident #192 returned from the hospital and that she would be monitored for a significant change for 14 days. The care plan was updated on 5/4/22 to include assist and encourage to be up in chair and ready for breakfast. There was no investigation to determine the root cause of the incident to ensure the interventions were appropriate to prevent further avoidable falls. On 5/16/22 after a fall the care plan was updated to implement use of preventative device: Bed pillows to help resident recognize edge of bed. Review of the incident report created on 5/31/22 showed on 5/30/22 at 11:30 p.m., the resident was found, sitting on floor. Unwitnessed fall. There was no documented investigation to determine the root cause of the incident. There was no documentation if the previous fall interventions were in place at the time of the fall. Review of the incident report dated 5/31/22 showed on 5/31/22 at 8:30 a.m., Resident #192 was observed on the floor besides her wheelchair in the café. She stated she was looking for her ID and slid out of her chair. There was no immediate intervention to prevent the resident from sliding out of her wheelchair. On 5/31/22 an incident report documented on 5/31/22 at 11:30 a.m., the resident was observed sitting on the floor beside her bed. She continues to report that she slid out of bed looking for her ID. There was no documentation if the previous interventions to prevent the resident from rolling out of bed were in place. There was no immediate intervention to prevent recurrence. On 5/31/22 at 3:30 p.m., an incident report documented Resident #192 was observed sitting on the floor between her wheelchair and over bed table. She slid out of the chair trying to pick up a puzzle piece. There was no investigation or immediate intervention to prevent recurrence. On 5/31/22 at 4:17 p.m., an incident report documented, Resident observed sitting on the floor beside her bed. She continues to report that she sled [sic] out of bed looking for her ID. There was no investigation or immediate interventions documented to prevent further avoidable falls and potential fall related injuries. All incident reports showed no investigation, and no actions taken for the resident's falls, no documented root cause of each incident. The resident was assessed for falls on 4/27/22, 5/14/22, and twice on 5/30/22. The four fall assessments completed by the facility show Resident #192 had an impaired balance. Resident #192 was taking cardiac medications, and narcotic analgesics. 6. On 7/24/22 at 10:33 a.m., Resident # 20 said she was rolled out of bed by a Certified Nursing Assistant (CNA) who was changing her. She said she told the CNA she was too close to the edge of the bed, but the CNA did it anyway. Resident #20 said she fell off the edge of the bed and landed face down on the floor. Resident #20 said she sustained a broken nose from the fall. Review of the MDS with the ARD of 1/21/22 indicated Resident #20 required the assistance of 2 staff when she fell out of bed on 1/22/22 while being assisted by one CNA. Review of the care plans for Resident #20 revealed the intervention requiring 2 staff at all times for Activities of Daily Living (ADLs) which includes toileting needs, was not updated until 2/17/22. Review of the progress notes for Resident #20 revealed a progress note on 1/22/2022 indicating resident #20 had a fall at the facility and transported by Emergency Medical Services (EMS) to the hospital. The hospital discharge records dated 1/23/22 indicated Resident #20's nose was fractured at the facility where she fell out of bed. The incident report dated 1/22/22 for Resident #20's fall included witness statements from five CNAs who were not in the room at the time of the incident and one CNA in the room assisting the resident. On 7/27/22 at 3:56 p.m., the MDS coordinator responsible for assessing Resident #20 verified the 7-day look back for the MDS with assessment reference date of 1/21/22 indicated Resident #20 required two staff for bed mobility and toileting. On 7/26/22 at 4:09 p.m., the Director of Nursing (DON) confirmed there was only one CNA in the room helping Resident #20 at the time she fell . He said he provided training two days later on 1/24/22. The DON said if the staff were in the facility on that day he provided the training, he would have trained them however, it was not mandatory. Review of the staff training r [TRUNCATED]

