Every finding on record at Cherry Blossom Health and Rehabilitation

Based on observations, staff interviews, and a review of the facility's policy titled, Storage Area, the facility failed to ensure food safety protocols and maintain sanitary conditions, specifically concerning the disposal of expired food. Additionally, food items opened in the walk-in refrigerator and dry storage area lacked proper labeling or dates. The deficient practices had the potential to place 54 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include:Review of facility's policy titled Storage Area reviewed dated 12/27/2025, revealed in Guideline items should be covered, sealed, labeled, and dated appropriately. Cleaning procedures should be a part of the routine cleaning schedules. First in first out (FIFO) should be followed. During the initial tour on 03/20/2026, at 7:43 am, the kitchen inspection revealed food in the dry storage area including one opened 4 lb. (pound) container of creamy peanut butter that was not labeled or dated and was improperly stored. Additionally, there was one opened 12 oz. (ounce) jar of grape jelly that also lacked labeling and dating, as well as one opened 25 lb. bag of brown rice that was similarly unlabeled and undated. Furthermore, two opened 32 oz. bags of light brown sugar were present, along with a 5 lb. cake mix that was missing both labeling and dating and was not stored correctly. The inspection also noted (16) 12 fl. (fluid) oz cans of evaporated milk, which had an expiration date of 12/13/2025. One box contained four 2 lb. bags of sweetened snowflakes coconut, with an expiration date of 06/4/2025. In addition, there was one 2 lb. package of sweetened snowflakes coconut that displayed multiple labels and dates, with the manufacturer's best by date marked as 02/24/2026.The walk-in refrigerator disclosed a serving pan identified by [NAME] FF as chicken gravy and opened turkey slice meat lacked proper labeling and dating. Additionally, there was a 0.58 lb. ham with an expiration date indicating it should be used by or frozen by 03/19/2026. A review of the emergency preparedness dry storage pantry revealed the Certified Dietary Manager (CDM) and Assistant Dietary Manager (ADM) oversaw the monitoring of food expiration dates; (24) 12 fl oz. of evaporate milk canned items was identified with an expiration date of 10/19/2025.On0 3/20/2026, at 10:53 AM, an observation revealed the presence of 57 ceiling tiles exhibiting a brown-orange residue, which varied in size and shape, located throughout the kitchen near the meal preparation area, dishwasher, and steam table. An interview with the CDM conducted on 3/20/2026 at 11:11 AM, the CDM explained that the stained ceiling tiles were not a result of any water issues, but rather due to a few food splatters. One splatter occurred while using the puree robot coupe with pasta sauce, and another was located near the prep station and the reach-in refrigerator resulting from pudding. DM noted that this concern had been raised several months prior.An interview with the Maintenance Director on 03/20/2026, at 11:21 AM revealed that he had recently been made aware of the ceiling tiles, as this information was not entered into TELS (maintenance order system) and was not categorized as a routine task to be performed. The Maintenance Director elaborated that the facility was experiencing some concerns regarding leaks, as condensation was evident on the tiles. However, following his recent review yesterday, he determined that these issues stem from the necessity of overhead cleaning.An interview on 03/21/2026 at 8:50 AM with [NAME] FF confirmed that the night shifts was responsible for the discovery of the open peanut butter and jelly, chicken gravy, and turkey slice meat. [NAME] FF shared that upon her arrival for the morning shift, she frequently had to correct issues left from the night shift. [NAME] FF explained that she discarded the items because she was uncertain about how long the food items had been exposed and whether anything had contaminated them. [NAME] FF revealed the potential risks to residents from consuming unlabeled, undated, expired, or improperly stored items, which could lead to illness.An interview was held with CDM on 03/21/2026 at 8:58 AM concerning kitchen observation. She confirmed that there was previously a different labeling process, where the guideline was solely used to identify the expiration date. However, the current practice involved marking the received date and then using the manufacturer date, and if the manufacturer date was unavailable, they referred to the guideline date. The CDM confirmed that the items found opened, unlabeled, undated, and improperly stored originated from the night shift snack tray preparation. The CDM explained that the ADM typically checked the refrigerator and kitchen for expired items, labeling, and dating, but he was absent due to bereavement.An interview with the Registered Dietitian (RD) conducted on 03/21/2026 at 9:16 AM disclosed that she was present the previous week and noted similar issues concerning labeling, dating, and expired food products. The RD clarified that the food items observed in the kitchen, particularly the one with three labels and varying dates, expired and posed a risk of illness to the residents.

Based on resident and staff interviews, record review, and the review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from verbal and physical abuse by a staff member for one of three sampled residents (R) (R10). The deficient practice placed R10 and other residents at risk for potential verbal and physical abuse by a staff member. Findings include:Review of the facility policy titled Abuse Prohibition documented INTENT-It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and/or their property. The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse. This policy applies to anyone subjecting a patient to abuse including, but not limited to, center staff, other patients, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. GUIDELINE: Definitions: For purposes of this policy, the following definitions apply: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caregiver, of goods or services that are necessary to obtain or maintain physical, mental and psychological well-being. Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. WILLFUL, as used in this definition of abuse means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm.Review of the electronic medical record (EMR) revealed R10 was admitted on [DATE] with pertinent diagnoses including but not limited to: chronic respiratory failure with hypercapnia, hypertension, dementia, psychotic disturbance, mood disturbance, and anxiety.Review of R10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R10 was cognitively intact. Section GG, functional status, revealed R10 uses a wheelchair. Section J. Health Conditions- No pain regimen and Section O. Special Treatments, Procedures, and Programs- Non-Invasive Mechanical Ventilator.Review of disciplinary action dated 11/14/2025 involving CNA CC revealed inappropriate resident interaction during care. The behavior was categorized as a conduct infraction. A final written warning was issued. The incident involved the CNA failing to disengage and seek assistance when the situation became confrontational. The nurse instructed the CNA to leave, but the CNA re entered the room and continued the confrontation. Interview on 03/20/2026 at 9:18 AM with R10 revealed that Certified Nursing Assistant (CNA) CC was nasty to her. R10 reported that during care, CNA CC was aggressive, balled her fist, and pushed it up against her private area, causing pain. R10 stated she did not want CNA CC to provide care. R10 reported that she wrote a letter describing her concerns and provided it to Wound Care Nurse BB. R10 gave her permission to follow up with the Administrator regarding her concerns.Interview on 03/20/2026 at 9:45 AM during the entrance conference it was revealed to the Administrator that R10 filed an abuse complaint against CNA CC and stated it had not been resolved. The Administrator stated this was his first time hearing about the incident and that he would follow up with the resident and proceed with an investigation.Interview on 03/21/2026 at 10:30 AM with R10 confirmed that CNA CC was very nasty, treated her poorly, and that she was scared of her. R10 stated she did not want CNA CC in her room anymore. R10 stated that during care she told CNA CC that she was hurting her, but CNA CC continued to push her hand outward toward the resident's private area, causing pain. The resident asked her to stop, and she refused. R10 stated she provided a written letter to Wound Nurse BB. R10 stated she feels safe in the facility but does not want CNA CC to provide any care for her.Interview on 03/21/2026 at 10:40 AM with CNA EE revealed that she provided care to R10. She stated that approximately two weeks ago, R10 told her that CNA CC was being rough with her. CNA EE reported that R10 told her she had written a two page letter regarding the incident. When asked whether she reported the alleged abuse, CNA EE stated she did not. She explained that she did not think she needed to report it because R10 had already written a letter, and she assumed the issue would be addressed. CNA EE also identified R38 as another resident who stated that CNA CC was aggressive with him. CNA EE stated this is just CNA CC's style, describing her as very drill sergeant like when interacting with residents.Interview on 03/21/2026 at 11:29 AM with R38 revealed that CNA CC was nasty and that he had reported concerns to management in the past but did not know the outcome. R38 described CNA CC as bossy and like a drill sergeant. He stated he and CNA CC had verbal disagreements on multiple occasions. R38 stated he is able to advocate for himself and did not feel afraid during interactions with her.Interview on 03/21/2026 at 12:25 PM with Wound Nurse BB confirmed that R10 did not want CNA CC providing her Activities of Daily Living (ADL) care. She confirmed that R10 gave her a letter, but she did not read it or allow R10 to read it to her. She placed the letter in the Director of Nursing's (DON's) mailbox and believed that was sufficient for reporting the abuse. She confirmed that R38 also had concerns with CNA CC. She stated he said, Y'all need to get some better CNAs, because this girl right here. while gesturing toward CNA CC as she walked out of the room. She stated she asked him what he meant, but he did not elaborate. She stated he appeared focused on going to an activity and may not have wanted to miss it.Interview on 03/20/2026 at 12:45 PM with the Administrator and DON revealed the DON was not aware of any letter placed in her mailbox by Wound Nurse BB, nor was she aware of any abuse concerns involving R38. The Administrator reported that the first time he heard about the incident was when it was brought to his attention during the entrance conference yesterday.Interview on 03/21/2026 at 1:18 PM with CNA CC revealed she was assigned to R10 and had worked with her without issues but was later told that R10 requested she not work with her. She stated this request had been in place for over a month. She stated nurses continued to assign her to the resident at times despite the request. She stated she informed the nurse each time that the resident did not want her providing care. She stated she did not provide care to R10 alone after being told the resident refused her. She stated the ADON made room assignments and that CNA DD was present in the room with her.Interview on 03/21/2026 at 2:35 PM with CNA DD revealed R10 was a two person assist and someone would always be in the room with her. She reported receiving abuse prevention training upon hire and that CNA CC was the person who trained her. CNA DD did not recall any issues between CNA CC and R10 but was aware that R10 did not want CNA CC to provide care. She stated CNA CC assisted her one time with pulling the R10 up in bed because no other CNA was available.Interview on 03/22/2026 at 9:30 AM with the Assistant Director of Nursing (ADON), he confirmed that CNA CC worked with R10 on March 15, 2026. He reported that no one informed him that R10 did not want CNA CC providing care, and R10 did not tell him directly. He stated he heard it from another staff member. ADON stated he expected staff to ensure residentswere safe and treated with dignity and respect and to notify the Abuse Coordinator of any suspected abuse.Interview on 03/22/2026 at 1:40 PM with the DON revealed her expectation was that staff report any suspected abuse immediately to their supervisor, who would then report it to the Abuse Coordinator/Administrator. She confirmed that Wound Nurse BB should have followed up on the letter placed in her mailbox.interview on 3/22/2025 at 2:29 PM with the Administrator confirmed that his expectation was for staff to report abuse immediately.

Based on resident and staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Reporting and Investigating, the facility failed to report abuse for one of three residents (R10) reviewed for abuse. This deficient practice placed R10 and other facility residents at risk of potentially being abused by a staff member.Findings include:Revived of the policy titled Abuse Prohibition- Reporting and Investigating with a review date of [DATE] revealed: INTENT-It is the intent of this center to establish standards of practice for investigation and reporting of abuse, neglect, mistreatment, exploitation, and misappropriation of property. GUIDELINE-Reporting: -Any person hearing a complaint of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation must immediately tell the Administrator, the Director of Nursing, the Social Services Director, any specific department leader, or the nurse in charge.-Any person identifying any signs and symptoms of abuse as listed in the Abuse Prohibition policy related to a specific patient is responsible to immediately inform the Administrator, the Director of Nursing, the Social Services Director, any specific department leader, or the nurse in charge.-It will be the responsibility of any department leader receiving the complaint of alleged abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation should inform the Administrator or designee immediately.-All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours.-Allegations that do not involve abuse or allegations with serious bodily injury must be reported immediately but no later than 24 hours. In addition:- The administrator or designee will take immediate action to prevent further potential occurrences while the alleged occurrence is being investigated.Review of the electronic medical record (EMR) revealed R10 was admitted on [DATE] with pertinent diagnoses including but not limited to: chronic respiratory failure with hypercapnia, hypertension, dementia, psychotic disturbance, mood disturbance, and anxiety.Review of R10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R10 was cognitively intact. Section GG, functional status, revealed R10 uses a wheelchair. Section J. Health Conditions- No pain regimen and Section O. Special Treatments, Procedures, and Programs- Non-Invasive Mechanical Ventilator.Interview on [DATE] at 9:18 AM with R10 revealed that CNA CC was nasty to her. R10 reported that during care. R10 reported that she wrote a letter describing her concerns and provided it to Wound Care Nurse BB.Interview on [DATE] at 9:45 AM during the entrance conference it was revealed to the Administrator that R10 filed an abuse complaint against CNA CC and stated it had not been resolved. The Administrator stated this was his first time hearing about the incident and that he would follow up with the resident and proceed with an investigation.Interview on [DATE] at 12:45 PM with the Administrator and DON revealed the DON was not aware of any letter placed in her mailbox by Wound Nurse BB, nor was she aware of any abuse concerns involving R38. The Administrator reported that the first time he heard about the incident was when it was brought to his attention during the entrance conference yesterday.Interview on [DATE] at 1:40 PM with the DON revealed her expectation is that staff report any suspected abuse immediately to their supervisor, who will then report it to the Abuse Coordinator/Administrator.interview on [DATE] at 2:29 PM with Administrator confirmed that his expectation was for staff to report abuse immediately.

