Every finding on record at Christwood

Based on record review and an interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required.Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2025 Quarter 4 (July 1- September 30) revealed the following:-No Registered Nurse hours, triggered.Review of the Facility's Timekeeping and Payroll Information revealed the following, in part:08/23/2025, Skilled Nursing, RN - SNF, S2DON, Hours: 5:45 a.m. - 2:30 p.m.09/06/2025, Skilled Nursing, RN - SNF, S2DON, Hours: 5:45 a.m. - 2:30 p.m.09/07/2025, Skilled Nursing, RN - SNF, S2DON, Hours: 5:45 a.m. - 2:30 p.m.09/20/2025, Skilled Nursing, RN - SNF, S2DON, Hours: 5:45 a.m. - 2:30 p.m.09/21/2025, Skilled Nursing, RN - SNF, S2DON, Hours: 5:45 a.m. - 2:30 p.m.An interview was conducted on 01/28/2026 at 8:10 a.m., with S2DON. She stated she was a Registered Nurse and worked 8 hours a day on 08/23/2025, 09/06/2025, 09/07/2025, 09/20/2025, and 09/21/2025. An interview was conducted on 01/28/2026 at 12:29 p.m., with S1ADM. He stated the facility's PBJ process was being transitioned between departments during the Fiscal Year 2025 Quarter 4 submission. S1ADM reviewed facility submitted payroll data for Fiscal Year 2025 Quarter 4 and confirmed no Registered Nurse hours were reported on the PBJ for the dates of 08/23/2025, 09/06/2025, 09/07/2025, 09/20/2025, and 09/21/2025 and should have been. He stated all quarters for payroll data submission for direct care staffing should be complete and accurate.

Based on observation, interviews, and record review, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure a resident's indication for emergency basic life support adequately reflected resident's wishes for 1 (#2) of 16 residents reviewed for Advanced Directives. Review of the facility's policy titled, Communication of Code Status with a revised date of 10/27/2025 revealed in part:Policy:It is the policy of this facility to adhere to residents' right to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.8. Code status will be verified in the electronic medical record (EMR) prior to initiation of any interventions. Visual indicators will be placed on the resident's name plate to prompt staff to verify code status in the EMR; a red dot indicates Do Not Resuscitate (DNR), and a blue dot indicates, Full Code (Code Blue). Review of the current Physician Orders dated 01/05/2026-01/27/2026 revealed the following: 01/16/2026 DNR status.Review of Resident #2's LaPost signed on 01/05/2026 by Resident #2's daughter/Power of Attorney indicating Resident #2's code status of DNR.An interview was conducted on 01/27/2026 at 3:01 p.m., with Resident #2. Resident #2 stated she signed a DNR upon admission to the facility. An interview was conducted on 01/28/2026 at 11:05 a.m., with S3LPN. S3LPN stated the colored dots on the residents' door plaque indicating their code status. S3LPN stated a red dot indicated a DNR code status and a blue dot indicated a Full Code status. S3LPN stated if a resident was unresponsive, staff would refer to the colored dot to determine code status.An interview was conducted on space 01/27/2026 at 3:17 p.m., with S2DON. S2DON stated the facility had no paper charts. S2DON stated residents have colored dots located on door plaques indicating their code status. An observation was made with S2DON of Resident #2's door plaque located near her room entrance. S2DON confirmed Resident #2's plaque had a blue dot indicating full code status. S2DON further confirmed Resident #2 had a signed LA Post indicating she was a DNR.

Based on observation, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff changed gloves during wound care treatment for 1 of 1 (#5) residents observed for wound care.Review of the facility's policy with a review date of 06/25/2025, titled, Hand Hygiene revealed the following, in part: Policy:All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines:1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.When, during resident care, moving from a contaminated body site to a clean body site: either soap and water or alcohol based hand rubReview of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE].Review of the Facility's Current Wound Log revealed Resident #5 had Pressure Ulcer/Injury Stage 3 to the Left Ankle.Review of Resident #5's current Physician Orders revealed the following, in part:Wound Care: Left lateral ankle wound healed. Cleanse with wound care cleanser and pat dry. Apply Vaseline or Aquaphor to the left lateral ankle wound area once daily and cover with bordered foam dressing in the morning.An observation was made on 01/28/2026 at 10:29 a.m. of S3LPN providing wound care to Resident #5. S3LPN cleansed the resident's left lateral ankle wound with wound cleanser and patted it dry with gauze. S3LPN, without changing gloves or performing hand hygiene, removed topical ointment from a clear medication cup and applied it to the wound. S3LPN then removed the gloves and without performing hand hygiene, donned a new pair of gloves before covering the wound with a bordered foam dressing.An interview was conducted on 01/28/2026 at 10:33 a.m. with S3LPN. S3LPN stated she should have patted the wound dry, removed the dirty gloves, performed hand hygiene, and donned new gloves before retrieving the ointment, but did not.An interview was conducted on 01/28/2025 at 11:50 a.m. with S2DON. S2DON confirmed hand hygiene should be completed between glove changes. S2DON further confirmed dirty gloves should not be used to apply ointment to a clean wound.