Based on record review and interview the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to prevention of avoidable falls and fall related serious injuries. On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell . Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 sustained a fall, was sent to the hospital and diagnosed with a left femoral neck fracture, left wrist fracture, left facial abrasion and contusion. On 5/14/22 Resident #85 was sent to the hospital after the fall and diagnosed with an acute head injury. Resident #292 was admitted to the facility on [DATE]. The resident was assessed to be at risk for falls. On 6/11/22 the resident was sent to an acute care hospital after he was found on the floor with a head wound actively bleeding, requiring staples. On 2/20/22 the facility developed a performance improvement plan to address the increase in falls and fall related injuries. The facility failed to ensure implementation, and monitoring of the approaches in the performance improvement plan to minimize the risk of falls and fall related injuries. The facility failure to implement effective corrective actions and monitor results, created a likelihood other residents suffer from falls resulting in serious harm, and resulted in noncompliance at the Immediate Jeopardy level starting on 4/20/22. The Administrator was informed to the determination of ongoing Immediate Jeopardy on 7/30/22 at 6:29 p.m. and provided the Immediate Jeopardy templates. The findings included: Cross reference to F689 and F835. Review of the facility's QAPI (Quality Assurance and Performance Improvement) plan with an effective date of May 16, 2022, noted, . The purpose of QAPI is to take a pro-active approach to continually improve the quality of care we provide . Eagle Room is a twice daily interdisciplinary care and service management process that functions as an on-going ad-hoc (for this situation) meeting of the center's QAPI Committee with a primary focus on clinical care and services . The scope of QAPI program encompasses all types and segments of care and services that impact clinical care. These include . patient safety .Aspects of service and care are measured against established performance goals and key measures are monitored and trended on a quarterly and/or annual basis . The Administrator, as the chair of the QAPI Committee, is responsible and accountable for ensuring that the QAPI program . is defined, implemented, maintained and addresses identified priorities . corrective actions address gaps in systems and are evaluated for effectiveness . The QAPI committee is responsible and accountable for . ensuring corrective actions are effective . analyzing QAPI program performance to identify and follow up on areas of concern or opportunities for improvement .The QAPI plan addresses the elements of systematic analysis and systemic action through the use of the following processes and systems: root cause analysis, use of a continuous cycle to evaluate the effectiveness of performance improvement initiatives, communication of performance improvement project efforts . On 7/29/22 at 2:39 p.m., the Administrator said the company's corporate office directed them to develop a performance improvement plan (PIP) since they had identified an increase in falls at different facilities. The Administrator said the PIP was initiated at the facility on 2/20/22 and lasted until 4/20/22. Review of the Performance Improvement Plan(PIP) titled Falls Management dated 2/2/22 noted the overall goal of the improvement project was to reduce the trends of falls and falls with major injury. The target end date was April 20, 2022. The summary of the findings of the root cause analysis noted a Knowledge deficit related to the process steps for identification of resident falls risks, interventions and systems to minimize fall risks while promoting quality of care. The measures included: 1. The facility will identify a subcommittee related to falls management reduction. The team consisted of two nurses, one therapist, two CNAs (Certified Nursing Assistants) and one leadership team member preference would be Activities Director. The committee will be tasked to review all current residents who have had more than three falls in 90 days or one major fall with injury. Discuss for each: Any with possible sleep deprivation/up frequently during night/awake most of the night. On March 29, 2022, the DON documented Medication review and causes associated with recent falls and correlation of effectiveness of interventions since PIP initiation. The result of the intervention was documented as In progress. 2. The Administrator/Designee will educate the interdisciplinary team and set expectations for the review of falls during Eagle Room and the completion of the Eagle Room QA (Quality Assurance) tool. On 2/28/2022, the DON documented education provided on fall interventions and preventions with implementation of increased rounding and monitoring by all nursing staff. On 3/29/22 the DON documented ongoing reminders and plan for fall documentation review. New falls added to monitoring list for IDT review of causes and preventions. The result of the interventions was documented as Successful. 3. The DON/Designee will educate CNAs and licensed nurses on post fall process review utilizing the FYI (For Your Information) post fall evaluation. On 2/28/22 the DON documented education provided to all nursing staff at mandatory meeting/education on 2/23, 2/24 and 2/25. On 3/18/22 the DON documented reminders to all staff based on situation and likelihood of falls or recurrent falls. Staff continue to monitor and implement fall preventions and interventions. On 3/29/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the interventions was documented as Successful. 