Based on staff interviews, record review, and review of the facility policy titled, Best Practices for PASRR, the facility failed to perform a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 14 sampled residents (R) (R5). This failure had the potential for residents with mental disorders not to receive identified specialized services.Findings include:A review of the facility policy titled Best Practices for PASRR, no date, revealed that all residents must be evaluated to determine their PASRR status. The Social Services Director (SSD) is responsible for maintaining an active, ongoing, and up-to-date list of PASRR patients. This list should indicate whether each resident requires services, and a Level 2 screening tool should be used to assess whether a resident qualifies for the PASRR population.A review of the electronic medical record (EMR) revealed that R5 had a history of anxiety disorder (11/29/2024), Major Depressive Disorder (1/19/2024), Post-Traumatic Stress Disorder (9/15/2023), and unspecified intellectual disabilities (9/13/2024).A review of the Minimum Data Set (MDS) OBRA Quarterly Assessment, dated 01/25/2026 revealed in Section C-Cognition, R5 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section I-Diagnoses revealed diagnoses for anxiety disorder, depression, and PTSD. Section N-Medications revealed that R5 received an antipsychotic, antianxiety, and antidepressant medication.A review of the physician's orders indicated that R5 was prescribed Aricept 10 mg (milligrams) by mouth daily, Abilify 30 mg by mouth daily, buspirone 15 mg by mouth three times a day, and sertraline 150 mg by mouth daily.During an interview with the Social Services Director (SSD) on 3/21/2026 at 01:59 PM, she indicated that R5 was experiencing some psychological and behavioral issues. According to the SW, R5 was prescribed multiple psychiatric medications and received psychological services through the facility. The SSD noted that she had not applied for Level II PASRR for R5 because he had access to the necessary services. However, she acknowledged that an application should have been submitted for R5 and that it was an oversight.

Based on observations, staff interviews, and review of the facility policy titled, Enhanced Barrier Precautions (Contact, Enhanced Barrier, Droplet, Airborne), the facility failed to use Personal Protection Equipment (PPE) for one of 41 sampled residents (R) (R4). The deficient practice had the potential to spread infection.Findings include:Review of the facility policy titled Enhanced Barrier Precautions (Contact, Enhanced Barrier, Droplet, Airborne) reviewed 12/27/2024, indicated under Implementing Contact Versus Enhanced Barrier Precautions: . EBP (enhanced barrier precautions) would be applied during care for residents with indwelling medical devices. A review of the physician's orders dated 01/21/2026 revealed R4 received tube feedings via the gastrostomy tube.During an observation of LPN AA, on 03/21/2026 at 9:41 AM, LPN AA entered R4's room to administer a tube feeding bolus (feeding method allows formula to flow directly into the stomach using a syringe or reusable squeeze pouch). R4 was sitting in his wheelchair. LPN AA washed her hands and put on gloves but did not don (put on) a gown. She lifted R4's shirt and took the tubing from inside his waistband. Using a stethoscope, she auscultated (listened to) R4's abdomen to check the proper placement of the tube. After confirming its placement, she attached a syringe to the tube to assess residuals (how much left in stomach). Once this was confirmed, she poured Isosource 1.5 into the syringe and began administering the feeding. When the Isosource did not enter the tubing, LPN AA applied pressure to various areas of R4's abdomen, near the stoma (entrance to stomach for feeding tube), to reposition the tubing and keep it patent; this occurred approximately three times. After the feeding was completed, LPN AA flushed the tube with 150 mL (milliliters) of water as per the physician's orders, again applying pressure to R4's abdomen. She then clamped the tubing, reinserted it into R4's waistband, and pulled his shirt down over it. At the end of the observation, the Assistant Director of Nursing (ADON) entered the room, holding a gown, and instructed LPN AA to put it on. LPN AA responded that she had already completed the tube feeding.During an interview with LPN AA on 03/21/2026 at 10:01 AM, she confirmed that the resident was under EBP. She acknowledged that she had handled the clothing of R4 and palpated the abdomen near the PEG (gastrostomy) tube site. LPN AA stated that she should have worn a gown before providing care and administering a tube feed bolus to R4.During an interview with the Assistant Director of Nursing (ADON) on 03/21/2026 at 10:04 AM, he stated that LPN AA should have worn a gown before administering a tube feeding and care to R4. He added that PPE was necessary because R4 was EBP due to his PEG tube.

Based on observations, staff interviews, and review of the facility policies titled Food Preparation and Distribution, and Ice Chests and Ice Machines, the facility failed to ensure the proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen. The deficient practices had the potential to place residents who received an oral diet at risk of foodborne illnesses. Findings Include: Review of the facility policy titled Food Preparation and Distribution, review date 12/27/2024, revealed the Intent section stated, It is the intent of this center to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. The Guideline section included, . Work surfaces and equipment should be cleaned and sanitized as needed. During preparation of modified consistency foods, safe food handling practices should be followed. Review of the facility policy titled Ice Chests and Ice Machines, review date 12/27/2024, revealed the Intent was To assure patient safety in use of ice and ice machines. The Guidelines section included . Clean, disinfect, and maintain ice-storage chests on a regular basis. Observation on 2/11/2025 at 8:57 am of the walk-in cooler revealed a package of polish sausage with a use-by date of 2/7/2025. Further observation revealed packages of opened, unwrapped, and undated sausage patties and bacon. Observation on 2/11/2025 at 9:18 am of the dry storage pantry revealed five bags of chips with a use product date of 1/28/2025. Further observation revealed an opened and unsealed package of macaroni noodles. Observations on 2/11/2025 at 9:24 am in the kitchen revealed pureed food in the puree blender sitting on the counter, and the mixer and slicer were observed to have food particles on the machines. Observation on 2/11/2025 at 9:40 am revealed the ice machine had a black flakey substance on the inside handle. In an interview on 2/11/2025 at 11:15 am, the Dietary [NAME] confirmed the pureed food was left in the puree blender sitting on the counter. She stated the food should not be left sitting at room temperature. In an interview on 2/12/2025 at 9:10 am, the Dietary Manager (DM) confirmed the pack of polish sausage was out-of-date, the sausage patties, bacon, and noodles were opened and undated, and the chips were past the expiration date. The DM further verified the pureed food was left in the puree blender on the counter and stated it should not be left sitting at room temperature. The DM verified the ice machine had a black, flaky substance on the inside handle. The DM stated the facility policies should be followed in the kitchen.

Based on observation, interview, and record review the facility failed to ensure that six of six residents (Resident (R) 21, R29, R43, R44, R57, and R50) reviewed for bed rail use of 20 sample residents had documented safety assessment for the use of bed rails and the Resident or Resident Representative (RR) were advised of the risks and/or benefits of rail use. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use. Findings include: A request for a bed rail policy, on 09/20/23 at 5:35 PM the Division Regional Nurse (DRN) stated, We don't have a rail policy, it's just part of the admission assessment. I even called in compliance and there isn't one. 1. Review of R21's Face Sheet from the electronic medical record (EMR) Resident tab showed a medical diagnoses that included hemiplegia and hemiparesis following cerebral infarct, congestive heart failure, osteoarthritis, anxiety disorder, and hypertension. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/23 showed R21 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicative of being cognitively intact. During an observation and interview on 09/18/23 at 11:56 AM, R21 was observed to have bilateral assist bars attached to his bed. When asked if he had been advised of the benefits and risks of assist bars R21 stated, No, I didn't get talked to about that. Review of the R21's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 11/16/22 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM, the Division DRN stated there were no further assessments Review of R21's Care Plan from the EMR Care Plan tab showed on 09/14/23 a self-care deficit care plan that noted the use of assist bars for R21 to turn and position himself in bed. 2. Review of R29's Face Sheet from the EMR Resident tab showed a medical diagnoses that included femur fracture, seizures, hypertension, heart disease, schizophrenia, early onset Alzheimer's, gout, and polyneuropathy. Review of a quarterly MDS with an ARD of 08/17/23 showed a BIMS score of 4 out of 15, or indicative of severe cognitive impairment. During an observation and interview on 09/18/23 at 3:44 PM, it was observed that R29 had bilateral assist bars attached to the bed. When asked if he had been advised of the benefits and risks, he thought perhaps his sister had been advised. Review of the R21's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 06/12/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments. Review of R29's Care Plan, from the EMR Care Plan tab, showed a focus of a self-care deficit with a goal that the Resident will be able to assist with turning and positioning self in bed and an intervention of the assist bars to the bed. 3. Review of R43's Face Sheet from the EMR Resident tab showed a facility admitted [DATE] with medical diagnoses that included hemiplegia and hemiparesis following a cerebral infarct, paroxysmal atrial fibrillation, convulsions, major depressive disorder, and dysphagia. Review of a quarterly MDS with an ARD of 08/22/23 showed R43 had a BIMS score of 15 out of a possible 15, indicative of being cognitively intact. During an observation and interview on 09/18/23 at 2:17 PM it was observed that R43 had bilateral assist bars attached to her bed. When asked if anyone had discussed the benefits and risks of the assist bars, R43 stated no. Review of the R43's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 04/24/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments R43's Care Plan from the EMR Care Plan tab showed she required assistance from sitting to lying in the bed, lying to sitting in the bed, and extensive assistance with bed mobility but did not note the use of assist bars. 4. Review of R44's Face Sheet from the EMR Resident tab showed a facility admitted [DATE] with medical diagnoses that included type II diabetes, quadriplegia, anxiety disorder, hypertension, anemia, and major depressive disorder. Review of a quarterly MDS with an ARD of 08/08/23 showed R44 had a BIMS score of 11 out of 15, indicative of moderate cognitive impairment. During an observation and interview on 09/19/23 at 10:19 AM R44 was observed to have bilateral assist bars attached to the bed. R44 stated she did not use them, and nobody had discussed the benefits and risks of the bars. Review of the R44's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 05/09/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments. Review of R44's Care Plan from the EMR Care Plan tab showed she required assistance from sitting to lying in the bed, lying to sitting in the bed, and extensive assistance with bed mobility but did not note the use of assist bars. 5. Review of R57's Face Sheet from the EMR Resident tab showed a medical diagnoses that included disorganized schizophrenia, gout, hypertension, skull fracture, muscle weakness, need for assistance with personal care, traumatic subarachnoid hemorrhage, and dementia. Review of a quarterly MDS with an ARD of 07/26/23 showed R57 had a BIMS score of 12 out of 15, indicative of moderate cognitive impairment. During an observation and interview on 09/18/23 at 11:47 AM, it was observed that R57 had bilateral assist bars attached to the bed. When asked if he had been advised of the benefits and risks and consented, R57 stated he didn't remember benefits and risks or signing anything, but that he used the bars. Review of the R57's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 03/11/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments. Review of R57's Care Plan from the EMR Care Plan tab showed he had limited mobility and used assist bars to aid in bed mobility. During an interview on 09/21/23 at 6:00 PM, regarding bed rail use, the Administrator stated an expectation was that the assessment, risk/benefit advisement, and consent would be completed upon admission. 20243 6. Review of R50's Face Sheet from the EMR Resident tab revealed diagnoses which included cerebral infarction, type 2 diabetes mellitus with diabetic nephropathy, congestive heart failure, chronic obstructive pulmonary disease, cardiomyopathy, schizoaffective disorder - bipolar type, hypothyroidism, hyperlipidemia, and dementia. Review of R50's admission MDS in the MDS tab of the EMR with an ARD of 07/30/23 revealed she required supervision with bed mobility and transfers. During an observation on 09/19/23 at 12:21 PM in R50's room, 1/4-length rails were on both sides of R50's bed at the head of the bed. During an interview, R50 stated she was unable to use the rails. R50 stated that she was able to move in bed without use of the rails and transfer independently to the wheelchair. Review of R50's EMR under the Data Collection tab revealed there was no assessment of her need for and use of the bed rails. During an interview on 09/21/23 at 10:28 AM the Director of Nursing, (DON) stated a bed rail assessment should have been completed for R50.

Based on observation, interview, and record review, the facility failed to ensure one of twenty residents (R) (R43) reviewed had the equipment required to exit their room as desired to attend activities. This failure had the potential to affect any resident that requires a bariatric wheelchair. Findings include: Interview on 09/19/2023 at 10:20 am, R43 stated she was unable to get out of her room and wanted to attend activities. Review of the Electronic Medical Record (EMR) for R43 under the Resident tab showed a medical diagnoses that included hemiplegia and hemiparesis following a cerebral infarct, convulsions. Review of the quarterly Minimum Data Set (MDS) for R43 dated 08/22/2023, showed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicative of being cognitively intact. Review of the activities participation documentation showed R43 attended bingo via Zoom during the month of August and September 2023. Review of the care plan located in the EMR under the care plan tab, dated 05/09/2023, noted Care Area/Problem: Needs assistance to participate in activities with an intervention of Assist with transportation to/from activity settings. Also, on 05/09/2023, a Care Area/Problem: Expresses past and/or present activity interests (strength) with a Goal: Patient will take part in preferred activities of interest during the review period and an intervention of Provide assist to/from activities of interest as needed. Interview on 09/20/2023 at 3:20 pm, the Activities Director (AD) stated R43 attended bingo via Zoom on a tablet. Observation with the Director of Nursing (DON) on 09/21/2023 at 9:56 am, Certified Nurse Aide (CNA) 2 un-collapsed R43's wheelchair and took it to the door. The entire set of left sided wheels were on the left side of the door frame opening. While in the room, R43 stated she didn't leave her room, and that activities would bring a tablet to her to participate in bingo. As we exited the room, the DON responded to the query of how long R43 had been confined to the room stating she didn't know. Review of facility provided wheelchair invoices on 09/21/2023 at 1:13 pm, the Administrator stated the secondary invoice showed he contacted a vendor regarding the fact the wheelchair did not fit through the door. The original chair was ordered on 06/28/2023. The second invoice (same order, updated) showed an anticipated ship date of 08/07/2023; and a note that on 08/11/2023 the Administrator called requesting to return the wheelchair as the wheelchair did not fit through the doorway. During a follow-up call on 09/21/2023 at 11:17 am, with the wheelchair vendor stated the Administrator started the return, processed on 8/11/2023, but the vendor denied the return. After checking the account, the vendor stated there was no reciprocal order on the account for a different wheelchair. Interview on 09/21/2023 at 4:30 pm, the Division Regional Nurse (DRN) stated a wheelchair was being delivered today for the resident. In a follow-up interview on 09/21/2023 at 6:17 pm regarding a policy for resident mobility or accommodation of needs, the DRN stated there was no policy.