Based on record review and interviews the facility failed to maintain medical records on each resident that are complete and/or accurately documented. The facility failed to ensure: 1) Suprapubic catheter care and intake and output documentation were completed for 1 (#7) of 1 (#7) residents reviewed for catheter care. 2) Side effects monitored for antidepressant, antianxiety and anticoagulation medication documentation were completed for 1 (#3) of 5 (#3, #6, #13, #15 and #124) residents reviewed for unnecessary medication and medication regimen. Findings: Review of the facility's policy titled Documentation in Medical Record, dated 02/06/2024, revealed the following, in part: Policy Explanation of Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation should be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 4. Principles of documentation include, but are not limited to: B. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 1. Review of Resident #7's clinical record revealed he was admitted to the facility on [DATE] with medical diagnoses which included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflux Uropathy. Review of Resident #7's current physician orders revealed the following, in part: Monitor daily intake and output two times a day. Suprapubic Catheter: daily care and cleaning of insertion site with soap and water, apply split gauze dressing and monitor for pain and skin redness, burning, excoriation, rash, and excoriation in the evening for suprapubic catheter care. Review of Resident #7's November 2024 Treatment Administration Record (TAR) revealed the following documentation, in part: Suprapubic catheter daily care and cleaning of insertion site with soap and water, apply split gauze dressing and monitor for pain and skin redness, burning, excoriation, rash, and excoriation, in the evening for suprapubic catheter care. The boxes for the dates 11/07/2024 and 11/12/2024 were blank. Review of Resident #7's December 2024 Medical Administration Record (MAR) revealed the following documentation, in part: Start Date: 12/04/2024. Monitor daily intake and output every shift. The boxes for the dates 12/04/2024 (night), 12/07/2024 (night), 12/11/2024 (day) and 12/14/2024 (day) were blank. Start Date: 12/14/2024. Monitor daily intake and output 2 times a day. The boxes for the dates 12/15/2024 (night) and 12/17/2024 (night) were blank. Review of Resident #7's November and December 2024 Progress/Nurse's Notes revealed no documentation of suprapubic catheter care or intake and output results. An interview was conducted on 12/17/2024 at 3:40 p.m. with S3LPN. S3LPN stated she worked 11/07/2024 and 11/12/2024 on the night shift and cared for Resident #7. She stated when suprapubic catheter care is completed for residents, the task was expected to be documented on the TAR. After review of Resident #7's November 2024 TAR, S3LPN confirmed the box was blank, which indicated she did not complete suprapubic catheter care documentation on 11/07/2024 and 11/12/2024 and should have. An interview was conducted on 12/18/2024 at 11:22 a.m. with S4LPN via telephone. S4LPN stated she was working the day shift 12/11/2024 and was taking care of Resident #7. She stated resident's intake and output was expected to be documented on the MAR each shift. After S4LPN was notified of Resident #7's December 2024 MAR related to intake and output boxes dated 12/11/2024 were blank on the day shift, she confirmed she forgot to document the intake and output results and should have. She stated she could have documented the intake and output results in the progress notes. An interview was conducted on 12/18/2024 at 11:27 a.m. with S5LPN via telephone. S5LPN stated she was working the night shift on 12/04/2024 and taking care of Resident #7. She stated resident's intake and output was expected to be documented on the MAR each shift. After S5LPN was notified of Resident #7's December 2024 MAR related to intake and output boxes dated 12/04/2024 were blank on the night shift, she confirmed she forgot to document the intake and output results and should have. An interview was conducted on 12/18/2024 at 2:15 p.m. S1DON. S1DON reviewed Resident #7's November 2024 TAR related to suprapubic catheter care dated 11/07/2024 and 11/12/2024 and confirmed the boxes were blank, which indicated no documentation. She further reviewed December 2024 MAR related to intake and output dated 12/04/2024 (night), 12/07/2024 (night), 12/11/2024 (day) and 12/14/2024 (day), 12/15/2024 (night) and 12/17/2024 (night) and she confirmed the boxes were blank, which indicated no documentation. S1DON confirmed she expected the nurses to correctly complete documentation for suprapubic catheter care once every shift and intake and output each shift and they did not. S1DON reviewed Resident #7's November and December 2024 Progress/Nursing notes and confirmed there was no evidence of documentation for suprapubic catheter or intake and output and should have been. 2. Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE] with medical diagnoses which included Depression, Unspecified, Anxiety Disorder, Unspecified and Unspecified Atrial Fibrillation. Review of Resident #3's current physician orders revealed the following, in part: Eliquis Oral Tablet 2.5mg, give 1 tablet by mouth two times a day for Anticoagulant. Buspirone HCl Oral Tablet, give 7.5mg by mouth three times a day for Anxiety. Xanax oral tablet 0.5mg, give 0.5mg by mouth every 6 hours as needed for Anxiety. Zoloft oral tablet (sertraline HCI), give 25mg by mouth in the morning for Depression. Review of Resident #3's September 2024 Treatment Administration Record (TAR) revealed the following, in part: Monitor for Side effects of antidepressant (N/V, Headache, dizziness, restlessness, insomnia, and constipation) two times a day 'Y' if no side effects noted, 'N' if side effects noted make progress note notify MD. The dates 09/16/2024, 09/25/2024 and 09/26/2024 for the evening shift boxes were blank. Anticoagulant medication- monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and or vital signs, sob, nose bleeds. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress notes findings every shift. The dates 09/16/2024, 09/25/2024 and 09/26/2024 for the evening shift boxes were blank. Antianxiety medication- monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings two times a day Y if not side effects, N if side effects noted, make progress note notify MD. The dates 09/16/2024, 09/25/2024 and 09/26/2024 for the evening shift boxes were blank. Review of Resident #3's September 2024 Progress/Nurse's Notes revealed no documentation of side effects monitored for antidepressant, antianxiety and anticoagulation medication. An interview was conducted on 12/17/2024 at 3:40 p.m. with S3LPN. S3LPN stated she worked 09/16/2024 on the night shift and cared for Resident #3. She stated Resident #3 was monitored for side effects related to antidepressant, antianxiety and anticoagulation medication and was expected to be documented on the TAR. After review of the September 2024 TAR, S3LPN confirmed she did not complete side effect documentation on 09/16/2024 and should have. An interview was conducted on 12/18/2024 at 1:45 p.m. with S2LPN. S2LPN stated she worked 09/26/2024 on the night shift and cared for Resident #3. She stated Resident #3 was monitored for side effects related to antidepressant, antianxiety and anticoagulation medication and was expected to be documented on the TAR. After review of the September 2024 TAR, S2LPN confirmed she did not complete side effect documentation on 09/26/2024 and should have. An interview was conducted on 12/18/2024 at 2:15 p.m. S1DON. S1DON reviewed the September 2024 MAR side effects monitored for antidepressant, antianxiety and anticoagulation medication and confirmed the boxes on 09/16/2024, 09/25/2024 and 09/26/2024 were blank, which indicated no documentation. She confirmed she expected the nurses to correctly complete documentation for the monitored side effects related to medication on each shift and did not. S1DON further reviewed the September 2024 Progress/Nursing notes and confirmed there was no evidence of side effect documentation related to antidepressant, antianxiety and anticoagulation medication.