4. The DON/Designee will educate licensed nurses on initial evaluation of residents past history or experiences of falls. Completing the admission/readmission screen with accuracy. On 3/18/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the interventions was Successful. The DON/Designee will educate licensed nurses on completing incident reports timely (Incident reports will be in incident report management by the end of the shift the incident occurred providing an accurate tracking process). On 3/29/22 the DON documented Monitoring of incident reports, review of preventions in place and new interventions added. The result of the intervention was Successful. The facility QAPI (Quality Assurance and Performance Improvement) team will conduct a trend review of falls to identify residents with falls and falls with major injury utilizing the Eagle Room QA tool to identify areas that are not completed weekly for four weeks then monthly for two months. The facility's incident log showed a total of 157 falls from January 1,2022 through July 22, 2022. Review of a sample of 10 residents with falls and fall related serious injuries revealed four residents sustained serious injuries (broken bones) and one resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/29/22 at 2:39 p.m. the Administrator said there was no documentation a trend review of falls in the building during the time of the PIP. On 7/29/22 at 2:19 p.m. The DON said the PIP was to last 30 days from 3/1/22 to 3/31/22. The DON stated he thought there was a 50% reduction in falls during that period. He said he noticed the biggest trend was that there were more falls on the weekend. Each Monday he counted the falls over the weekend and noticed more falls occurred on the weekend than during the week. The DON said there was no documentation in QAPI or the PIP regarding the trending of weekend falls. The DON said there was no documented intervention put in place to reduce falls on the weekend. He said the intervention put in place were activities was more involved and we tried to give stuffed animals for them it calms them. The DON said he also directed the direct care staff to increase their rounds. He also increased his rounds. The DON said there was no policy or minimum requirements for when and how often the staff were to round. He asked the staff to round more frequently. The DON said on 4/20/22 at the end of the PIP he told staff to keep up the increased rounding. No other interventions related to the PIP were put into place. The DON said did one to one education verbally back and forth and educated all staff on expectations for completing incident reports and fall protocols. He said he could not remember which nurses he spoke to or educated. The DON said there was no post fall education, he just used copies of incident reports which he kept in an education book. The education was just informative but not a fill out form. He said he would have to look for additional documentation for education. On 7/29/22 at 2:39 p.m., and on 7/29/22 at 3:29 p.m., the DON said he did not have any additional documentation of education provided to the licensed nurses or CNAs related to the interventions listed in the performance improvement plan for falls. Review of Quality Assurance and Performance Improvement Committee Meeting (QAPICM) dated 2/18/22 documents a PIP was in place for falls. The QAPICM minutes dated 3/11/22 shows a fall PIP was in progress and was due to be completed on 3/31/22. The The QAPI Committee Summary Findings dated March reads, Fall PIP updated 2/28/22 Please see attached Tracking and Trending. A Floor plan with red dots of the first and second floor, A graph of the regional number of falls dated 2/28/22, and documentation of 6 falls Resident #27 had during the month of February form 2/9/22 to 2/27/22 are noted at this time. The QAPICM minutes dated 4/8/22 show audits were being conducted for falls. There was no further QAPICM minutes regarding falls after 4/8/22. A form titled Abaqis shows the PIP had a target end date of 4/20/22. The goal of the PIP is documented as a less than 5% reduction in falls. The DON documented on the PIP form on three dates, 2/28/22, 3/18/22, and 3/29/22. On 2/28/22 the DON documented, Audits continue of recent falls indication adherence to previous fall interventions in place. On 3/18/22 the DON documented Monitoring for effectiveness . Repeated falls associated with one resident and has improved fall likelihood and occurrences. None to report at this time. Ongoing review during Eagle Room standup and stand down . Falls decreased and interventions in place. Monitoring or results of interventions completed .Reminders to staff based on situation and likelihood of falls or recurrent falls. Staff continue to monitor and implement fall prevention interventions .Completed initial and ongoing .Great success with anticipation of exceeding goal of 50% reductions in falls. Monitoring ER tool shows 7 falls since implementation of PIP and increased monitoring, Audits, and education. 