Based on record review, staff interviews, and a review of the facility policy titled Abuse Policy, the facility failed to ensure that an allegation of resident to resident physical abuse was reported to the State Agency (SA) for one of one resident (R) (35) reviewed for reporting in a timely manner of 20 sampled residents within the required two hours of discovery. Findings include: Review of facility's policy titled Abuse Policy with a review Date of 12/30/2022, revealed If reasonable suspicion of a crime resulting in serious bodily injury is identified, police notification should occur within 2 hours. If reasonable suspicion of a crime is identified without seriously bodily injury involved, then police notification should occur within 24 hours. Review of facility investigative report dated 08/07/23 revealed R35's had a diagnoses of hallucinations, delusional disorders, legal blindness, and other psychotic disorder not due to a substance or known physiological condition. Review of R35's quarterly Minimum Data Set (MDS) found in the MDS tab of the electronic medication record (EMR) with Assessment Reference Date of 08/16/23 revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated R35 was cognitively intact. No alterations in mood were coded and R35 was coded zero for physical, verbal, or other behavioral signs and symptoms. Review of the facility's Incident Investigation provided on paper, dated 08/07/23, revealed On 08/03/2023 at. [approximately] 7:30pm after visiting with another resident in the hallway, [R35] went to his room to lie down. This room has three beds and [R35] is in the last bed. R 35 is legally blind, and instead of lying down in his bed he laid down on [R37's] bed. [R37] was in the chair next to the bed. This is when [R37] tried to physically remove [R35]. [R35], not understanding what was going on, yelled and pushed tried to push [R37] off of him. Staff came into the room and immediately separated the residents . An investigation was initiated by the Administrator immediately upon notification of the incident. The Administrator interviewed both residents. They both agreed that it was a misunderstanding, and they want no further action on it. Both had physical skin assessments done. Physician was notified. [R37] had a scratch on his neck that was treated. [R35] complained about left shoulder pain, which is chronic in nature. [R35] had an X-ray done and found no issues and was given a referral for physical therapy to be evaluated. [R35] went to another room for the night. The next morning, [R37] decided to change rooms . After investigation, the facility acknowledges [R37] and [R35] did have resident-to-resident mistreatment. The pharmacy consultant reviewed all medications on the resident. Both residents are enrolled into Geriatric Behavior services and will consult on August 10th. Social services interviewed residents to see if they feel safe. None reported any issues. During an interview on 09/20/23 at 6:00 PM, the Administrator stated that he did not consider the resident-to-resident physical altercation abuse. The Administrator stated that he had followed the National Long Term Care Ombudsman Resource Center guide on preventing and responding to resident-to-resident mistreatment during the investigation. The Administrator stated that he had not referenced the federal regulatory requirements. The Administrator confirmed that the police had not been notified of the incident.

Based on observation, record review, interviews, and a review of the facility policy titled, Skilled Nursing Services Patient's Plan of Care and ADL [Activities of Daily Living] Plan of Care, the facility failed to develop and implement comprehensive person-centered care plans for three residents (R) (50,112, and 44) of 20 sample residents reviewed for care plans. R50 did not have a comprehensive care plan addressing dental needs, vision, and bed rails; R112 did not have a comprehensive care plan addressing dental needs, restorative services, and pain management; and R44 did not have a comprehensive care plan addressing bed rail use. Findings include: Review of the facility's policy titled Skilled Nursing Services Patient's Plan of Care with a review date of 12/20/22, revealed the facility had a policy to ensure that each patient would have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. 1. Record review of the admission Minimum Data Set (MDS) for R50 dated of 07/30/2023 located in the MDS tab of the EMR, revealed R50 had a Brief Interview for Mental Status (BIMS) score of 12 (indicating moderate cognitive impairment). R50was coded as having adequate vision, no broken teeth or tooth fragments, and was able to move about in bed with assistance and transfer with the help of two persons. Record review of the care plan for R50 in the Electronic Medical Record (EMR) revealed no dental needs care plan, vison care plan, or bed rail care plan. Observation on 09/19/2023 at 12:21 pm quarter rails were observed on R50's bed. In an interview, R50 stated she was unable to use them. R50 stated that she needed a dental appointment but could not pay for it and needed a follow up appointment for her vision. R50 stated that she previously saw an eye doctor and thought she was supposed to have cataract surgery but had not been told what would happen. R50 stated she had difficulty with her vision and had closed the blinds over the window to keep the glare out. Interview on 09/21/23 at 10:28 am the Director of Nurses (DON) stated she would look for R50's care plans for dental, vision and bed rail. No care plans were presented. 2. Record review of the admission MDS for R112 dated 09/03/2923 located in the MDS tab of the EMR revealed a had a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). The MDS revealed that the resident had pain almost constantly, pain affected her daily activities and her ability to sleep at night. The worst pain was rated as a 10 on a one to 10 scale. Review of the Care Area Assessment (CAA) revealed pain was triggered for further assessment. R112's pain disturbed her sleep, limited day to day activities, and limited independence with at least some activities of daily living. She received insufficient pain relief as pain relief occurred, but the duration was not sufficient, resulting in breakthrough pain. The CAA further revealed dental was triggered for care planning. Resident had broken teeth which she stated happened last year-resident denied pain/discomfort. The resident saw a dentist prior to admission to the facility and would see the resident while in facility. The resident did have Diabetes Mellitus (DM) and took medication which could impact oral health. Record review of care plan under in the EMR revealed there was no care plan for dental needs. Interview on 09/21/2023 at 10:28 am the Director of Nurses (DON) stated she would look for R112's dental care plan. No care plan was presented. Record review of the Medication Administration Record (MAR) for R112 dated 09/2023 revealed R112 expressed pain several times during the month rated at 10 out of 10, and tramadol (pain medication) was given as ordered to address the pain. Medication order for tramadol 50 mg (milligram) tablet give one tablet by mouth every eight hours as needed for pain with a start date of 09/04/2023. Interview on 09/19/2023 at 11:28 am, with R112 stated that her dental bridge broke during a fall prior to admission and that she could feel the screws remaining from the bridge in her mouth. R112 stated that she took pain medication and that there had not been any facility action yet to make a dental appointment. Record review of the nurses' notes tab in the EMR revealed on 09/20/2023, the resident was complaining of the screws on the bridges in her mouth hurting her mouth. The note documented, Will inform oncoming nurse and put on clinical dashboard that resident needs to see a dentist asap [as soon as possible]. Review of the comprehensive care plan, located in the EMR, revealed no care plan addressing the resident's pain management needs. Interview on 09/21/2023 at 10:28 am the Director of Nursing (DON) stated she would look for R112's pain care plan and confirmed there should have been a plan addressing R112's pain. No care plan was presented. Record review of R112's Physical Therapy (PT) note found under Therapy tab in EMR dated 08/29/2023 revealed R112 had a past medical history reason for referral. R112's PT evaluation was completed on 08/29/2023. R112 was referred for skilled PT for establishment of restorative program to further maintain current functional status. Record review of the restorative flowsheet dated 09/01/2023-09/18/2023 for R112 in the EMR revealed a plan for OMNICYCLE training for BLE (bilateral lower extremity) strengthening and coordination x 15-20 minutes with 0-2 resistance. Provide rest periods as needed. Documentation for 15 minutes was completed on 09/02/2023-09/14/2023, and 09/17/2023.There was no documentation on 09/15/2023-09/16/2023, and on 09/18/2023. Record review of the care plan located in the EMR revealed no restorative care plan. Interview on 09/21/2023 at 10:28 am the DON stated she would look for R112's restorative care plan. No care plan was presented. 28154 Review of the facility's policy titled ADL [Activities of Daily Living] Plan of Care, reviewed 12/30/22, showed: Intent. Develop and communicate patient needs for assistance with ADLs. Guideline. -Resident's ADL needs are assessed on admission and are addressed on the Baseline Care Plan and communicated to staff. -Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. -The ADL care plan will be updated in conjunction with the comprehensive care plan as required per regulatory and RAI [Resident Assessment Instrument] guidance and with changes in patient needs. 3. Record review of the EMR for R44 revealed a medical diagnoses that included quadriplegia, anxiety disorder, and major depressive disorder. Record review of the most recent quarterly MDS dated [DATE] revealed R44 had a BIMS of 11 indicating moderate cognitive impairment. Observation and interview on 09/19/2023 at 10:19 am, R44's bed was noted to have bilateral assist bars on her bed. R44 stated she didn't use them. Record review of the care plan for R44 located in the EMR showed a focus of limited mobility due to quadriplegia and was noted to require assistance with moving from a lying to a sitting position at the side of the bed but did not include any interventions noting the use of bed assist bars for bed mobility.

Based on record review and interviews, the facility failed to review and revise care plan interventions for one of four residents (R) (53) reviewed for fall prevention of 20 sample residents. This failure had the potential to delay appropriate interventions for care needs and safety concerns. Findings include: Record review of the care plan dated 09/16/2023 revealed fall interventions to include the resident in the activities program, to the assist patient with activities of daily living (ADLs) 08/21/2023 and to assist with mobility as needed, to keep the bed in a low position 08/20/2023, to keep the call light in in reach 08/20/2023, to decrease stimuli, to encourage rest periods 8/20/2023, to provide appropriate footwear such as non-skid socks 8/20/2023, to keep her personal items within reach 8/20/2023, to redirect her as needed , to remind the patient to call when needing assistance, and provide a toileting schedule for the resident. 8/20/2023. Record review of the nurse's notes for R53 dated 09/18/2023 at 12:57 pm, revealed that a Certified Nursing Assistant (CNA) reported that R53 had attempted to sit in chair and fell on her bottom. The CNA stated that R53 complained of bilateral hip pain. The Nurse Practitioner was notified regarding R53's fall and her pain. An order was given for an X-ray of her bilateral hip and to conduct neuro checks. Review of Event Initial Note, dated 09/18/2023, revealed a fall on 09/18/2023 with no injury. A new care plan fall prevention intervention was not added. Review of Event Initial Note, dated 09/20/2023, revealed R53 had a fall on 09/20/2023. A new care plan fall prevention intervention was not added. Under the new intervention added after the event section a comment was made that [R53] has dementia and does not remember to ask for assistance and wanders around the room. Interview on 09/21/2023 at 11:03 am with Director of Nursing (DON) regarding fall prevention interventions in place for R53 related to two falls this week on 09/18/2023 and 09/20/2023, the DON stated that the resident was hard to redirect due to cognition. The DON acknowledged that reminding the resident to call when needing assistance was not an appropriate intervention. DON did not offer additional interventions related to the falls on 09/18/2023 and 09/20/2023.