Based on record reviews and interviews, the facility failed to correctly implement Physician's Orders to meet professional standards of quality for 1 (#3) of 16 sampled residents' reviewed for medication administration records. Findings: Review of the facility's policy titled Medication Administration, dated 07/02/2024, revealed the following, in part: Policy: Medications are administered .as ordered by the physician and in accordance with professional standards of practice. Policy explanation and compliance guidelines: 8. Obtain and record vital signs, when applicable or per Physician's Orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with medical diagnoses, which included Unspecified Atrial Fibrillation, Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Peripheral Vascular Disease, and Acute Pulmonary Edema. Review of Resident #3's current Physician's Orders revealed the following, in part: Amlodipine Besylate oral tablet, give 10 milligrams by mouth in the morning for blood pressure greater than 140/90 mmHg. Blood pressure parameters: Obtain blood pressure/pulse before giving as needed beta blockers/antihypertensive medications. Hold medication with a systolic blood pressure of 100 mmHg or less. If systolic blood pressure is above 180 mmHg, give medication and call medical doctor to review plan. Hold if pulse is 50 BPM or less and call medical doctor to review plan. Review of Resident #3's December 2024 Medication Administration Record (MAR) revealed the following documentation for the Amlodipine Besylate medication, in part: 12/02/2024- blood pressure 128/62 mmHg, check mark, which indicated medication was administered, S2LPN's initials. 12/03/2024- blood pressure 138/67 mmHg, check mark, which indicated medication was administered, S2LPN's initials. 12/04/2024- blood pressure 134/61 mmHg, check mark, which indicated medication was administered and S2LPN's initials. 12/05/2024- blood pressure 135/62 mmHg, check mark, which indicated medication was administered and S2LPN's initials. An interview was conducted on 12/18/2024 at 1:45 p.m. with S2LPN. S2LPN reviewed Resident #3's December 2024 MAR and confirmed she administered Amlodipine Besylate medication, as indicated by the check marks, to Resident #3 every morning on 12/02/2024 through 12/05/2024. After further review, S2LPN confirmed the blood pressure results dated 12/02/2024 through 12/05/2024 were all less than 140/90 mmHg. S2LPN reviewed Resident #3's current Physician's Order blood pressure parameters, and December 2024 MAR blood pressure parameters for Amlodipine Besylate medication and confirmed Amlodipine Besylate medication should not have been given to Resident #3 every morning on 12/02/2024 through 12/05/2024 with blood pressures less than 140/90 mmHg. She stated when she administered Amlodipine Besylate medication on the previously mentioned dates, she did not notice on Resident #3's December 2024 MAR the parameters to give medication for blood pressure greater than 140/90mmHg. She stated for Resident #3 she was only aware of one order with parameters to hold blood pressure medication for systolic blood pressure less than 100 mmHg, which was the reason she did not hold the medication. An interview was conducted on 12/18/2024 at 2:15 p.m. with S1DON. S1DON reviewed Resident #3's aforementioned December 2024 MAR and current Physician's Orders and confirmed S2LPN gave Amlodipine Besylate medication with blood pressure results less than 140/90 mmHg and should not have. S1DON stated she expected the S2LPN to correctly follow the Resident #3's current physician orders and hold blood pressure medication per physician's parameters.

Based on observations, record review, and interviews, the facility failed to follow Enhanced Barrier Precautions (EBP) and proper hand hygiene procedures to prevent the development and transmission of infections by staff for 1 (#7) of 4 (#7, #10, #12, and #15) residents observed for EBP. Findings: Review of the facility's policy titled Enhanced Barrier Precautions, dated 06/06/2024, revealed the following, in part: Policy: It is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of EBP b. PPE for EBP is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: g. Device care or use: urinary catheters . Review of Resident #7's clinical record revealed he was admitted to the facility on [DATE] with medical diagnoses which included Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Obstructive and Reflux Uropathy. Review of Resident #7's current physician orders revealed the following, in part: Start date: 11/06/2024 Suprapubic Catheter: daily care and cleaning of insertion site with soap and water, apply split gauze dressing. An observation was made on 12/17/2024 at 4:30 p.m. of Resident #7's room. There was a sign on the wall by the door that stated the following, in part: EBP Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Device care An observation was made on 12/17/2024 at 4:31 p.m. of S3LPN providing suprapubic catheter care for Resident #7. S3LPN did not put on a gown prior to providing suprapubic catheter care. After providing catheter care to Resident #7, S3LPN removed her gloves, and with bare hands, she picked up the soiled linens used for the catheter care and placed them in a pile on the resident's chair. S3LPN then removed the wash basin from the bedside table and emptied it into the bathroom sink. S3LPN walked back towards the resident with bare hands and without performing hand hygiene. S3LPN touched the resident's water pitcher, newspapers and pen, and then placed the items on the bedside table, and pushed the bedside table towards the resident. S3LPN grabbed the soiled linens from the chair with her bare hands and placed them in the bathroom soiled linen basket. She then washed her hands with soap and water and exited Resident #7's room. An interview was conducted on 12/17/2024 at 5:01 p.m. with S3LPN. S3LPN confirmed the observations above. She stated she should not have touched the soiled linens with her bare hands after she performed suprapubic catheter care. She confirmed she should have performed hand hygiene after touching the soiled linens and before touching Resident #7's personal belongings. S3LPN further confirmed she was unaware Resident #7 was on EBP and, after reviewing the EBP sign on the wall, stated she should have worn a gown and did not. An interview was conducted on 12/18/2024 at 3:45 p.m. with S1DON. S1DON stated S3LPN told her she did not wear a gown during suprapubic catheter care. She confirmed all nurses had been educated on the EBP policy and she expected them to follow the policy. She further confirmed S3LPN did not use proper hand hygiene after suprapubic catheter care, and should have.

Based on interviews and record review the facility failed to ensure residents understood the binding arbitration agreement signed on admission for 3 (#21, #77, and #177) of 3 (#21, #77, and #177) residents reviewed for arbitration. All 24 residents who currently resided in the facility had binding arbitration agreement. Findings: Review of the facility's form titled Admission Agreement on page 9 of 11 revealed an arbitration agreement was included in the Admission Agreement with no option for declination. This agreement revealed in part, the following: Section 8.2 Arbitration. Any dispute, claim or controversy of any kind between you and us arising out of, in connection with, or relating to this Skilled Nursing Facility Admission Agreement and any amendment hereof, or the breach hereof, which cannot be resolved by you or us to small claims court for disputes or claims within the scope of its jurisdiction or determined by arbitration in [NAME], LA in accordance with the then-current commercial arbitration rules of the Federal Arbitration Act, and the arbitrator will be required to render a decision adopting, in full, either one or the other of such proposed resolutions on a per issue basis, and no compromises or alternative resolutions shall be allowed or considered. Resident #21 Review of the clinical record revealed Resident #21 was admitted to the facility on [DATE]. Further review revealed Resident #21 was their own responsible party. Review of Resident #21's record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #21 and the S3AC on 09/03/2021. Further review revealed a binding arbitration agreement was included with no option for declination. An interview was conducted on 12/18/2023 at 12:28 p.m. with Resident #21. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated on what it meant. Resident #77 Review of the clinical record revealed Resident #77 was admitted to the facility on [DATE]. Further review revealed Resident #77 was their own responsible party. Review of Resident #77's record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #77 and S3AC on 12/14/2023. Further review revealed a binding arbitration agreement was included with no option for declination. An interview was conducted on 12/18/2023 at 12:48 p.m. with Resident #77. Resident #77 was able to answer questions appropriately and was alert and oriented. She stated she was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. She stated she would not have signed the arbitration agreement had she been educated on what it meant. Resident #177 Review of the clinical record revealed Resident #177 was admitted to the facility on [DATE]. Further review revealed Resident #177 had a designated RP as their responsible party. Review of Resident #177's record revealed a form titled, Admission Agreement. The Admission Agreement form was dated and signed by Resident #177's RP and S3AC on 12/15/2023. Further review revealed a binding arbitration agreement was included with no option for declination. An interview was conducted on 12/18/2023 at 12:50 p.m. with Resident #177's RP. He stated he was not educated by the facility on what an arbitration agreement was prior to signing the admission agreement. He stated he would not have signed the arbitration agreement had he been educated on what it meant. An interview was conducted on 12/18/2023 at 12:09 p.m. with S3AC. She reviewed Resident #21, #77, and #177's signed Admission Agreements and confirmed all 3 residents agreements included an arbitration agreement. She stated she did not know the Admission Agreement included an arbitration agreement. S3AC reviewed all 24 residents' Admission Agreement and confirmed all 24 had signed arbitration agreements included. She confirmed all 24 residents, who currently resided in the facility, had signed a binding arbitration agreement when they signed the Admission Agreement. She confirmed none of the 24 residents or their RPs had been educated on what an arbitration agreement was. She stated she was responsible for educating the residents and RPs of the Admission agreement upon admission. She stated she should have educated them on what an arbitration agreement was and did not. She confirmed the Admission Agreement form had not been changed in many years and currently included arbitration agreements for new admissions. An interview was conducted on 12/18/2023 at 1:09 p.m. with S1ADM. He stated he did not know there was an arbitration agreement included in the Admission Agreement form. He confirmed all 24 residents on the census had signed a binding arbitration agreement and were not educated on what an arbitration agreement was.