2 of the current falls are from the same residents for a total of 6 residents with 7 falls in 19 days . Conclusions Was PIP successful? Yes Final notes Fall reduction was greater than 50% during the last 30 days Increased Monitoring and early detection of fall risks at the time of admission has decreased falls and the risk of falls. Several of the falls counted in this PIP were the same resident with repeated falls. Resident fall risks were greatly increased due to resident confusion which has increased since admission. Resident has been placed at the nursing station during the day and while awake to increase integration and monitoring. The Medical Director on 7/30/22 at 5:30 p.m. said, I have had had discussion with the administrator about incomplete incident reports and making sure they were completing the incident reports and notifying the physicians about any falls. The physician was asked if these discussions were in QAPI, she said it was when she had seen things were missed was when she had had these discussions with the administrator. The Medical Director was asked about staffing issues at the facility, she said, Overall, we do discuss staffing because the past year has been very difficult. They try to fill in the staffing with minimum as required. The pandemic has impacted staffing as well. We need to work more as a team have a more team approach into these issues. The physician said at other facilities there had been fall committees. The Medical Director was asked if she was aware of a fall committee at the facility, she said she was not aware of the facility having a fall committee during the last year.

Based on record review, staff, and resident interview the facility administration failed to use its resources effectively to ensure consistent and ongoing implementation of effective measures to prevent avoidable falls and fall related injuries. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right [CONDITION(S)]. On 1/10/22 the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell . Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 was diagnosed with a left femoral neck, and left wrist fracture, left facial abrasion and contusion. On 5/14/22 Resident #85 was sent to the hospital after the fall and diagnosed with an acute head injury. On 2/20/22 the facility developed a performance improvement plan to address the increase in falls and fall related injuries. The facility administration failed to ensure implementation, and monitoring of the approaches in the performance improvement plan to minimize the risk of falls and fall related injuries. The failure of the facility's administration to implement and monitor effective fall preventive measures resulted in noncompliance at the Immediate Jeopardy level starting on 4/20/22. The Administrator was informed to the determination of ongoing Immediate Jeopardy on 7/30/22 at 6:29 p.m. and provided the Immediate Jeopardy templates. The findings included: Cross reference to F689 and F867. Review of the Administrator's job description signed on 5/10/19 revealed the Administrator, . Manages all business-related activity the HCR (Health Care and Retirement Corporation) Manorcare vision and supporting strategies and assures that . high-quality provider of health services is maintained . follows established safety policies and procedures. Ensures potential safety/health hazards are eliminated . Directs the staff to provide high quality in daily care which meets/exceeds all internal/external standards. The Director of Nursing Job Description signed on 6/21/21 showed the Director of Nursing is responsible to, . Follow established safety policies and procedures . Communicates care delivery trends, issues and opportunities to administration, medical director, and the quality assurance committee. Anticipates customer's needs and works to minimize potential problems. Establishes and manages goals and objects for the nursing department through analysis and strategic planning consistent with the company's mission. Promotes nursing process and critical thinking in nursing care delivery . Participates in clinical risk identification, strategy planning, and risk reduction. Ensures and evaluates systems to plan, promote, develop, assess, interpret, validate, and evaluated the implementation of clinical programs, policies and procedures and forms. Ensures personnel are adequately educated to care for acute events, chronic illnesses of the frail elderly, cognitive impairment, end of life . The facility's incident log showed a total of 157 falls from January 1,2022 through July 22, 2022. Review of a sample of 10 residents with falls and fall related serious injuries revealed four residents sustained serious injuries (broken bones) and one resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Performance Improvement Project (PIP) titled Falls Management dated 2/2/22 noted the overall goal of the improvement project was to reduce the trends of falls and falls with major injury. The target end date was April 20, 2022. The summary of the findings of the root cause analysis noted a Knowledge deficit related to