Based on observation, interviews, record review, and a review of the facility policy titled Care of Fingernails/Toenails, the facility failed to provide assistance with nail care to preserve and promote the dignity of two residents (R) (21 and R57) of four residents reviewed for activities of daily living out of 20 sample residents. This failure resulted in residents' appearance that did not maintain the resident's dignity. Findings include: Review of the facility policy titled Care of Fingernails/Toenails, reviewed 12/30/22, showed: Intent. It is the intent of this center to provide appropriate nail care to patients. Procedure. -Use appropriate hand hygiene/hand washing as situation dictates before beginning the Procedural Guidelines. -Assemble the equipment and supplies that should be necessary to perform the Procedural. Guidelines and take them to the patient's room. -Knock before entering the room. -Place the equipment on the bedside stand or over bed table. -Arrange the supplies so they can be easily reached. -Identify yourself. Ask the patient's permission to perform the nail care. Explain the Procedural Guidelines to the patient. -Pull the cubicle curtain around the bed for privacy. -Gently, clean under each nail. Soaking hand /foot before cleaning may be appropriate. -Trim the fingernails/toenails. -Smooth with nail file or emery board if needed. -Clean the bedside stand or over bed table if needed. -Clean the nail clipper. -Use appropriate hand hygiene/hand washing as situation dictates. 1. Record review of the Electronic Medical Record (EMR) Resident tab showed a medical diagnoses that included hemiplegia and hemiparesis following cerebral infarct, congestive heart failure, osteoarthritis, anxiety disorder, and hypertension. Record review of the most recent quarterly Minimum Data Set (MDS) for R21 dated 06/07/2023 showed R21 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicative of being cognitively intact. R21 was totally dependent on staff for personal hygiene. Interview and observation on 09/18/2023 at 4:09 pm it was noted R21 had long fingernails. When queried about the length of his fingernails, R21 confirmed he needed his nails trimmed. Observation on 09/21/2023 at 2:46 pm along with the Director of Nursing (DON) R21's hands were confirmed to have long nails. R21 stated he wanted to go back to room. The DON started pushing him back and the resident stated he was needing his nails shorter because they got in the way. 2. Record review of the EMR for R57 revealed a medical diagnoses that included disorganized schizophrenia, skull fracture, muscle weakness, need for assistance with personal care, traumatic subarachnoid hemorrhage, and dementia. Record review of the most recent quarterly MDS dated [DATE] for R57 had a BIMS score of 12 out of 15, indicative of moderate cognitive impairment. R57 was assessed as requiring supervision/oversight with set up help for personal hygiene. Interview and observation on 09/18/2023 at 11:46 am, R57's fingernails were noted to be long. When asked if long nails were his preference, R57 stated he needed his nails trimmed. When asked if staff helped with nail care, R57 stated, No, but they need to, my toenails too. Follow-up observation and interview on 09/21/2023 at 2:42 pm showed the nails remained long and R57 again confirmed his fingernails need cut and my toenails too. During a follow-up observation and interview with the DON and R57 on 09/21/2023 at 2:50 pm, the DON confirmed R57 had long nails. R57 stated he did not want to have long nails and his toenails are too long too. The DON expressed an expectation that resident nails were to be trimmed on shower days unless the resident was a diabetic and then it was different. During an interview on 09/21/2023 at 5:50 pm, Certified Nurse Aide (CNA) 1 stated nail care was to be done on shower days. When queried what happened if the resident refused showers, CNA1 stated We can still do nail care. When asked what nail care was done if the resident received a bed bath, CNA1 responded, It's still to be done. During an interview on 09/21/23 at 6:00 pm, the Administrator expressed that if the resident requested or needed nail care it was his expectation that he expected it would be done.

Based on observations, record review, and staff interview, the facility failed to ensure one resident (R) (27) of four residents reviewed for limited range of motion of 20 sample residents received restorative services as needed to address limited range of motion in his right arm. This created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown. Findings include: Record review of the Electronic Medical Record (EMR) revealed a diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting the right dominant side. Record review of the most recent quarterly Minimum Data Set (MDS) for R27 dated 08/20/2023 revealed R27 required extensive assistance with bed mobility, dressing, and toilet use and required total assistance with personal hygiene. R27 had limited range of motion on one side in the upper and lower extremities. Observation on 09/19/2023 at 9:11 am, R27 was in his bed, holding his right arm with his left hand. R27's right arm was bent at a 90-degree angle and the hand was balled in a fist. R27 was unable to move his right arm. There was no splint or protection device on the elbow or hand. Record review of R27's active Physician's Orders, located in the Orders tab of the EMR, revealed there was no order for restorative services. Review of the Occupational Therapy Discharge Summary, dated 12/15/2021, located under the Therapy tab of the EMR, revealed a functional maintenance program of exercise and range of motion services was established with the facility's restorative nursing program. Review of R27's nurse practitioner's Progress Note, located in the Scan Docs tab of the EMR, dated 08/07/2023, revealed Contracture of right upper arm - 90 degrees at elbow. No swelling or erythema. Monitor for changes in joint/contractures and refer to OT [occupational therapy]/PT [physical therapy] as indicated. Review of R27's Care Plan, located in the Care Plan tab of the EMR, dated 09/05/2023, revealed he experienced decreased range of motion and contracture. The goal was, Patient will maintain functional mobility and accept assistance with physical function in bed mobility, transfer, locomotion, and ROM [range of motion] during the review period. The approaches included: Assist with ADLs [activities of daily living] as needed . Provide appropriate level of assistance to promote safety of resident . Provide cues as needed . Refer to Therapy as indicated . [and] See Restorative POC [plan of care]. Review of the Restorative tab of R27's EMR revealed the POC goal, Patient will maintain adequate AROM [active ROM] and strength in L [left] UE [upper extremity] and PROM [passive ROM] on R [right] UE to allow daily participation in mobility and other functional/ADL activities, and to decrease the risk of injury and prevent contracture development in R UE. The interventions included: Provide moderate resistance exercises in L UE using green [resistance band] for 10 reps [repetitions] x 2 sets each plane and provide gentle PROM exercises in R UE to patient's tolerance for 10 reps each plane. Review of R27's April 2023 to September 2023 restorative Participation Record revealed there were no restorative services provided during the six-month period. During an interview on 09/21/2023 at 10:28 AM, the Director of Nursing (DON) stated the facility had been having an issue with restorative. She stated R27's restorative program had been discontinued but was unable to find documentation to indicate why the program was stopped. During an interview on 09/21/2023 at 2:49 PM, Certified Nurse Aide (CNA)5 stated R27 was not on a restorative program. She stated he received passive range of motion when she assisted him with putting on his shirt or other ADLs but did not receive any formal or documented range of motion services. CNA5 stated R27 was unable to move his right arm or hand. During an interview on 09/21/2023 at 4:40 PM, the DON stated she believed R27 had been discharged from the restorative program based on an OT recommendation; however, the OT stated he needed to be on a restorative program for range of motion and was going to re-instate the program. During an interview on 09/21/2023 at 5:23 PM, the OT stated he worked with R27 in 2021 and discharged R27 from therapy on 12/15/2021. The OT stated at discharge, he recommended a restorative program for R27 for range of motion services. The OT stated the restorative program established upon OT discharge was still appropriate for R27, as he had not heard of any changes or a need to make a reassessment. The OT stated he did not know why the restorative program for R27 was discontinued and he had not seen R27 since 12/15/2021. The OT stated R27 should have been on a restorative program.

Based on record review and staff interview, the facility failed to ensure appropriate fall interventions were implemented resulting in continued falls for one (Resident (R) 53) of four residents reviewed for falls. This failure presented a potential risk for increased falls and physical injury. Findings include: Review of R53's Face Sheet tab found in the electronic medical record (EMR) revealed the following diagnoses: Alzheimer's disease, hypertension, iron deficiency anemia, type 2 diabetes mellitus, and dementia. Review of R53's quarterly Minimum Data Set (MDS) found in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/14/23 revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and staff assessment revealed memory problems and severely impaired cognition. She occasionally rejected care but had no other behavioral symptoms. R53 required limited assistance with transfers, bed mobility, and walking and required extensive assistance with toileting. R53's balance was not steady, and she was only able to stabilize with assistance. She used a walker for mobility. Review of Event Initial Note provided on paper by the DON dated 12/08/22, revealed R53 had a fall on 12/08/22. She had a bruise on the right hand as a result of the fall. A new care plan fall prevention intervention was added to include R53 in activities. Review of Event Initial Note, provided on paper by the DON dated 02/08/23, revealed R53 had a fall on 02/08/23. She had a head injury to her lateral right eye area. A new care plan fall prevention invention was added to include placing R53 in an open area of the facility for maximum observation opportunities. Review of Event Initial Note, provided on paper by the DON dated 02/26/22, revealed R53 had a fall on 02/26/23 and there was no injury. A new care plan fall prevention intervention was added to decrease stimuli for R53. Review of Event Initial Note, provided on paper by the DON dated 03/25/23, revealed R53 had a fall on 03/25/23 and did not have an injury. A new care plan fall prevention intervention was added to provide redirection for R53. Review of Event Initial Note provided on paper by the DON, dated 08/20/23 revealed R53 had a fall on 08/20/23 and there was no injury. There were care plan fall prevention interventions added which included placing the bed in low a position to the floor making sure the call light in her reach, encourage her to take rest periods, and to provide her with footwear, such as nonskid socks and start a toileting schedule for her. Review of R53's Resident's Data Collection tab of the EMR revealed R53 fell on [DATE] from her bed and slipped down to the floor. Record review of R53's nurses notes found under the Nurses Notes tab of the EMR, dated 09/18/23 revealed R53 was alert and verbal afterwards, and that no injury was noted from fall on 09/18/23. R53 was ambulating in her room without difficulty, denied pain at this time, and nursing staff would continue to monitor R53. Review of R53's nurse's notes found under the Nurses Notes tab of the EMR, dated 09/18/23 revealed R53 was alert and verbal. She was ambulating in her room without difficulty. The X-ray results were received and there were no new orders for R53. Nursing staff will continue to monitor. Review of R53's nurse's notes found under the Nurses Notes tab of the EMR, dated 09/18/2023 at 12:57 PM revealed that a Certified Nursing Assistant (CNA) reported that R53 had attempted to sit in chair and fell on her bottom. The CNA stated that R53 complained of bilateral hip pain. The Nurse Practitioner was notified regarding R53's fall and her pain. An order was given for an X-ray to her bilateral hip and to conduct neuro checks. Review of R53's nurse's notes found under the Nurses Notes tab of the EMR, on 09/19/23 revealed R53 fell on [DATE] and an X-ray was performed. There were no results mentioned in the nurse's note. Review of R53's Event Initial Note provided on paper by the DON dated 09/18/23 revealed a fall on 09/18/23 with no injury. A new care plan fall prevention intervention was not added. Review of Event Initial Note dated 09/20/23 revealed R53 had a fall on 09/20/23. Under the new intervention added after the event section a comment was made that R53 had dementia and did not remember to ask for assistance and wandered around the room. During an interview on 09/21/23 at 11:03 AM the DON stated that R53 was hard to redirect due to impaired cognition. The DON acknowledged that reminding the resident to call when needing assistance was not an appropriate intervention and the interventions in place were ineffective. DON did not offer additional interventions related to the falls on 09/18/23 and 09/20/23. The DON stated the facility used to perform a root cause analysis of each fall in order to determine appropriate interventions to prevent a recurrence; however, they had not done it in a long time.

Based on interview and record review, the facility failed to ensure two of two eligible Certified Nurse Aides (CNAs) 1 and CNA 4 had an annual performance review completed to enable in-service education based on the outcome of the reviews. This failure could affect the skills and knowledge required to correctly and efficiently provide care for residents. Findings include: Review of two CNA personnel files, chosen for a hire date greater than twelve months prior to the review showed the following data: CNA 1: Date of Hire 06/17/21 and had an Associate Performance Appraisal dated 06/12/23. CNA 4: Date of Hire 10/06/21 and had an Associate Performance Appraisal dated 10/12/22. The Associate Performance Appraisal had the following categories and sub-areas graded as Consistently Superior, Consistently Satisfactory, or Consistently Unsatisfactory: -Quality if work (accuracy, neatness, and ethical); Quantity of work (productivity and teamwork); Dependability (follows instructions, judgement, punctuality, attendance, and helpful); Cooperation (with supervisor, with fell ow employees, inspires others, and innovative); Initiative (ingenuity, self-reliance, planning, ambition, and compassion); Self-Improvement (interest, observation, questions, study, and attitude); and Personality (appearance, courtesy, friendliness, and expression). The form did not include any performance reviews regarding areas of in-service education required to address improvement in areas of care provision weaknesses, special resident needs, and needs of residents with cognitive impairment. During an interview on 09/21/23 at 6:00 PM regarding expectation of annual performance reviews, the Administrator confirmed the current review did not meet the regulation, stating, It's going to be where the annual review will assess skills so we can work towards those issues. During an interview on 09/21/23 at 6:17 PM regarding a policy for annual performance reviews, the Division Regional Nurse stated there was no policy.