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 1 (Med Cart 1) of 2 (Med Cart 1 and Med Cart 2) Medication Carts observed for medication storage. Findings: Review of the facility's policy titled, Medication Storage revealed in part, the following: 6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the medication room. An observation was made on 12/18/2023 at 9:10 a.m. of Med Cart 1 with S4LPN. One bottle of Lorazepam Concentrate 2mg/mL for Resident #79 was observed in the narcotic lock box drawer of the medication cart at room temperature. The Lorazepam Concentrate bottle revealed a label which read Refrigerate. An interview was conducted on 12/18/2023 at 9:10 a.m. with S4LPN. S4LPN confirmed the label on Resident #79's bottle of Lorazepam Concentrate read Refrigerate and should have been placed back into the medication room refrigerator after administration. S4LPN confirmed the bottle of Lorazepam Concentrate was room temperature. S4LPN stated she was unsure how long the Lorazepam Concentrate was stored in the medication care, and Resident #79 last received a dose of Lorazepam Concentrate on 12/13/2023. An interview was conducted on 12/18/2023 at 1:20 p.m. with the facility's Pharmacist. He confirmed Lorazepam Concentrate should be stored in the medication room refrigerator after each use. He stated Lorazepam Concentrate should not be left out of the refrigerator for long periods of time. He stated if Lorazepam Concentrate remained at room temperature for long periods of time, the effectiveness of the medication greatly decreased. An interview was conducted on 12/18/2023 at 1:24 p.m. with S2DON. S2DON confirmed all medications requiring refrigeration, as indicated on the label of the medication, should be returned back into the medication room refrigerator after administration. S2DON provided a medication pamphlet for Lorazepam Concentrate which indicated the medication should have been stored at a cold temperature from 36 degrees Fahrenheit to 46 degrees Fahrenheit S2DON confirmed Resident #79's Lorazepam Concentrate was not stored at the proper temperature and should have been.

Based on observations, interviews, and record review, the facility failed to implement appropriate infection control practices of COVID-19 by failing to ensure: 1. IPCP standards, policies, and procedures were current and based on the facility assessment and national standards. 2. All visitors were properly screened upon entering the facility. Findings: 1. Review of the facility's current infection control policy revealed Interim COVID-19 Visitation policy had not been updated since March 22, 2021. Interim COVID-19 Visitation Review/Revised: 03/22/2021 Policy Explanation and Compliance Guidelines: 6. Indoor visitation will not be conducted at this time. 7. Residents on transmission-based precautions for COVID-19 will be restricted to virtual visits. An interview was conducted on 11/08/2021 at 1:20 p.m. with S1ADM. He confirmed the facility's Interim COVID-19 Visitation Policy had not been updated and revised to meet the current standards. An interview was conducted on 11/09/2021 at 1:30 p.m. with S2DON and S6RN. They confirmed the facility's Interim COVID-19 Visitation Policy had not been updated and revised to meet the current standards. S6RN is currently the infection control nurse. 2. Review of the facility's Coronavirus Surveillance Policy dated 05/21/2021 revealed the following: Policy: Facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for illness. Policy Explanation and Compliance Guidelines: 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19; these include but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Signs and symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell) b. in the last 14 days, has had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Travel within the last 14 days to geographic areas with sustained community transmission d. residing in a community where community-based spread of COVID-19 is occurring. 4. Visitors will be denied entry into the facility if they exhibit any of the criteria listed above they may be directed to the Infectious Control Nurse, Director of nursing, or nurse manager on duty if they have any questions. Review of the facility's Interim COVID-19 Visitation Policy dated 05/21/2021 revealed the following: The visitation at facility will be person-centered, consider the resident's physical, mental, and psychosocial well-being, and support their quality of life. Exceptions will be in accordance with current CMS directives and CDC recommendations, or as directed by state government (whichever is more stringent). Policy Explanations and Compliance Guidelines: 4. The core principles of COVID-19 infection prevention will be adhered to and as follows: a. Screening of all who enter the facility for signs and symptoms of COVID-19 (ex. Temperature checks, questions or observations about signs and symptoms), and denial of entry to those with signs or symptoms. 8. Special Considerations: a. Essential Health care workers: Essential healthcare workers will be allowed to come into the facility as long as they meet current CDC guidelines for healthcare workers. Screening for fever and respiratory symptoms apply in accordance with surveillance procedures. b. Surveyors: Screening for fever and respiratory symptoms along with requesting hand hygiene apply. Inform them of facility policy regarding standard and transmission-based precautions. On 11/08/2021 at 8:30 a.m., upon arrival at this facility, 4 of 7 surveyors were not asked screening questions by S7FD prior to entering the skilled unit. The facility's kiosk system, which was normally used to screen visitors, was confirmed by S7FD to be nonfunctional. An interview was conducted on 11/08/2021 at 1:20 p.m. with S1ADM. He stated S7FD should be asking screening COVID questions whenever the kiosk was broken. An interview was conducted on 11/09/2021 at 1:30 p.m. with S2DON and S6RN. They both stated that visitors were to sign into the kiosk at the front door where screening questions were asked. They stated if the kiosk was broken, visitors were to sign in with S7FD, and S7FD was required to ask the screening questions at that time. An interview was conducted on 11/10/2021 at 3:15 p.m. with S7FD. She stated if the kiosk was down, she did not ask the screening questions. She stated she was not aware she was supposed to ask the COVID-19 screening questions.