the process steps for identification of resident falls risks, interventions and systems to minimize fall risks while promoting quality of care. The measures included: 1 The facility will identify a subcommittee related to falls management reduction. The team consisted of two nurses, one therapist, two CNAs (Certified Nursing Assistants) and one leadership team member preference would be Activities Director. The committee will be tasked to review all current residents who have had more than three falls in 90 days or one major fall with injury. Discuss for each: Any with possible sleep deprivation/up frequently during night/awake most of the night. On February 28, 2022, the DON documented increased rounding/observation education provide to all nursing staff with refresher on fall, documentation, interventions and preventions. On March 18, 2022, the DON documented Ongoing review during Eagle Room standup and stand-down. Falls decreased and interventions in place. Monitoring of results of interventions completed. On March 29, 2022, the DON documented Medication review and causes associated with recent falls and correlation of effectiveness of interventions since PIP initiation. The result of the intervention was documented as In progress. 2 The Administrator/Designee will educate the interdisciplinary team and set expectations for the review of falls during Eagle Room and the completion of the Eagle Room QA (Quality Assurance) tool. On 2/28/2022, the DON documented education provided on fall interventions and preventions with implementation of increased rounding and monitoring by all nursing staff. On 3/29/22 the DON documented ongoing reminders and plan for fall documentation review. New falls added to monitoring list for IDT review of causes and preventions. The result of the intervention was documented as Successful. 3 The DON/Designee will educate CNAs and licensed nurses on post fall process review utilizing the FYI (For Your Information) post fall evaluation. On 2/28/22 the DON documented education provided to all nursing staff at mandatory meeting/education on 2/23, 2/24 and 2/25. On 3/18/22 the DON documented reminders to all staff based on situation and likelihood of falls or recurrent falls. Staff continue to monitor and implement fall preventions and interventions. On 3/29/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the intervention was documented as Successful. 4. The DON/Designee will educate licensed nurses on initial evaluation of residents past history or experiences of falls. Completing the admission/readmission screen with accuracy. On 3/18/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the intervention was Successful. The DON/Designee will educate licensed nurses on completing incident reports timely (Incident reports will be in incident report management by the end of the shift the incident occurred providing an accurate tracking process). On 3/29/22 the DON documented Monitoring of incident reports, review of preventions in place and new interventions added. The result of the intervention was Successful. The facility QAPI (Quality Assurance and Performance Improvement) team will conduct a trend review of falls to identify residents with falls and falls with major injury utilizing the Eagle Room QA tool to identify areas that are not completed weekly for four weeks then monthly for two months. On 7/29/22 at 2:19 p.m. The DON said the PIP was to last 30 days and the time counted during the PIP for the falls was from 3/1/22 to 3/31/22. The DON stated he thought there was a 50% reduction in falls during that period. He said he noticed the biggest trend was he thought there were more falls on the weekend. He counted the falls over the weekend on each Monday and noticed more falls occurred on the weekend than during the week. The DON verified there was no documentation in QAPI or the PIP regarding the trending of weekend falls. The DON verified there was no documented intervention put in place to reduce falls on the weekend. He stated the intervention put in place were activities were more involved in giving residents stuffed animals to calm them. The DON said he implement increased rounding for both him and the staff caring for the residents. The DON said there was no policy or minimum requirements for how often the staff were to round or when they were to round. The DON said he asked the staff to round more frequently. On 4/20/22 at the end of the PIP the DON said he spoke to staff regarding increased rounding and told them to keep up the increased rounding. No other interventions were put in place due to the PIP. The DON said he had educated all staff on expectations of completing incident reports and fall protocols. He said he did one to one education verbally back and forth. He said he could not remember at the time any nurse he had spoken to or educated. The DON said there was no post fall education he just used the incident reports he said he had copies in an education book, but it was not a fill out form, just informative. He said he would have to look for additional documentation