Based on observation, interview, record review, and a review of the facility policy titled, Dental Services/Oral Assessments, the facility failed to assist two of eight residents (Resident (R) 50 and R112) reviewed for dental services in obtaining routine dental care out of 20 sample residents. Findings include: Review of facility's policy titled, Dental Services/Oral Assessments, with a review date of 12/30/22, revealed that the facility would assist residents obtain dental services by making appointments and arranging transportation and that they would perform oral assessments on admission, annually, and as needed. 1. Review of R50's Face Sheet tab located on the home page in the electronic medical record (EMR) revealed diagnoses which included cerebral infarction, unspecified, type 2 diabetes mellitus with diabetic nephropathy, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, Ischemic cardiomyopathy, schizoaffective disorder, bipolar type, hypothyroidism, unspecified, hyperlipidemia, unspecified, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, peripheral vascular disease, unspecified. Review of R50's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/30/23 revealed she was edentulous. Review of the Brief Interview Mental Status (BIMS) score revealed R50 scored 12 out of 15 which indicated R50 had moderately impaired cognition. During an interview on 09/19/23 at 12:21 PM, R50 stated that she needed a dental appointment as she did not have teeth and would like dentures. Review of a resident appointment list provided on paper on 09/20/21 revealed that R50 did not qualify for the facility dental plan because she received Social Security Income (SSI). During an interview on 09/21/23 at 1:03 PM the Social Services Director (SSD) stated she consulted with the social work consultant to identify other payor sources and resources to assist residents with dental needs when the resident did not qualify for the facility dental plan. The SSD stated R50 was a previous resident at the facility and the family had previously informed her that they would take care of the dental needs and so the facility did not initiate services. The SSD stated she did not document the previous conversation with the family and there was no additional documentation regarding facility actions to assist the R50 for dental needs. 2. Review of R112's Face Sheet tab located on the home page in the EMR revealed the following diagnoses: chronic kidney disease, unspecified, Type 2 diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic systolic (congestive) heart failure, essential (primary) hypertension, anemia, unspecified, hyperlipidemia, unspecified, major depressive disorder, single episode, unspecified, other abnormalities of gait and mobility and muscle weakness (generalized). Review of R112's admission MDS with an ARD of 09/03/23 revealed she had obvious or likely cavity or broken natural teeth. The Care Area Assessment section revealed a dental problem was triggered for care planning and documented, Resident has broken teeth which she states happened last year-resident denies pain/discomfort. Resident saw dentist prior to admission to facility and will see resident while in facility. Resident does have Diabetes Mellitus (DM) and takes medication which may impact oral health. During an interview on 09/19/23 at 11:28 AM, R112 stated her dental bridge broke during a fall prior to admission and she could feel the screws remaining from bridge in her mouth, which were painful and bothersome. Review of R112's Comprehensive Nursing Assessment located in the Data Collection tab of the EMR and dated 08/28/23, reflected: Mouth inspection: No visible problems to the mouth (i.e., lips moist and oral mucosa pink/moist). Review of R112's Nurses Notes tab in EMR on 09/20/23 revealed, Before she went to dialysis resident was complaining of the screws on the bridges in her mouth hurting her mouth. Will inform oncoming nurse and put on clinical dashboard that resident needs to see a dentist asap [as soon as possible]. During an interview on 09/21/23 01:03 PM, the SSD stated that an appointment had been made for R112 and provided a list which revealed her appointment as 10/05/23.

Based on record review, interview, and a review of the facility policy titled, Medication Orders, the facility failed to ensure accurate documentation of medical conditions for three (Resident (R) 27, R112, and R31) of 20 sample residents. These failures had the potential to contribute to inappropriate care or unnecessary medication use. Findings include: Review of the facility's policy titled Medication Orders, dated 2019 and provided on paper, revealed, Medication orders specify the following: -Full patient name -Name of medication -Strength of medication, where indicated -Dosage-Route of administration -Time or frequency of administration -Quantity or duration (length) of therapy . -Diagnosis or indication for use -Date and time of order Any dose or order that appears inappropriate considering the patient's age, condition, or diagnosis is verified with the prescriber. 1. Review of R27's Face Sheet of the electronic medical record (EMR) under the Resident tab revealed a diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke), aphasia (problems speaking), seizures, anemia, hypertension, urine retention, and neurogenic bladder. Review of R27's Orders tab of the EMR revealed the following active orders with inappropriate diagnoses: -Tamsulosin (used to treat symptoms of an enlarged prostate gland), 0.4 milligrams (mg) one time per day for a diagnosis of constipation. -Folic acid (a vitamin B-9 supplement used to treat anemia), 1 mg daily for a diagnosis of depression. -Levothyroxine (a medicine used to treat an underactive thyroid gland), 50 micrograms (mcg) daily for a diagnosis of seizure disorder. -Rosuvastatin (a medication that reduces the amount of cholesterol in the blood) 5 mg daily for a diagnosis of supplement. 2. Review of R112's Face Sheet, of the EMR under the Resident tab revealed a diagnoses including stroke, coronary artery disease, diabetes, hypertension, chronic kidney disease, anemia, hyperlipidemia, and congestive heart failure. Review of R112's Orders tab of the EMR revealed the following orders with inappropriate diagnoses: -Pregabalin (a medication that treats nerve and muscle pain), 50 mg once daily on Tuesday, Thursday, Saturday, and Sunday and twice daily on Monday, Wednesday, and Friday for a diagnosis of type 2 diabetes mellitus. -Rosuvastatin, 10 mg daily for a diagnosis of Major depressive disorder. -Senna (a laxative), 8.6 mg daily for a diagnosis of hypertension. -Tamsulosin, 0.4 mg daily for a diagnosis of hypertension. -Tramadol (a pain medication), 50 mg every 8 hours as needed for a diagnosis of hypertension. -Plavix (an antiplatelet drug to prevent blood clots), 75 mg every Tuesday, Thursday, Saturday and Sunday for a diagnosis of Major depressive disorder. 3. Review of R31's Face Sheet, of the EMR under the Resident tab revealed a diagnoses including: hypertension, heart failure, kidney failure, hypokalemia, thyroid disorder, Alzheimer's disease, and asthma. Review of R31's Orders tab of the EMR revealed the following orders with inappropriate diagnoses: -Bactrim (sulfamethoxazole/trimethoprim antibiotic medication), 800 mg/160 mg twice daily for a diagnosis of Alzheimer's disease. During an interview on 09/21/23 at 4:50 PM, the Director of Nursing (DON) stated on 08/01/23, the facility transitioned to a new EMR system, and the staff who entered physician orders were no longer able to input diagnoses into the system. She stated diagnoses were populated from the Minimum Data Set (MDS) assessment and the nursing staff who input orders could only select from a drop-down list of medications. The DON had not implemented any corrective measures to ensure diagnoses were input accurately with medication orders.

Based on interview, record review, and a review of the facility policy titled, Antibiotic Stewardship, the facility failed to identify trends in antibiotic use, maintain documentation for clinical indication of use for antibiotics, implement systematic protocols to monitor, decrease use and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics that did not meet criteria with the potential to effect 61 census residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship with a review date of 12/30/22 revealed that the team members included the Quality Assessment Performance Improvement (QAPI) committee members and other members were brought in on an as needed basis. The policy revealed that the facility's antimicrobial stewardship program included but not limited to formulary restriction, prospective audit and feedback by contracted pharmacy and feedback to physicians, staff, and physician education, parenteral to oral conversion protocol, dose optimization/automatic dose adjustment, streamlining/de-escalation of therapy, indication clarification required in patient record and ID consult when necessary. The policy revealed the DON/designee in collaboration with the QAPI team worked to educate departments of the facility whether they were involved directly or indirectly with patient care about stewardship. Review of the HAI [Healthcare Acquired Infections] Summary report, dated 07/23, revealed there were 11 infections in the month, 11 antibiotic starts in the facility, and three did not meet criteria. Six infections were recorded on B-hall and one on C-hall for fungal, oral, or perioral and skin infections. There were three additional infections identified as other. There was an error discrepancy for the number of total infections by unit, which totaled 11, but should have been 10. Record review of HAI Summary report, dated 08/23, revealed there was one infection of cellulitis, and 12 antibiotic starts. Eight did not meet criteria and were not indicated by unit. There was no specific information documented related to the type of antibiotic, reason for use, or prescriber to identify potential trends for antibiotic stewardship for 11 residents who received antibiotics that month, without the presence of infection. There was no additional documentation provided to address the discrepancies, rationale for antibiotic starts, and rationale for infections that did not meet criteria. During an interview on 09/21/23 5:52 PM the Division Regional Nurse (DRN) stated the report included the facility acquired, community acquired, and the not met antibiotic starts for each month. The DRN stated the wound nurse may not have had enough documentation at the time of the order and that would be why that antibiotic start did not meet criteria. The DRN and the Director of Nursing (DON) did not state a rationale for the evaluation of six residents on B-Hall with fungal type infections, for root cause, and transmission between residents or prevention. The DRN stated there needed to be more education on signs and symptoms, clinical indication for use, documentation for routine orders when a medication was refilled, and how to track it. The DRN and the DON could not explain why so many infections did not meet criteria or what actions the facility took in response.

Based on record review and interview, the facility failed to implement and maintain a training program for dementia training for one of two Certified Nurse Aides (CNA1) and emergency evacuation of bariatric residents for all staff. This failure had the potential to affect the care and services provided to 27 of the 61 residents with dementia and two bariatric residents reviewed in the survey sample of 20 in the facility. Findings include: 1. Review of two CNA educational documentation, chosen for a hire date greater than twelve months prior to the review, showed: CNA 1: Date of Hire 06/17/21 did not have documented dementia care training. 2. During the course of the investigation into two Resident's (R)1 and R43 interviewed that did not have wheelchairs that fit through their room doorways, a concern regarding emergency evacuation was raised and, on 09/21/23 at 1:03 PM the Administrator stated no training regarding emergency evacuation of bariatric patients had been done as part of the facility Emergency Preparedness Program (EPP). During an interview on 09/21/23 at 1:10 PM Licensed Practical Nurse LPN3 stated, During an emergency we would take out the residents that can walk, then those in wheelchairs and then those in their bed. The bariatric beds can be collapsed, and the assist bars removed to get the bed through the door. I have not received any training about the bariatric beds at this facility, I received training at a previous facility that I worked at. During an interview on 09/21/23 at 6:00 PM regarding training for bariatric resident evacuation, the Administrator stated No training prior to today, but it's being done now. There is no policy and the EPP only has general evacuation policies. After today, there will be a policy and training. When asked his expectation regarding dementia training for direct care staff, the Administrator stated, Expectation is that staff will receive training prior to working with residents and annually. In a follow-up interview on 09/21/23 at 6:17 PM, the Division Regional Nurse stated there was no policy regarding staff training.

Based on record review and interview, the facility failed to implement and maintain a training program regarding the prevention of abuse and neglect for one of two Certified Nurse Aides (CNA) 1 reviewed and one of two Licensed Practical Nurses (LPN) 1 reviewed for training. This failure had the potential to affect the safety, care, and services provided to the 61 residents in the facility. Findings include: Review of two CNA training transcripts, chosen for a hire date greater than twelve months prior to the review, showed: CNA1: Date of Hire 06/17/21 did not have documented abuse/neglect prevention training. Review of two LPN training transcripts, randomly chosen from the State Agency Personnel review form showed: LPN1: Date of Hire 12/10/21 had no documented abuse/neglect prevention training. During an interview on 09/21/23 at 6:00 PM, the Administrator stated it was an expectation that staff would receive training prior to working with residents and annually. During an interview on 09/21/23 at 3:23 PM the Division Regional Nurse (DRN) confirmed the training was not on the list but knew it was in a (facility computerized training program). The DRN stated she was going to check with the corporate office. No further documentation was provided. In a follow-up interview on 09/21/23 at 6:17 PM, the DRN stated there was no policy regarding staff training.