Based on record review and interviews, the facility failed to promote and facilitate self-determination through support of resident's choices by failing to allow a resident to shower twice a week for 1 of 1 (#13) sampled residents reviewed for choices. Findings: Resident #13 Review of Resident # 13's record revealed an admitted [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/06/2021 revealed Resident #13 had a BIMS (Brief Interview of Mental Status) score of 13, which indicated he was cognitively intact. He required one-person physical assist with bathing. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's ADL (Activities of Daily Living) Bathing Task Flowsheet dated 10/12/2021-11/07/2021, revealed he received a shower on 10/16/2021, 10/23/2021, 10/30/2021, and 11/3/2021. An interview was conducted on 11/08/2021 at 11:48 a.m. with Resident #13's daughter. She stated the resident was only getting showers once a week. She stated his last shower was on Wednesday 11/03/2021. An interview was conducted on 11/10/2021 at 2:15 p.m. with S2DON. She reviewed the ADL Bathing Task Flowsheet dated 10/12/2021-11/07/2021. She confirmed Resident #13 received a shower on 10/16/2021, 10/23/2021, 10/30/2021, and 11/3/2021. She verified Resident #13 had 4 showers in 27 days and he should have received 2 showers per week.

Based on record review and interviews, the facility failed to ensure assessments were accurate for 1 (#17) of 2 (#17 and #18) residents reviewed for closed records. The facility failed to ensure the discharge status was correct in the MDS (Minimum Data Set). Findings: Resident # 17 Review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 17's discharge MDS dated [DATE] revealed a discharge date of [DATE] and discharge status of 03- Acute Hospital. An interview was conducted on 11/09/2021at 1:15 p.m. with S5SS. She said Resident #17 was discharged to home and the MDS entry as a discharge to the hospital was an error. An interview was conducted on 11/10/2021at 12:55 p.m. with S2DON. She said Resident #17 was discharged to home. She verified she was responsible for the MDS entry as a discharge to the hospital and it was an error.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 (Resident #9) of 13 residents sampled by failing to ensure the resident's call light was within reach. Findings: Fall Prevention Program Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 5. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: iii. Call light and frequently used items within reach. 6. High Risk Protocols: b. Implement interventions from Low/Moderate Risk Protocols. d. Provide additional interventions as directed by the resident's assessment, including, but not limited to: vi. Alternate call system access Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses, which included Fracture of Unspecified Part of Neck of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, and Pain in Right Hip. Review of the MDS with an ARD of 09/29/2021 revealed Resident #9 had a BIMS of 13, which indicated she was cognitively intact. Review of Resident #9's current Care Plan revealed the following, in part: Impaired physical mobility related to weakness and instability s/p hospitalization for right hip fracture. Interventions: Ensure call light is available to resident. The resident has a right hip fracture Interventions: Be sure call light is within reach and respond promptly to all request for assistance. Risk for falls Interventions: Assist resident with ambulation and transfers, utilizing therapy recommendations 09/23/2021 Unwitnessed fall - reeducate on call light 10/03/2021 Unwitnessed fall - call don't fall signs 10/19/2021 Witnessed fall - add floor mat 10/28/2021 Unwitnessed fall - bed alarm An observation was made on 11/09/2021 at 11:09 a.m. of Resident #9 sitting in a recliner in her room while the call light was connected to her bed out of reach. During the observation, Resident #9 stated she uses the call light to contact the nurses when she needs to get up. Resident #9 confirmed she could not reach the call light at this time. S8AA came in to assist resident into wheelchair for lunch, and confirmed the call light should have been next to the resident. An interview was conducted on 11/09/2021 at 1:30 p.m. with S2DON. She confirmed a resident's call light should be within reach at all times while the resident was in their room.

Based on record review and interview, the facility failed to ensure the ombudsman was notified of a resident's discharge to the hospital for 1 of 1 (#11) residents who were investigated in the final sample for hospitalization s. There were 13 residents investigated in the final sample. Findings: Review of Resident #11's medical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Fracture of unspecified part of Neck of Right Femur, Primary Generalized [CONDITION(S)], Cognitive Communication Deficit, Anxiety Disorder, and Major Depressive Disorder. Review of the Nurses' Notes for Resident #11 revealed she was transferred to the hospital on 10/08/2021 with a return to the facility on [DATE]. Review of the Emergency Transfer Log provided by S1Admin revealed no documentation of the Ombudsman being notified of any residents' transfer to the hospital for May, June, July, August, September, and October 2021. On 11/10/2021 at 9:45 a.m., an interview was conducted with S1Admin. S1Admin confirmed the facility had not completed an Ombudsman transfer log since April of 2021. He stated he was aware the facility should have completed a log monthly and sent it to the Office of the Ombudsman.