for education. On 7/29/22 at 2:39 p.m., and on 7/29/22 at 3:29 p.m., the DON said he did not have any additional documentation of education provided to the licensed nurses or CNAs related to the interventions listed in the performance improvement plan for falls. On 7/29/22 at 2:30 p.m., the Administrator said there was no documentation of education of the interdisciplinary team and the set expectations for the review of falls. The Administrator and the DON said they could not provide documentation of subcommittee meetings with review of residents with multiple falls or major injury. The DON said the meetings were held in the Eagle room daily and the only documentation they could provide was the Eagle room tool and the MDS Coordinator's documentation of interventions put in place after each fall was reviewed that same day. The facility provided documentation 32 staff members were educated on March 3, 2022. The topic was falls, falls prevention and incident reporting. Fall management initiatives which included post fall evaluation, vital signs, mental status, and assessment, and medication. There was no documentation the five Registered Nurses employed at the facility were educated. Seven of 18 Licensed Practical Nurses (LPNs) were educated. Eight of 32 Certified Nursing Assistants received the education. An active employee list provided by the facility showed on 3/3/22 five RNs, 13 LPNs, and 30 CNAs were listed on the active roster. On 7/29/22 at 3:00 p.m., the Administrator and the DON said the interdisciplinary team (IDT) reviewed the falls every morning and afternoon, Mondays through Fridays through the Eagle Room process. The Eagle Room process consists of a check list to ensure the following areas were completed after a fall: Neurological checks, Medication review, Notification of physician and family, electronic incident report, Investigation complete, reportable, fall evaluation completed, Pain evaluation completed, Referral or new intervention, Calcium and Vitamin D protocol, root cause IDT management document, care plan and task list (updated). A sample of 10 residents with falls from March 2022 through 7/28/2022 showed: Resident #293 sustained a fall on 3/24/22. There was no incident report completed. The resident reported he fell and sat on the floor. Review of the Eagle room process shows interventions circled in red. The DON said they added the interventions but did not update the Eagle Room tool. Resident #294 sustained an unwitnessed fall in the bathroom on 3/30/22. An incident report was initiated but was incomplete. The Eagle Room tool was not updated. Resident #295 sustained a fall on 6/15/22. The resident suffered head trauma. An incident report started but lacked an investigation of the fall. No new interventions were noted in the care plan at that time. The Eagle Room tool was checked as completed. Resident#296 sustained a witnessed fall on 4/19/22 at the nurse's station. An incident report initiated but not completed. The Eagle Room tool was checked as completed. Resident #85 was observed on the floor on 5/14/22. The resident reported she slid off the wheelchair. The incident report was initiated but not completed. Care plan updated with an intervention. The Eagle Room process checked off as completed. Resident #146 sustained a fall on 6/22/22. She was observed on the floor in front of her wheelchair at the nurse's station. An incident report was initiated but not completed. The care plan was updated. The Eagle Room tool was checked off as completed. Resident #26 was observed on the floor on 7/3/22. An Investigation was initiated but not complete. There was no update to the fall care plan noted. The Eagle room tool was checked off as completed. Resident #6 was observed on the floor on 7/3/22. An incident report was partially completed and did not include an investigation of the fall. The Care plan was updated with an intervention. The Eagle Room tool was checked off as being completed. On 7/24/22 at 10:33 a.m., Resident #20 said she was rolled out of bed by a Certified Nursing Assistant (CNA) who was changing her. She said she told the CNA she was too close to the edge of the bed, but the CNA did it anyway. Resident #20 said she fell off the edge of the bed and landed face down on the floor. Resident #20 said she sustained a broken nose from the fall. On 7/29/22 at 2:29 p.m. the DON said he had no documentation of rounding on residents or any auditing for resident falls he completed. The DON said the only intervention put in place during the time of the PIP was he increased his rounding of residents and he asked the staff to increase rounding of residents. He said he did not have documentation of the rounds he or the staff completed. He did not have documentation of which residents they increased rounds for or how often the staff was to round. The DON said he did not have documentation he reviewed the results of the rounds to evaluate the effectiveness of the intervention. The Administrator who was present during the interview said there were no minimum standards for rounding at the facility.