Based on record review, staff interviews, and review of the Change in a Patient Condition policy, the facility failed to notify the Physician and responsible party in a timely manner to obtain guidance and to ensure appropriate care for one resident (R#1) of 12 sampled residents. Resident (R) #1 was receiving an anticoagulant and had an unwitnessed fall from his bed. An Abbreviated/Partial Extended Survey investigating complaint GA 433 was initiated on [DATE] and concluded on [DATE]. After review by the State Survey Agency, further investigation was needed for complaint GA 433, and a re-entry was initiated on [DATE] and concluded on [DATE]. Complaint GA 433 was substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on [DATE] was 64. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Nurse Consultants VV and WW were informed of an Immediate Jeopardy on [DATE] at 2:06 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: Resident (R)#1 on (MONTH) 24, 2019 at 3:45 a.m. had an unwitnessed fall from his bed and was receiving [MEDICATION NAME] 75 milligrams (mg) orally per day. R#1's roommate, R#5 with a Brief Interviewable Mental Status (BIMS) score of 14 (indicating R#5 is cognitively intact) alerted the nurse on duty that R#1 was on the floor. The Licensed Practical Nurse (LPN) AA, assessed R#1 and found a skin tear to the right arm. On the Event form dated (MONTH) 24, 2019, LPN AA noted that the physician was notified at 3:45 a.m. however, the investigation revealed that the physician nor the family member were notified at that time. On (MONTH) 24, 2019 at 7:15 a.m., the Certified Nurse Aide (CNA) notified LPN BB (day shift nurse) who entered R#1's room and observed R#1 to be non-verbal, pale in color with shallow breathing. LPN BB left the room and, did not notify the physician. Instead, she called the family member. The family member gave instructions to send R#1 to the hospital, but R#1 expired before this could be done. Immediate Jeopardy was identified on (MONTH) 25, 2019 and determined to exist on (MONTH) 24, 2019 in the areas of 42 CFR 483.10 (g) (14) (i)-(iv) Notify of Changes (Injury/Decline/Room, Etc.), F580; 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, and Exploitation, F600; 42 CFR 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, and Exploitation, F600. A Credible Allegation of Compliance was received on (MONTH) 26, 2019. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on (MONTH) 27, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Notification system and to ensure resident were protected from neglect. Findings include: Review of the Change in a Patient Condition Intent: it is the intent of this center, except in medical emergencies, to notify the patient, his/her attending physician and responsible party/patient representative of changes in the patient's condition and/or status. Procedural Guidelines 1. Nursing services should be responsible for notifying the patient's attending physician when: A. The patient is involved in any accident or incident; D. Deemed necessary or appropriate in the best interest of the patient. 2. Nursing services should be responsible for notifying the patient, his/her next-of-kin, or responsible party/patient representative, as each case may apply, when: A. The patient is involved in any accident or incident; 4. All notifications should be made as soon as practical but should not exceed twenty-four (24) hours. Reviewed and updated for Release (MONTH) (YEAR). Review of the Face Sheet revealed R#1 was admitted to the facility with the following [DIAGNOSES REDACTED]. Review of the Event-Initial Note dated [DATE] revealed R#1 was found lying on floor on his right side. He had a skin tear to his right arm. It was noted that the Physician was notified at 3:45 a.m. and the family member was notified at 7:30 a.m. However, during the investigation it was revealed that the attending Physician was not contacted until 7:50 a.m. after R#1 had expired and pronounced by Director of Nursing (DON). Review of the Nurse Note dated [DATE] through [DATE] revealed an entry dated [DATE] at 8:48 a.m. which stated R#1 was pronounced at 0745 (military time) and the daughter was notified. The second entry at 8:56 a.m. revealed LPN BB was called to the room by caregiver at 7:15 a.m. R#1 was nonverbal, pale in color with shallow breathing. LPN BB left the room to contact next of kin. The third entry at 9:10 a.m. revealed LPN BB at 7:30 a.m. spoke with family member and gave change of condition report. LPN BB discussed the Physician order [REDACTED].#1 to be sent out for evaluation. The entry at 9:20 a.m. revealed LPN BB at 7:45 a.m. notified family member that resident was observed with no blood pressure, pulse or respiration. Director of Nursing, Nurse Practitioner, and Physician CC were notified of R#1's status. The fifth entry at 10:41 a.m. revealed resident body to be released to the Funeral home. The finally entry at 11:27 a.m. revealed Funeral Home picked up body. During an interview on [DATE] at 2:16 p.m. with Physician CC who revealed that his expectation is to be notified immediately after a fall and not four hours post fall as in the case of R#1. The Physician stated that he would send residents to the hospital after a fall if the residents were taking an anticoagulant and as warranted. During an interview on [DATE] at 2:43 p.m., Licensed Practical Nurse (LPN) AA revealed that she was the assigned nurse on [DATE] the night (early morning) when R#1 fell . LPN AA revealed that they (staff) have 24 hours to notify the family. Record review of the Event-Initial Note with LPN AA, at this time, which documented that a Physician was notified on [DATE] at 3:45 a.m. by LPN AA; however, she could not recall if the physician was notified. During an interview on [DATE] at 3:04 p.m., LPN BB revealed that she documented a change in R#1 condition of shallow breathing on [DATE] at 7:15 a.m. she further revealed that the resident's POLST said do not send to hospital without talking to the family first. Continued interview with LPN BB revealed that she received report from the night nurse of R#1's fall. When the Certified Nurse Aide (CNA) told her that the resident didn't look right, LPN BB stated that she went and checked the resident and called the family instead of the Physician. During an interview on [DATE] at 3:10 p.m. with the Director of Nursing (DON) revealed that R#1 had a fall unwitnessed by the staff and the facility had 24 hours to notify family of any changes in condition. Continued interview with the DON revealed she stated that four hours is a reasonable time frame to notify family if no apparent or visible injuries were noted. The DON stated that she didn't think that the facility would've done anything differently regarding the fall. During an interview on [DATE] at 3:42 p.m. the Nurse Practitioner (NP) revealed that she was not contacted at the time of the resident's fall. The NP stated that their office has a ,[DATE] on call service and she would have to check their logs to see when they were notified. The NP revealed that she received report the following morning after the fall. A follow-up statement with the NP revealed that no one from the facility had contacted the Physician or the NP at 3:45 a.m. on [DATE] regarding R#1's fall. During an interview on [DATE] at 2:59 p.m. with the Administrator revealed that she expects the Physician and family to be notified if a change in condition for a resident occurs. The nurses are to follow the protocol or use clinical judgment when a change in condition occurs. Continued interview with the Administrator revealed that she did not question the nurse on why the Physician was not notified of R#1's fall and that LPN AA could have handled the situation differently, LPN AA used poor judgment. Cross refer to F600. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Patient #1 identified in the survey no longer reside in the center. Nurse AA identified during the survey has been suspended indefinitely by the Director of Nurses on [DATE]. 2. Patients with a change in condition have the potential to be affected. 3. The Patient Change in Condition policy has been reviewed by the Director of Nurses, Administrator and Regional Nurse on [DATE] and no changes were made to this policy. 64 active patient files were audited by the LPN Minimum Data Set Coordinator, RN Minimum Data Set Coordinator and the RN Minimum Data Set Consultant on [DATE] looking back at changes in condition over the last 14 days. The audit includes the change in condition assessment for patients with an acute condition such as a fall, skin tear or other new medical condition. These charts were audited for a noted nursing assessment, subsequent assessments if required such as neuro checks, nursing to physician notification, family notification, care plan updated if necessary and follow-up documentation every shift for 72 hours. This audit will be listed on a Change of Condition documentation Audit Tool. Following this initial audit, the Director of Nursing or RN supervisor will audit new changes in condition daily x two weeks, then 5 days per week for 2 weeks, then once per week for 4 weeks. These same components will be audited and contained on the Change of Condition Documentation Audit Tool: noted nursing assessment, subsequent assessments if required such as neuro checks, nursing to physician notification, family notification, care plan updated if necessary and follow-up documentation every shift for 72 hours. 4. 10:11 LPN charge nurses, 3:3 RN supervisors, 2:2 LPN Resident Care Coordinator Nurses, 1:1 LPN Wound Care Coordinator, 1:1 RN Minimum Data Set coordinator and 1:1 LPN Minimum Data Set Coordinator nurses were educated on [DATE] by the Director of Nursing on responding to a patient with a change in condition, what constitutes a change in conditions i.e. falls, skin tears, any accident or incident, significant behavior changes, or other physical changes that vary from the patient's baseline. This training also included change in condition monitoring, the need for the nursing assessment, physician notification, family notification, nursing interventions, care plan updated, and follow-up documentation for 72 hours or longer as necessary. Supplementary nursing documentation tools were reviewed during this education as well to include the neuro check tool. Any associates on FMLA will be educated upon their return to work. New hires will be educated during their orientation period. 5. Observations and findings of corrective actions will be forwarded by Director of Nurses for review of an evaluation of effectiveness to the Quality Assurance/Performance Improvement Committee monthly and as needed. Revisions and or updates will be made as indicated by QAPI committee which is led by the Administrator every month. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Resident #1 is no longer in the facility. Confirmed that LPN AA was suspended on [DATE]. Review of the separation notice dated [DATE], LPN AA's employment was terminated. ,[DATE]. Reviewed the change of condition (C[NAME]) documentation tool for 64 residents currently in the facility dated [DATE] which revealed that 12 residents were identified with a change in condition. One resident was identified with a change in condition on the documentation tool dated [DATE]. Review of the C[NAME] documentation tool contained: Nursing assessment complete, 72 hour follow up, Physician (MD) notification, Family notification, Care Plan checked, Neuro check indicated. All residents listed indicated the six items were completed. Review of the Performance Improvement Project (PIP) dated [DATE], PIP related to timely MD notification with any change in condition which clarified what constituted a change in condition that included any accident to include falls. Additionally, the PIP covered by MD notification, family notification, nursing assessment with neuro checks initiated if indicated, Care Plan updated, and 72 hours follow up documentation. The C[NAME] audit tool will be utilized for evaluation of the effectiveness of the plan, including an action plan that included education of nursing staff, 100% audit of records for active residents, Director of Nursing (DON) or Registered Nurse (RN) supervisor to audit C[NAME] daily for two weeks, then five times per week for two weeks then one time per week for four weeks, C[NAME] to be discussed in clinical meeting with benchmarks set at 100%. 4. Review of in-service sign in sheets to confirm staff attended the in-services. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) and Registered Nurses (RN) confirming they had attended the MD notification in-service on [DATE] and confirmed they were knowledgeable of the Change in Condition and what constitutes as change in condition and that the MD should be notified should there be a Change in Condition. Interviews were conducted on [DATE] with LPN OO present at all interviews at the request of the Administrator, LPN XX at 7:20 a.m., LPN HH at 7:27 a.m., LPN AAA at 8:18 a.m., LPN QQ at 8:23 a.m., LPN PP at 8:28 a.m., LPN BBB at 8:38 a.m., LPN BB at 9:35 a.m., LPN III at 9:55 a.m. and LPN OO at 7:44 a.m. Interviews with Registered Nurses (RN) were conducted on [DATE] with LPN OO present at the Administrator's request: RN/MDS Director MM at 9:41 a.m. and RN NNN at 11:46 a.m. 5. Confirmation through interview with the DON on [DATE] at 1:50 p.m. revealed that she is responsible for reviewing and forwarding the results of the C[NAME] audits to the QAPI monthly meetings.