Based on interviews and record reviews, the facility failed to fully develop and implement written policies and procedures that prohibited and prevented abuse for 4 (#1, #2, #4, #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for abuse. The facility failed to ensure: 1. Residents (#1, #2, #4, and #5) were protected after staff witnessed suspected abuse; 2. Staff promptly reported any incident of suspected abuse of residents (#1, #2, #4, and #5) to facility management; 3. The written abuse and neglect policy included specific reporting timeframes; and 4. 2 (S3LPN and S10LPN) of 4 (S3LPN, S5LPN, S8CNA, S10LPN) of staff reviewed did not receive annual training on abuse reporting. Findings: Review of the facilities abuse and neglect policy and procedure revealed the following, in part: Policy: To provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and Dementia management and resident abuse prevention. II. Employee Training B. Existing staff will receive annual education through planned in-services and as needed. VI. Protection of Resident The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. 4. Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: c. Training staff on changes made and demonstration of staff competency after training is implemented. 1. and 2. Resident #1 Review of the SIMS report dated 03/01/2021 revealed the following, in part: Incident Occurred: 02/27/2021 at 7:00 p.m. Incidents Discovered: 02/28/2021 at 7:00 a.m. Summary of Complaint- Multiple staff members witnessed S3LPN yelling at Resident #1 after Resident #1 refused medication. Accused Allegation: Verbal Abuse Review of S7CNA's witness statement from the incident on 02/27/2021 at 7:00 p.m., revealed the following: S7CNA stated S3LPN was yelling at Resident #1 to take her medication and knock it off. She stated S3LPN said I am sick of her doing this every night. Review of S5LPN's witness statement from the incident on 02/27/2021 at 7:00 p.m., revealed the following: S5LPN stated S3LPN stood in front of Resident #1 and would not let her leave the activity room. She stated S3LPN stated, you are going to take your medicine. She stated S3LPN and Resident #1 argued back and forth before Resident #1 took the medication and said when I get sick you're going to go to the hospital with me. Review of S4LPN's witness statement from the incident on 02/27/2021 at 7:00 p.m., revealed the following: S4LPN stated S3LPN walked over and took the medication out of my hands and insisted Resident #1 take the medications. S4LPN stated S3LPN was yelling and bullied Resident #1. Resident # 2 Review of SIMS Report dated 02/24/2021 revealed, in part: Report Received: 02/24/2021 at 11:00 a.m. Incident Discovered:02/24/2021 at 6:00 am Incident Description: On 02/24/2021 at 11:00 a.m. S9LPN stated S8CNA was verbally abusing Resident #2 by yelling at him. Accused allegations: Verbal Abuse An interview was conducted with S9LPN on 03/23/2021 at 10:15 a.m. She stated S7CNA reported an allegation of verbal abuse towards Resident #2 on the night shift of 02/23/2021 to 02/24/2021. S9LPN stated she reported the allegation to S1ADM after their morning meetings were completed on 02/24/2021 at 11:00 a.m. S9LPN stated she had 48 hours to report allegations of verbal abuse, and 8-24 hours to report physical abuse to administration. Resident #4 Review of S4LPN's witness statement from 02/27/2021 night shift, revealed the following: S4LPN stated Resident #4 refused her medications. She stated she had plans to reattempt later that night. She stated S3LPN took Resident #4's medications and shoved them into the resident's mouth. Resident #5 Review of S7CNA's witness statement dated 02/27/2021 night shift, revealed the following: S7CNA stated S3LPN asked her to hold Resident #5's hands down while she started the tube feeding. She stated she told S3LPN she did not want to restrain the resident. S7CNA stated S3LPN was yelling at the resident, Be still. Review of S8CNA's witness statement dated 02/27/2021 night shift, revealed the following: S8CNA stated she witnessed S3LPN yelling at Resident #5 when she was trying to hook up her tube feeding. S3LPN had S7CNA hold Resident #5's hands. An interview was conducted with S5LPN on 03/23/2021 at 10:54 a.m. She stated on the morning of 02/28/2021, S4LPN reported, during the previous night shift, that S3LPN forced resident #4 to take medication and also requested S8CNA to hold Resident #5's hands down. S5LPN stated S4LPN had not reported the allegations of abuse to administration. An interview was conducted on 03/24/2021 at 2:28 p.m. with S4LPN. She stated she reported allegations of abuse to S5LPN on the morning of 02/28/2021 regarding S3LPN and Resident's #1, #4, and #5. She stated all the incidents had occurred on the night shift the evening before. She confirmed she waited until the morning of 02/28/2021 to report the allegation. An interview was conducted with S2DON on 03/24/2021 at 2:22 p.m. S2DON confirmed she was notified of the allegations of abuse towards Resident #1, # 4 and #5 on 02/28/2021. She confirmed staff should have immediately reported the allegations of abuse on 02/27/2021 at 7:00 p.m. when S3LPN was observed yelling at Resident #1. An interview was conducted with S1ADM on 03/25/2021 at 10:32 a.m. She stated the incident with Resident #2 happened on the night shift of 02/23/2021-02/24/2021. She stated S7CNA reported to S9LPN Resident #2 said S8CNA had raised her voice at him and was not friendly. She stated S9LPN did not report the allegation until the following morning at 11:00 a.m. She verified S7CNA should have immediately notified administration when Resident #2 made allegations of verbal abuse. S1ADM confirmed being aware of the incident that occurred with Resident #1's, #4, and #5 on 02/27/2021 from 7:00 p.m. to 7:00 a.m. She stated she would have expected S5LPN to have notified administration immediately after the first incident occurred at 7:00 p.m. She confirmed S3LPN should have been removed from duty after staff witnessed her yelling at Resident #1 on 02/27/2021 at 7:00 p.m. in order to protect residents from any further abuse. She confirmed S3LPN continued to exhibit abusive behavior towards 2 other residents (#4 and #5) after 7:00 p.m. on 02/27/2021. She confirmed S3LPN worked the full 12 hour shift from 7:00 p.m. to 7:00 a.m. on the night of 02/27/2021 and should not have. She verified staff in-services should have been conducted immediately following the incidents on 02/24/2021 and 02/27/2021 to ensure residents were free from abuse and staff were aware of the facilities policy and procedures when allegations of abuse were made. 3. Review of the Facility's policy revealed no written procedures for abuse reporting time frames. 4. Review of the facility's required annual clinical staff trainings included the following, in part; 1. Preventing, Recognizing, and Reporting Abuse Review of Staff Personnel Files revealed the following: S3LPN, hire date 08/31/2011, no training noted in 2020 for Preventing, Recognizing and Reporting Abuse. S10LPN, hire date 10/16/2017, no training noted for Preventing, Recognizing and Reporting Abuse. An interview was conducted with S1ADM on 03/25/2020 at 11:00 a.m. She verified prior to 03/24/2021, the facility's abuse policy did not include specific reporting timeframes. She reviewed the training transcripts for S3LPN and S10LPN. She confirmed S3LPN and S10LPN were missing the annual training titled Preventing, Recognizing, and Reporting Abuse.