Based on observation and staff interview the facility failed to ensure a safe, functional, and comfortable environment for residents in 9 (Room 225, 226, 227,228, 229, 231, 232, 239, 230) of 31 rooms observed by failure to store personal items in a sanitary manner, failure to repair walls and peeling wallpaper, failure to secure exposed cable wires. The findings included: Review of Promedica Senior Care AM Care procedure- #19 Return equipment to designated area and clean/dispose as indicated. #20 Verify that personal items are stored separately in closed, labeled containers. On 7/24/22 at 10:12 a.m., observation revealed an uncovered, unlabeled wash basin was sitting on the toilet of bathroom 225. On 7/24/22 at 10:15 a.m., observation revealed several personal care items including bed pans and wash basins were unlabeled and uncovered in bathroom of room 226. One bedpan was on the floor, one bedpan was tucked between the grab bar and wall behind the toilet and 2 wash basins were sitting on the toilet. On 7/24/22 at 10:29 a.m., observation revealed an uncovered specimen collection item used to collect urine and/or feces was wedged between the grab bar and wall in the bathroom of room 227. An uncovered wash basin was on the floor between the wall and toilet of room 227. On 7/24/22 at 10:54 a.m., observation revealed an uncovered, unlabeled wash basin was in the sink of the bathroom of room 228. An uncovered emesis basin was uncovered and unlabeled sitting on the back of the toilet. On 7/24/22 at 11:36 a.m., observation revealed several personal care items were wedged between the grab bar and the wall in the bathroom of room 229. The items contained 2 wash basins and a bed pan. The items were not covered or labeled. On 7/24/22 at 11:55 a.m., observation revealed a bedpan, and two wash basins were unlabeled and uncovered in the bathroom of room 231. On 7/24/22 at 12:03 p.m., observation revealed an uncovered and unlabeled bedpan and wash basin were wedged between the wall and the toilet of the bathroom of room 232. There was another bedpan uncovered and sitting in the corner on the floor. On 7/24/22 at 4:18 p.m., room 222 was observed to have peeling wallpaper above the floor molding and an unsecured cable wire protruding from the wall. On 7/24/22 at 5:00 p.m., observation revealed the cold water in bathroom 239 did not function properly. Faucet turns and opens wide, but cold water comes out in only a small trickle. On 7/24/22 at approximately 5:01 p.m., in an interview, the Resident in 239A said she likes to rinse her hair with cold water and cannot do that. She said she told staff. She said it has been that way for a while. On 7/24/22 at 5:20 p.m., Observation revealed peeling paint and several unpatched holes above the television in room 240. On 7/25/22 at 9:06 a.m., second observation of the uncovered bed pan wedged between the grab bar and wall, basin uncovered on the toilet and bed pan uncovered on the floor in room 226. On 7/25/22 at 9:12 a.m., second observation of the uncovered urine/feces collection container uncovered and wedged between the toilet and the wall in room 227. On 7/27/22 at 4:32 p.m., third observation of room 226 with two bedpans, two basins and measuring cylinder. During this observation, the items were stacked and sitting on the floor. On 7/27/22 at 4:33 p.m., third observation of room 227 with urine/feces specimen collection container uncovered and wedged between the wall and the grab bar. The wash basin remained uncovered behind the toilet on the floor. On 7/29/22 at 2:39 p.m., the Administrator and Director of Nursing said they were aware of the storage issue for personal care items. On 7/29 at 2:44 p.m., the maintenance director said his routine for maintenance and repair include checking the computer. He said staff and residents also let him know of repair and maintenance issues when they see him in the hall, or they call him. He confirmed the cold water was not working in room 239 and he would tend to that immediately. He agreed the cable wire was an easy fix and he would take care of that. He agreed the peeling wallpaper should be corrected also.