Based on record review, staff interviews and Change in a Patient Condition policy review, the facility failed to thoroughly assess the resident's vital signs, to provide neuro-check at the pre-populated times and to notify the Physician of a Change in Condition after one resident (R#1) of 12 sampled residents, who had an unwitnessed fall from bed and was receiving an anticoagulant. The resident was found four hours post fall without vital signs which was not communicated to the Physician and responsible party timely. An Abbreviated/Partial Extended Survey investigating complaint GA 433 was initiated on [DATE] and concluded on [DATE]. After review by the State Survey Agency, further investigation was needed for complaint GA 433, and a re-entry was initiated on [DATE] and concluded on [DATE]. Complaint GA 433 was substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on [DATE] was 64. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Nurse Consultants VV and WW were informed of an Immediate Jeopardy on [DATE] at 2:06 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: Resident (R)#1 on [DATE] at 3:45 a.m. had an unwitnessed fall from his bed and was receiving [MEDICATION NAME] 75 milligrams (mg) orally per day. R#1's roommate, R#5 with a Brief Interviewable Mental Status (BIMS) score of 14 (indicating R#5 is cognitively intact) alerted the nurse on duty that R#1 was on the floor. Licensed Practical Nurse (LPN) AA, assessed R#1 and found a skin tear to the right arm. On the Event form dated [DATE], LPN AA noted that the Physician was notified at 3:45 a.m. however, during the investigation it was revealed that the Physician nor the family member were notified at that time. On [DATE] at 7:15 a.m., the Certified Nurse Aide (CNA) notified LPN BB (day shift nurse) who entered R#1's room and observed R#1 to be non-verbal, pale in color with shallow breathing. LPN BB left the room and, did not notify the Physician. Instead, she called the family member. The family member gave instructions to send R#1 to the hospital, but R#1 died before this could be done. Immediate Jeopardy was identified on (MONTH) 25, 2019 and determined to exist on (MONTH) 24, 2019 in the areas of 42 CFR 483.10 (g) (14) (i)-(iv) Notify of Changes (Injury/Decline/Room, Etc.), F580; 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, and Exploitation, F600; 42 CFR 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, and Exploitation, F600. A Credible Allegation of Compliance was received on (MONTH) 26, 2019. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on (MONTH) 27, 2019. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Notification system and to ensure resident were protected from neglect Findings include: Review of the Change in a Patient Condition policy revealed, Intent: it is the intent of this center, except in medical emergencies, to notify the patient, his/her attending Physician and responsible party/patient representative of changes in the patient's condition and/or status. Procedural Guidelines 1. Nursing services should be responsible for notifying the patient's attending Physician when: A. The patient is involved in any accident or incident; D. Deemed necessary or appropriate in the best interest of the patient. 2. Nursing services should be responsible for notifying the patient, his/her next-of-kin, or responsible party/patient representative, as each case may apply, when: A. The patient is involved in any accident or incident; 4. All notifications should be made as soon as practical but should not exceed twenty-four (24) hours. Reviewed and updated for Release (MONTH) (YEAR). Review of the Face Sheet revealed R#1 was admitted to the facility with the following [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Nurse Practitioner Comprehensive evaluation and physical exam dated [DATE] revealed the resident had a history of [REDACTED]. The resident's blood pressure was documented as ,[DATE]. Review of the Event-Initial Note dated [DATE] revealed R#1 was found lying on floor on his right side. He had a skin tear to his right arm. His skin color was pale. The resident's blood pressure was noted as ,[DATE] with a pulse rate of 63. Medications listed as taken in the last eight hours included clipidogrel 75 mg, one daily. Neuro-check schedule was checked yes with a start time of 3:45 a.m It is noted that the Physician was notified at 3:45 a.m. and the family member was notified at 7:30 a.m. However, during the investigation it was revealed that the attending Physician was not contacted until 7:50 a.m. after R#1 had expired and pronounced by Director of Nursing (DON). Review of the Physician order [REDACTED]. Review of the Nurse Note dated [DATE] through [DATE] revealed an entry dated [DATE] at 8:48 a.m. which revealed R#1 expired and was pronounced at 0745 (military time) and the daughter was notified. The second entry at 8:56 a.m. revealed LPN BB was called to the room by caregiver at 7:15 a.m. R#1 was nonverbal, pale in color with shallow breathing. LPN BB left the room to contact next of kin. The third entry at 9:10 a.m. revealed LPN BB at 7:30 a.m. spoke with family member and gave change of condition report. LPN BB discussed the POLST with the family member who wanted R#1 to be sent out to the hospital for evaluation. The entry at 9:20 a.m. revealed LPN BB at 7:45 a.m. notified family member that the resident was observed with no blood pressure, pulse or respiration. The Director of Nursing, Nurse Practitioner, and Physician CC were notified of R#1's status. The fifth entry at 10:41 a.m. revealed the resident's body to be released to the Funeral home. The finally entry at 11:27 a.m. revealed Funeral Home picked up body. Review of the Quarterly Minimum Data Set (MDS) for R#5 (R#1's roommate) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, indicating no cognitive impairment. An interview with R#5 on [DATE] at 1:56 p.m. revealed that on [DATE] at approximately 3:15 a.m., that R#5 went to the bathroom and noted on return to bed that his roommate, R#1, was being restless while in bed. Once R#5 was back in bed, he heard a loud thump as R#1 hit the floor from his bed. It did sound like, to R#5, that R#1's head hit the floor based on sound. R#5 did not see the fall which occurred between the two beds. R#5 revealed that after R#1 fell that he began cursing and yelling. R#5 stated that he went out into the hall to summon help. He further revealed that five staff members came into the room and put R#1 back into bed. R#5 stated he saw the nurse put a dressing on the resident arm. R#5 revealed that R#1 regularly yells but that after the fall he was mostly quiet and the nurse came in the room to check on R#1 twice after the fall. R#5 further revealed that he was very upset regarding R#1's fall and his death and had spoken to the DON regarding his concerns. During an interview on [DATE] at 2:16 p.m. with Physician CC revealed that his expectation is to be notified immediately after a fall and not four hours post fall as in the case of R#1. Physician CC stated that he would send residents to the hospital after a fall if the resident was taking an anticoagulant and as warranted. During an interview on [DATE] at 2:43 p.m., Licensed Practical Nurse (LPN) AA revealed that she was the assigned nurse on [DATE] the night (night shift) of R#1 fall. LPN AA stated that she went into the resident's room about a dozen times after the fall and documented neuro-check after each observation although she did not enter the information in the Electronic Record (ER) until later in the shift. LPN AA stated that this was her method of documentation three times during the interview. LPN AA revealed that the resident tried to fight her off every time she did his neuro-check. When she was asked about the time stamp noted on the neuro-check in the chart, she stated that she would have to go with the times in the computer. LPN stated that she normally writes everything down on paper and then entered them in the computer before she leaves her shift for the day. However, during her interview, she revealed that she had not done the neuro-check at the times which automatically populate in the ER when checked on the Event-Initial Note. LPN AA continued to state that the resident was responsive when they (staff) picked him up off the floor and that she checked the resident's blood pressure which was also documented on the Neuro-check sheet which was recorded ranging between ,[DATE] to ,[DATE]. LPN AA could not say if the blood pressure readings were a change from the resident's normal blood pressure. LPN AA stated she was following facility protocol as far as notifying family and had 24 hours to notify the family. Further interview revealed that her shift ended at 7:00 a.m. During an interview on [DATE] at 3:03 p.m., Nursing Consultant WW revealed that the facility does not have a policy on neuro-check, but it is an understood rule that unwitnessed falls are to have a neuro-check and neuro-check were a clinical judgment for nurses. A sequential interview on [DATE] at 1:59 p.m., LPN AA was asked if there was any part of her initial interview on [DATE] that she wanted to recant or change. She stated no. In a handwritten statement completed by LPN AA dated [DATE] revealed a sentence that read Writer was able to continue neuro-check for the first hour and a half after fall at the least. LPN AA was asked to explain what at the least meant. She stated at the least meant that she checks on the first hour every 15 minutes and that she was following the facility policy. When asked what policy? She said that there was a written neuro-check policy on the chart that she followed. She was asked to provide a copy after the interview. LPN AA continued to state that resident had fallen out of the bed from the right side and he had a skin tear to his right arm and around 5ish (5:00 a.m. or thereafter), and R#1 had refused his medications. LPN AA could not recall if R#1 was receiving [MEDICATION NAME] ([MEDICATION NAME] bisulfate) 75 milligrams (mg) orally daily. When LPN AA was asked if there was a possibility that R#1 could have hit his head on the floor when he fell , she stated that he was a total care and the fall was not witnessed by staff; therefore, neuro-check were started. LPN AA stated that R#1 roommate, R#5, had alerted staff that R#1 fell from the bed (R#5 had a Brief Interview for Mental Status score of 14 indicating intact cognition). In regards to her documentation, she continued to state that she notified the doctor at 3:45 a.m. and that she entered all her neuro-check into the system around 5ish (same time she stated she did medication pass for the 6:00 a.m. medications). LPN AA provided what she stated was the policy for neuro-check. The document she provided was an Interact Version 4.0 Tool for Vital Signs, Laboratory Tests/Diagnostic Procedures and Signs and Symptoms A - W. Nurse Consultant WW reviewed the document that LPN AA stated was the neuro-check policy. Nurse Consultant WW again stated that there was not a facility policy for the neuro-check. During an interview on [DATE] at 3:04 p.m. with LPN BB, who was working on [DATE] starting at 7:00 a.m., revealed that she documented a change in R#1 condition of shallow breathing and reviewed the POLST which revealed the resident was a Do Not Resuscitate (DNR) and it read do not send to hospital without talking to the family first. LPN BB continued to state that she received report from the night nurse (LPN AA) of R#1's fall. She stated that when the Certified Nurse Aide (CNA) told her that the resident didn't look right she went and checked the resident and called the family instead of the Physician. LPN BB stated that she reached the resident's daughter and she was told to call the brother. The daughter did call back to the facility and stated that she wanted the resident to be sent to the hospital to be evaluated. LPN BB revealed that the resident expired before the daughter called the facility back. The family was contacted at 7:15 a.m. then at 7:30 a.m. the family member gave instructions to send the resident to the hospital although the resident expired before transfer to the hospital could occur. During an interview on [DATE] at 3:10 p.m. the Director of Nursing (DON) revealed that R#1 had a fall unwitnessed by the staff and the facility has 24 hours to notify family of any changes in condition. Continued interview with the DON revealed that four hours is a reasonable time frame to notify family if no apparent or visible injuries were noted. The DON stated that she didn't think that the facility would have done anything differently regarding the fall. A sequential interview on [DATE] at 2:40 p.m., the DON was asked if she was aware if R#1 was on an anticoagulant. The DON revealed that she had not reviewed R#1 chart and was not aware that he was on [MEDICATION NAME]. In response to the question, what is the possibility that R#1 could have hit his head on the floor? She stated that there was a possibility that R#1 could have hit his head on the floor. During an interview on [DATE] at 3:42 p.m. the Nurse Practitioner (NP) revealed that she was not contacted at the time of the resident's fall. The NP stated that their office has a ,[DATE] on call service and she would have to check their logs to see when they were notified and that she received report the following morning after the fall. A follow-up statement from the NP revealed that no one from the facility had contacted the Physician or the NP at 3:45 a.m. on [DATE]. During an interview on [DATE] at 2:59 p.m. the Administrator revealed that she expects the Physician and family to be notified of a Change in Condition, which includes a fall. The nurses are to follow the policy for Change in Condition or use clinical judgment and that LPN AA used poor judgement for assessing this resident and not contacting the Physician. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Patient # 1 identified in the survey no longer reside in the center. Nurse AA identified during the survey has been suspended indefinitely by the Director of Nurses on [DATE]. 2. Patients with a change in condition have the potential to be affected. 3. The Patient Change in Condition policy has been reviewed by the Director of Nurses, Administrator and Regional Nurse on [DATE] and no changes were made to this policy. 64 active patient files were audited by the LPN Minimum Data Set Coordinator, RN Minimum Data Set Coordinator and the RN Minimum Data Set Consultant on [DATE] looking back at changes in condition over the last 14 days. The audit includes the change in condition assessment for patients with an acute condition such as a fall, skin tear or other new medical condition. These charts were audited for a noted nursing assessment, subsequent assessments if required such as neuro-check, nursing to Physician notification, family notification, care plan updated if necessary and follow-up documentation every shift for 72 hours. This audit will be listed on a Change of Condition Documentation Audit Tool. Following this initial audit, the Director of Nurses or RN supervisor will audit new changes in condition daily x two weeks, then 5 days per week for 2 weeks, then once per week for 4 weeks. These same components will be audited and contained on the Change of Condition Documentation Audit Tool: noted nursing assessment, subsequent assessments if required such as neuro-check, nursing to Physician notification, family notification, care plan updated if necessary and follow-up documentation every shift for 72 hours. 4. 10:11 LPN charge nurses, 3:3 RN Supervisors, 2:2 LPN Resident Care Coordinator Nurses, 1:1 LPN Wound Care Coordinator, 1:1 RN Minimum Data Set coordinator and 1:1 LPN Minimum Data Set Coordinator nurses were educated on [DATE] by the Director of Nursing on responding to a patient with a change in condition, what constitutes a change in conditions i.e. falls, skin tears, any accident or incident, significant behavior changes, or other physical changes that vary from the patients baseline. This training also included change in condition monitoring, the need for the nursing assessment, Physician notification, family notification, nursing interventions, care plan updated, and follow-up documentation for 72 hours or longer as necessary. Supplementary nursing documentation tools were reviewed during this education as well to include the neuro-check tool. Any associates on FMLA will be educated upon their return to work. New hires will be educated during their orientation period. 5. Observations and findings of corrective actions will be forwarded by Director of Nurses for review of an evaluation of effectiveness to the Quality Assurance/Performance Improvement (QAPI) Committee monthly and as needed. Revisions and or updates will be made as indicated by QAPI committee which is led by the Administrator every month. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Resident #1 is no longer in the facility. Confirmed that LPN AA was suspended on [DATE]. Review of the separation notice dated [DATE], LPN AA's employment was terminated. ,[DATE]. Review of the policy Patient Change in Condition dated [DATE] which includes: What constitutes a change in condition (C[NAME]), what nursing assessments should be completed, an initial C[NAME]-Report to Physician (MD), Notification of MD and Family, Nursing interventions, updating the care plan and follow up documentation. Reviewed the change of condition (C[NAME]) documentation tool for 64 residents currently in the facility dated [DATE] which revealed that 12 residents were identified with a change in condition. One resident was identified with a change in condition on the documentation tool dated [DATE]. Review of the C[NAME] documentation tool contained: Nursing assessment complete, 72 Hour follow up, Physician (MD) notification, Family notification, Care Plan checked, Neuro-check indicated. All residents listed indicated the six items were completed. Review of the Performance Improvement Project (PIP) dated [DATE], PIP related to timely MD notification and neglect, with any change in condition which clarified what constituted a change in condition that included any accident to include falls. Additionally, the PIP covered by MD notification, family notification, nursing assessment with neuro- check initiated if indicated, Care Plan updated and 72 hour follow up documentation. The C[NAME] audit tool will be utilized for evaluation of the effectiveness of the plan, including an action plan that included education of nursing staff, 100% audit of records for active residents, Director of Nursing (DON) or Registered Nurse (RN) supervisor to audit C[NAME] daily for two weeks, then five times per week for two weeks then one time per week for four weeks, C[NAME] to be discussed in clinical meeting with benchmarks set at 100%. 4. Review of the in-service sign in sheets to confirm staff attended the in-services. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) and Registered Nurses (RN) confirming they had attended the MD notification and neglect in-service on [DATE] and confirmed they were knowledgeable of the Change in Condition, what constitutes as change in condition and that the MD should be notified should there be a Change in Condition, and their responsibility for the residents. Interviews were conducted on [DATE] with LPN OO present at all interviews at the request of the Administrator, LPN XX at 7:20 a.m., LPN HH at 7:27 a.m., LPN AAA at 8:18 a.m., LPN QQ at 8:23 a.m., LPN PP at 8:28 a.m., LPN BBB at 8:38 a.m., LPN BB at 9:35 a.m., LPN III at 9:55 a.m. and LPN OO at 7:44 a.m. Interviews with Registered Nurses (RN) were conducted on [DATE] with LPN OO present at the Administrator's request: RN/MDS Director MM at 9:41 a.m. and RN NNN at 11:46 a.m. 5. Confirmation through interview with the DON on [DATE] at 1:50 p.m. revealed that she is responsible for reviewing and forwarding the results of the C[NAME] audits to the QAPI monthly meetings.