Based on interviews and record reviews, the facility failed to ensure an alleged violation of verbal abuse was reported within 2 hours to the state agency for 4 (#1, #2, #4, #5) of 5 (#1, #2, #3, #4, #5) residents reviewed for abuse. The facility failed to complete a SIMS (Statewide Incident Management System) report timely when: 1.) S5LPN reported allegations of verbal abuse for Residents #1, #4, and #5; and 2.) S9LPN reported allegations of verbal abuse for Resident #2. Findings: Review of the facility's abuse and neglect policy and procedure revealed the following, in part: The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. Resident #1 Review of the SIMS (Statewide Incident Management System) report for Resident #1 revealed the following, in part: Entry Date: 03/01/2021 at 4:42 p.m. Report received: 03/01/2021 (no time) Incident Occurred: 02/27/2021 at 7:00 a.m. Incident Discovered:02/28/2021 at 7:00 a.m. Accused Allegations: Verbal abuse Resident #2 Review of the SIMS (Statewide Incident Management System) report for Resident #2 revealed the following, in part: Entry Date: 02/24/2021 at 5:25 p.m. Report received: 02/24/2021 at 11:00 a.m. Incident Occurred: 02/24/2021 (no time) Incident Discovered:02/24/2021 at 6:00 a.m. Accused Allegations: Verbal abuse Resident #4 Review of S4LPN's witness statement from 02/27/2021 night shift, revealed the following: S4LPN stated Resident #4 refused her medications. She stated she had plans to reattempt later that night. She stated S3LPN took Resident #4's medications and shoved them into the resident's mouth. Resident #5 Review of S7CNA's witness statement dated 02/27/2021 night shift, revealed the following: S7CNA stated S3LPN asked her to hold Resident #5's hands down while she started the tube feeding. She stated she told S3LPN she did not want to restrain the resident. S7CNA stated S3LPN was yelling at the resident, Be still. Review of S8CNA's witness statement dated 02/27/2021 night shift, revealed the following: S8CNA stated she witnessed S3LPN yelling at Resident #5 when she was trying to hook up her tube feeding. S3LPN had S7CNA hold Resident #5's hands. Review of facility's SIMS report revealed no SIMS were initiated regarding allegations of abuse towards Resident's #4 or #5 on the night shift of 02/27/2021. An interview was completed with S2DON on 03/24/2021 at 2:22 p.m. S2DON stated she was made aware of the allegation of verbal abuse towards Resident # 1 on Sunday 02/28/2021. S2DON stated she immediately contacted S1ADM and reported the allegation of verbal abuse. An interview was conducted with S1ADM on 03/24/2021 at 2:48 p.m. She stated the allegation of verbal abuse towards Resident #2 occurred during the night shift of 02/23/2021-02/24/2021 and was reported to her on 02/24/2021 at 11:00 a.m. She confirmed she initiated a SIMS report on 02/24/2021 5:25 p.m. S1ADM stated the allegation of verbal abuse towards Resident's #1, #4, and #5 occurred during the night shift of 02/27/2021-02/28/2021 and was reported to her on 02/28/2021. She verified she initiated a SIMS report, that only included Resident #1, on Monday 03/01/2021 at 4:42 p.m. She confirmed she was responsible for the facility's SIMS reporting and had 24 hours to report any allegations of abuse. S1ADM confirmed she did not know allegations of abuse were to be reported to the state agency within 2 hours.

Based on interviews and record reviews, the facility failed to ensure a resident's right to be free from verbal abuse and physical intimidation for 1 (#1) of 5 (#1, #2, #3, #4, #5) residents reviewed for abuse. Findings: Review of the Facility's Abuse, Neglect and Exploitation Policy revealed in part: Definitions: Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 12/30/2020 revealed Resident #1 had a BIMS of 12, which indicated she had moderate cognitive impairment. Review of Resident #1's Care Plan revealed, in part: Date Initiated: 12/28/2020 History of problem behaviors as manifested by resistance to care, combativeness, crying, increased confusion, trying to stand up out of wheelchair, easily angered. Interventions: Always approach resident calmly and unhurriedly. Speak in a calm voice. If appropriate, stop giving care when resident is hostile and try later. Review of the SIMS report dated 03/01/2021 revealed the following, in part: Summary of Complaint- Multiple staff members witnessed S3LPN yelling at Resident #1 after Resident #1 refused medication. Review of S7CNA's witness statement from the incident on 02/27/2021 at 7:00 p.m., revealed the following: S7CNA stated S3LPN was yelling at Resident #1 to take her medication and knock it off. She stated S3LPN said I am sick of her doing this every night. An interview was completed with S7CNA on 03/23/2021 at 6:33 p.m. S7CNA stated she witnessed S3LPN yelling at Resident #1 on the night shift of 02/27/2021. S7CNA stated she heard S3LPN tell Resident #1, you are going to take your medication and I am sick of this. S7CNA stated S3LPN was panicky and argumentative with Resident #1. S7CNA stated she told S3LPN to stop trying to give Resident #1 the medication because the resident was not a child and she could refuse medications, but S3LPN ignored the request and continued arguing with Resident #1. Review of the Social Service Note dated 03/02/2021 revealed the following: S6SW was called to evaluate Resident #1 on 03/02/2021. Resident #1 talked about S3LPN yelling at her. She stated S3LPN wanted her to take a pill that helps her eat. Resident #1 stated she did not want to take the pill because she had already taken it earlier. Resident #1 stated when she told S3LPN she had already taken the pill, S3LPN yelled at her and she yelled at S3LPN. Resident #1 scored a 12 on the BIMS assessment indicating moderate cognitive impairment. A mood assessment was started but appeared to cause anxiety for Resident #1. The resident was crying and saying she didn't want to get in trouble. Resident #1 continued to say she was so sorry she yelled at the nurse. Resident #1 stated she didn't want the nurse to get in trouble and she did not want to get in trouble. An interview was completed with S6SW on 03/23/2021 at 10:34 a.m. S6SW stated she interviewed Resident #1 after the incident on 02/27/2021. S6SW stated Resident #1 told her S3LPN wanted her to take a pill that helps her eat. Resident #1 stated she did not want to take the pill because she had already taken it earlier. Resident #1 stated when she told S3LPN she had already taken the pill, S3LPN yelled at her and she yelled back at S3LPN. S6SW reviewed the note from 03/02/2021 and confirmed Resident #1 became anxious during the interview. She stated Resident #1 began to cry and was scared she was in trouble for yelling back at S3LPN. Review of S5LPN's witness statement from the incident on 02/27/2021 at 7:00 p.m., revealed the following: S5LPN stated S3LPN stood in front of Resident #1 and would not let her leave the activity room. She stated S3LPN stated, you are going to take your medicine. She stated S3LPN and Resident #1 argued back and forth before Resident #1 took the medication and said when I get sick you're going to go to the hospital with me. An interview was conducted with S5LPN on 03/23/2021 at 10:54 a.m. S5LPN confirmed she worked the day shift on 02/27/2021 and was familiar with Resident #1. She stated Resident #1 did refuse medications often, but if you gave her time to calm down and reattempt later she would normally take it. She stated on 02/27/2021, around evening medication pass, Resident #1 was propelling her wheelchair out of the activity room. She explained S3LPN stood in front of Resident #1, blocking her way, and attempted to administer medication. She stated Resident #1 refused the medication and S3LPN started yelling at Resident #1. She stated Resident #1 yelled back at S3LPN and took the medication. Resident #1 then told S3LPN if you overdose me, you will need to go with me to the hospital. S5LPN stated she attempted to deescalate the situation by asking S3LPN to leave the resident alone, but S3LPN ignored her and continued yelling and insisting Resident #1 take her medication. S5LPN stated S3LPN went too far with Resident #1. She stated the resident gets medication at 5:00 p.m. and 8:00 p.m. She stated the resident was confused and thought she had already taken the medication. Review of S4LPN's witness statement from the incident on 02/27/2021 at 7:00 p.m., revealed the following: S4LPN stated S3LPN walked over and took the medication out of her hands and insisted Resident #1 take the medications. S4LPN stated S3LPN was yelling and bullied Resident #1. An interview was completed with S4LPN on 03/24/2021 at 2:28 p.m. S4LPN stated on the night of 02/27/2021, she attempted to administer medication to Resident #1 and the resident refused. S4LPN stated she walked away with the intention of trying to administer the medication at a later time. S4LPN stated S3LPN then took the medications from her and went to stand in front of Resident #1. S4LPN stated S3LPN and Resident #1 began to argue. S4LPN stated S3LPN intimidated Resident #1. She stated the tone S3LPN used when speaking with the resident was verbally abusive. On 03/25/2021 at 10:44 a.m., an interview was conducted with S1ADM. S1ADM stated the facility confirmed verbal abuse had occurred on 02/27/2021 when S3LPN yelled at and intimidated Resident #1. She stated the facility had based the decision on video footage from when the incident occurred, Resident #1's statement, and witness statements. She stated the video did not have sound but she could see S3LPN's body posture was physically intimidating towards Resident #1. She stated Resident #1 told her she took the medications from S3LPN to shut her up. She stated the lack of S3LPN's regard for Resident #1's right to refuse medication, her body posture in the video, physically blocking Resident #1's path to exit the activity room, and the witness statements lead her to believe S3LPN had verbally abused and physically intimidated Resident #1.