Based on staff interviews, record review, policy review titled Changes in a Patients Condition, policy titled Advance Directives - Do Not Hospitalize (DNH) Guidelines and review of the Georgia Nurse Practice Act the facility failed to ensure that accepted standards of clinical practice were followed regarding accurately assessing a resident after a fall. The facility failed to notifiy the Physician of a Change in Condition, which included a fall/accident and failed to notifiy the responsible party of a change in condition, timely, for one resident (R#1) of 12 sampled residents. An Abbreviated/Partial Extended Survey investigating complaint GA 433 was initiated on [DATE] and concluded on [DATE]. After review by the State Survey Agency, further investigation was needed for complaint GA 433, and a re-entry was initiated on [DATE] and concluded on [DATE]. Complaint GA 433 was substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on [DATE] was 64. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and Nurse Consultants VV and WW were informed of an Immediate Jeopardy on [DATE] at 2:06 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The Immediate Jeopardy is outlined as follows: Resident (R)#1 on [DATE] at 3:45 a.m. had an unwitnessed fall from his bed and was receiving [MEDICATION NAME] 75 milligrams (mg) orally per day. R#1's roommate, R#5 with a Brief Interviewable Mental Status (BIMS) score of 14 (indicating R#5 is cognitively intact) alerted the nurse on duty that R#1 was on the floor. Licensed Practical Nurse (LPN) AA, assessed R#1 and found a skin tear to the right arm. On the Event form dated [DATE], LPN AA noted that the Physician was notified at 3:45 a.m. however, during the investigation it was revealed that the Physician nor the family member were notified at that time. On [DATE] at 7:15 a.m., the Certified Nurse Aide (CNA) notified LPN BB (day shift nurse) who entered R#1's room and observed R#1 to be non-verbal, pale in color with shallow breathing. LPN BB left the room and, did not notify the Physician. Instead, she called the family member. The family member gave instructions to send R#1 to the hospital, but R#1 expired before this could be done. Immediate Jeopardy was identified on (MONTH) 25, 2019 and determined to exist on (MONTH) 24, 2019 in the areas of 42 CFR 483.10 (g) (14) (i)-(iv) Notify of Changes (Injury/Decline/Room, Etc.), F580; 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, and Exploitation, F600; 42 CFR 483.21 (v)(3)(i) Services Provided Meet Professional Standards, F658, all at a Scope and Severity (S/S) of a J. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, and Exploitation, F600. A Credible Allegation of Compliance was received on [DATE]. Based on interviews, record reviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of the Notification system and to ensure residents were protected from neglect. Findings include: Review of the facility policy titled Advance Directives - Do Not Hospitalize (DNH) Guidelines revealed the policy intent statement reads: A DNH order is a type of Advance Directive, which indicates that the patient is not to be hospitalized . This type of Advance Directive is primarily for the patient who wishes to have comfort and pain control measures only and wants to reduce the aggressiveness of medical care. 3. F. The utilization of a DNH order (or clause in an Advance Directive) does not prohibit a facility from sending a resident to the hospital in appropriate instances. For example, for sutures in case of a laceration or an x-ray after a fall. Review of the facility policy titled Changes in a Patient's Condition reviewed and updated for release (MONTH) (YEAR), revealed: Intent: It is the intent of this center, except in medical emergencies, to notify the patient, his/her attending Physician and responsible party/patient representative of changes in the patient's condition and/or status. Procedural Guidelines: 1. Nursing services should be responsible for notifying the patient's attending Physician when: A. The patient is involved in any accident or incident. 2. Nursing services should be responsible for notifying the patient, his/her next-of-kin, or responsible party/patient representative, as each case may apply, when: A. The patient is involved in any accident or incident. 4. All notifications should be made as soon as practical, but should not exceed twenty-four hours. Review of the Rules and Regulations of the State of Georgia, Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurse addressed Rule ,[DATE]-.02 (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or health care facilities in area of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. (f) Performing other specialized tasks as appropriately educated. 2. Responsibility: Each individual is responsible for personal acts of negligence under the law. Licensed practical nurses are liable if the perform functions for which they are not prepared by education and experience and for which supervision is not provided. Review of the Face Sheet revealed R#1 was admitted to the facility with the following [DIAGNOSES REDACTED]. Review of the Event-Initial Note dated [DATE] revealed R#1 was found lying on floor on his right side. He had a skin tear to his right arm. It is noted that the Physician was notified at 3:45 a.m. and the family member was notified at 7:30 a.m. However, during the investigation it was revealed that the attending Physician was not contacted until 7:50 a.m., after R#1 had expired and pronounced by Director of Nursing (DON). Review of the POLST (Physician Orders for Life Sustaining Treatment) signed by the family member on [DATE], the attending Physician on [DATE], and concurring physician signature dated [DATE], had a handwritten instruction hospitalize only after conversation with family. Review of the Nurse Note dated [DATE] through [DATE] revealed an entry dated [DATE] at 8:48 a.m. stated that R#1 was pronounced dead at 0745 (military time) and the daughter was notified. The second entry at 8:56 a.m. revealed LPN BB was called to the room by caregiver at 7:15 a.m. finding R#1 was nonverbal, pale in color with shallow breathing. The third entry at 9:10 a.m. revealed LPN BB at 7:30 a.m. spoke with family member and gave change of condition report. LPN BB discussed the POLST with the family member who wanted R#1 to be sent to the hospital for evaluation. The entry at 9:20 a.m. revealed LPN BB at 7:45 a.m. notified family member that resident was observed with no blood pressure, pulse or respiration. Director of Nursing, Nurse Practitioner, and Physician CC were notified of R#1's status at that time. The fifth entry at 10:41 a.m. revealed the resident's body to be released to the Funeral home. The finally entry at 11:27 a.m. revealed Funeral Home picked up body. Review of the Quarterly Minimum Data Set (MDS) for R#5 (R#1's roommate) dated [DATE] revealed a Brief Interview for Mental Status of 14, indicating no cognitive impairment. An interview with R#5 on [DATE] at 1:56 p.m. revealed that on [DATE] at approximately 3:15 a.m., that R#5 went to the bathroom and noted on return to bed that his roommate, R#1, was being restless while in bed. Once R#5 was back in bed, he heard a loud thump as R#1 hit the floor from his bed. It did sound like, to R#5, that R#1's head hit the floor based on sound. R#5 did not see the fall which occurred between the two beds. R#5 revealed that after R#1 fell that he began cursing and yelling. R#5 stated that he went out into the hall to summon for help. He further revealed that five staff members came into the room and put R#1 back into bed. R#5 stated he saw the nurse put a dressing on the resident arm. R#5 revealed that R#1 regularly yells but that after the fall he was mostly quiet and the nurse came in the room to check on R#1 twice after the fall. R#5 further revealed that he was very upset that his roommate had died and spoke to the DON regarding his concerns. During an interview on [DATE] at 2:16 p.m., Physician CC revealed that his office was not notified that R#1 had a fall and that he expected to be notified immediately after a fall and not four hours post fall. During an interview on [DATE] at 2:43 p.m. Licensed Practical Nurse (LPN) AA revealed that she was the assigned nurse on [DATE] the night (early morning) when R#1 fell . LPN AA stated that she went into the resident's room about a dozen times after the fall and documented neurochecks after each time that she obtained them. LPN AA stated that this was her method of documentation three times during the interview and that the resident tried to fight her off every time she did his neurochecks. When she was asked about the time stamp note on the neuro-check in the chart, she stated that she would have to go with what was in the computer. LPN AA stated that she normally writes everything down on paper and then entered them in the computer before she leaves her shift for the day. However, in her interview, she revealed that she had not done the neuro-check as ordered. LPN AA continued to state that the resident was responsive when they (staff) picked him up off the floor and that she checked the resident's blood pressure. LPN AA stated she was following facility protocol as far as notifying family and had 24 hours to notify the family. She could not confirm that the Physician was notified at 3:45 a.m. as documented in the Initial-Event Note she further revealed that her shift ended at 7:00 a.m. During an interview on [DATE] at 3:03 p.m., Nursing Consultant WW revealed that after an unwitnessed fall staff should begin preforming neuro-check and documenting the Electronic Record (ER). A sequential interview with LPN AA on [DATE] at 1:59 p.m., revealed when asked about the handwritten statement given to the DON on [DATE] which reads Writer was able to continue neurochecks for the first hour and a half after fall at the least. She was asked to explain what at the least meant. She stated at the least means that she checks on the first hour every 15 minutes and that she was following the facility policy. When ask what policy? She said that there is a written neurocheck policy on the chart that she was following. She was asked to provide a copy after the interview. LPN AA continued to state that resident had fallen out of the bed from the right side and he had a skin tear to his right arm and around 5ish (5:00 a.m. or thereafter), R#1 had refused his medications. LPN AA could not recall if R#1 was receiving [MEDICATION NAME] ([MEDICATION NAME] bisulfate) 75 milligrams (mg) orally daily and was unaware of the order for the [MEDICATION NAME]. In regards to her documentation, she continued to state that she notified the doctor at 3:45 a.m., that she entered all her neuro-check into the system, at one time, around 5ish (same time she stated she did medication pass for the 6:00 a.m. medications). Continued interview with LPN AA provided what she said was the policy for neuro-check. The document she provided was an Interact Version 4.0 Tool for Vital Signs, Laboratory Tests/Diagnostic Procedures and Signs and Symptoms A - W. The Nursing Consultant WW, at this time, reviewed the document that LPN AA stated was the neuro-check policy and revealed that this was not a facility policy for the neuro-check. During an interview on [DATE] at 3:04 p.m., LPN BB revealed that she documented a change in R#1's condition of shallow breathing and on the POLST it read do not send to hospital without talking to the family first. LPN BB continued to state that she received report from the night nurse of R#1's fall. When the Certified Nurse Aide (CNA) told her that the resident didn't look right; LPN BB stated that she went and checked the resident and called the family instead of the Physician. LPN BB stated that she reached the resident's daughter and she said that she had to call her brother and the daughter did call back to the facility and stated that she wanted the resident to be sent to the hospital for evaluation. LPN BB revealed that the resident expired before the daughter called the facility back. The family was contacted at 7:15 a.m. and at 7:30 a.m. the family gave instructions to send R#1 to the hospital; however, R#1 was pronounced deceased at 7:45 a.m. by the Director of Nursing (DON). During an interview on [DATE] at 3:10 p.m. the Director of Nursing (DON) revealed that R#1 had a fall unwitnessed by the staff and the facility has 24 hours to notify family of any changes in condition. Continued interview revealed that the DON stated that four hours was a reasonable time frame to notify family if no apparent or visible injuries were noted. The DON stated that she didn't think that the facility would have done anything differently regarding R#1 fall. A sequential interview on [DATE] at 2:40 p.m. the DON revealed that she had not reviewed R#1 chart and was not aware that he was on [MEDICATION NAME]. The DON revealed that it was possible that R#1 had his head during the fall. During an interview on [DATE] at 3:42 p.m. the Nurse Practical (NP) revealed that she was not contacted at the time of the resident's fall. The NP stated that their office has a ,[DATE] on call service and she would have to check their logs to see when they were notified and that she received report the following morning after the fall. A follow-up correspondence from the NP revealed that no one in the facility had contacted the Physician or the NP at 3:45 a.m. on [DATE]. During an interview on [DATE] at 2:59 p.m. the Administrator revealed that she expects the Physician and family to be notified of a change in condition, which includes an accident. The Administrator continued to state that she did not question the nurse on why the physician was not notified as soon as possible after the fall and that LPN AA could have handled the situation differently and that LPN AA used poor judgment. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Patients # 1, identified in the sample are no longer active in the center. Nurse AA identified during the survey has been suspended indefinitely by the DON on [DATE]. 2. Education by the Director of Nurses began on [DATE] and was completed on [DATE] to review professional services and standards related to advanced directives, initiation of CPR, family and MD notification of changes in condition, implementation of patient care plan interventions, and adherence to professional standards. 10:11 LPN's, the LPN wound care nurse, 3:3 RN Supervisors, 2:2 LPN Resident Care Coordinators, 1:1 RN Minimum Data Set Coordinator, and 1:1 LPN Minimum Data Set Coordinator are receiving this education. The Director of Nurses will audit this professionalism by auditing 3 LPNs charge nurses per week x 4 weeks for their ability to articulate the steps to addressing a change in condition with a patient. The audit will include articulation of the following steps: nursing assessment tools to use, MD notification, family notification, care plan updated if necessary and follow-up documentation every shift for 72 hours. Any associates on FMLA will be educated upon their return to work. New hires will be educated during their orientation period. 3. Observations and findings of corrective actions will be forwarded by Director of Nurses for review of an evaluation of effectiveness to the Quality Assurance/Performance Improvement Committee monthly and as needed. Revisions and or updates will be made as indicated by QAPI committee which is led by the Administrator every month. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Jeopardy Removal as follows: 1. Resident #1 is no longer in the facility. Confirmed that LPN AA was suspended on [DATE]. Review of the separation notice dated [DATE], LPN AA's employment was terminated. 2. Review of the in-service documentation for Professional Standards related to Advanced Directives, initiation of CPR, family and Physician (MD) notification of changes in condition (C[NAME]), implementation of care plan interventions, and adherence to professional standards dated [DATE] revealed all licensed nurses attended. The following interviews were conducted on [DATE] with Licensed Practical Nurses (LPN) and Registered Nurses (RN) confirming they had attended the Professional Standards in-service on [DATE] and confirmed they were knowledgeable of their role, as a professional nurse, related to Change in Condition and what constitutes as change in condition and that the MD and family should be notified for a Change in Condition, initiation of CPR and updating the resident's care plan to reflect a change in condition. Interviews were conducted on [DATE] with LPN OO present at all interviews at the request of the Administrator, LPN XX at 7:20 a.m., LPN HH at 7:27 a.m., LPN AAA at 8:18 a.m., LPN QQ at 8:23 a.m., LPN PP at 8:28 a.m., LPN BBB at 8:38 a.m., LPN BB at 9:35 a.m., LPN III at 9:55 a.m. and LPN OO at 7:44 a.m. Interviews with Registered Nurses (RN) were conducted on [DATE] with LPN OO present at the Administrator's request: RN/MDS Director MM at 9:41 a.m. and RN NNN at 11:46 a.m. Per the DON on [DATE] at 1:50 p.m. there had been one new hire that had not begun work yet and would be in-serviced prior to working in the facility with residents. 5. Confirmation through interview with the DON on [DATE] at 1:50 p.m. revealed that she is responsible for reviewing and forwarding the results of the C[NAME] audits to the QAPI monthly meetings.