Based on record review, interviews and observations the facility failed to date and label food appropriately in the freezer and keep food stored under sanitary conditions. This deficient practice had the potential to affect all residents receiving meals prepared by the facility's kitchen as documented by the facility's Resident Census and Condition of Resident's form (CMS-672). Findings: Review the facility's food storage policy titled Food Safety Guidelines revealed in part; under Storage: Perishable foods are stored in coolers/freezers. Containers used for storage are durable, leak proof, and able to be sealed and covered. Food containers are used for food only. All items must be dated and labeled correctly. Observation on 10/31/2016 at 10:30am during the initial tour with the S8/Director of Food Services, revealed an opened partially full coke bottle in the freezer, ten (10) pancakes in a plastic bag undated and unlabeled and ten (10) biscuit dough in a plastic bag undated and unlabeled. Observation on 10/31/2016 at 10:55am during the initial tour of the kitchen storage room with S/13/Executive Chef revealed a container labeled Rice was noted to have a scooper inside of the container with the rice. Further observation revealed a scooper lying in the container of bread crumbs. In interview on 10/31/2016 at 10:30am with S8/ Food Service Director agreed the food should be dated in the freezer. S8/ Food Service Director further agreed the coke bottle should not be in the freezer. In interview on 10/31/2016 at 10:55am with S13/Executive Chef agreed the scooper should not be in the rice or bread crumbs containers. In interview on 11/2/2016 at 10:55am with S7/Dietitian indicated all food in the freezer should be labeled and dated and the coke bottle should not have been in the freezer. S7 further indicated the scoops should not be lying in the rice and bread crumbs containers. S7 further indicated most staff has had a two hour in-service with ServSafe training. S7 further indicated they know better.

Based on record review and interview the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse of a resident are reported to other officials in accordance with State law through established procedures for 1 of 1 Stage 2 sample residents (Resident #10) investigated for an allegation of abuse. This failed practice had the potential to affect any of the 22 residents residing in the facility who may report an allegation of abuse as documented on Resident Census and Conditions Form-672. Findings: Review of OTIS regulations and requirements revealed in part: all nursing homes in the state of Louisiana are required by law to submit all reported allegations of Physical, Emotional, or Sexual Abuse, Caregiver Neglect, &/or Misappropriation of Resident Property in the OTIS system. Further review revealed a preliminary report will be entered into the OTIS system within 24 hours of the incident having been reported. Review of the facility 's abuse and neglect procedure for reporting response component revealed in part, under #9: The administrator or the director of nursing shall conduct an investigation, as appropriate to the incident; the incident will be reported to the Online Incident Tracking System (OTIS) as per the OTIS user guide. The OTIS document will be updated throughout the investigation. Upon completion of the investigation, the administrator or the director of nursing shall determine if the abuse is substantiated, unsubstantiated, or unable to verify. This will then be entered into OTIS and the report will be completed. Review of the Grievance/Complaint report dated 10/26/2016 revealed Resident#10 called the administrator to room stating a man pulled her by the arms and a woman by the legs to transfer her prior to breakfast. In interview on 11/1/2016 at 09:38am Resident #10 indicated that two people grabbed her by the arms when trying to sit her down recently. Resident #10 pointed to her left arm and stated it still hurt. Resident #10 indicated she told the person in charge but was unable to indicate the name of the person. Resident #10 was unable to name the persons involved. Resident #10 was unable to give any further details except that it happened recently. In interview on 11/1/2016 at 10:45am with S2/Administrator indicated she was aware of the incident and an OTIS report was not done. In interview on 11/2/2016 at 12:25pm with S2/Administrator indicated no OTIS report was filed in response to Resident #10 's abuse allegation.

Based on interviews and record reviews the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 (Resident #3) of 5 (Residents #1, #2, #3, #4, #5) residents who were reviewed for accident hazards. The facility failed to ensure a search was conducted promptly, when a resident was missing for 14 hours. The failed practice resulted in an actual harm for Resident #3 when she exited the facility through a door at 5:50 p.m. on 01/09/16 and was not found until 07:57 a.m. on 01/10/16 (14 hours later). Resident #3 was found lying on the ground outside the facility with lacerations, hematoma, abrasions and hypothermic. The resident was transferred to the hospital and placed in the Intensive Care Unit. Findings: Review of the clinical record for Resident #3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3 ' s most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 12/10/15, revealed the following: Section C (Cognitive Patterns) - BIMS (Brief Interview for Mental Status) Score of 4 indicating Resident #3 was severely cognitively impaired. Section E (Behavior-Wandering) - Behavior not exhibited. Section G (Functional Status) - the resident required extensive assistance with bed mobility, transfer, locomotion on unit, dressing, toilet use, personal hygiene, and walk in corridor. She required limited assistance for eating. The resident was not steady when moving on and off the toilet and surface to surface transfer. Her mobility device was coded as a wheelchair. A review of the facility ' s investigation documentation for Resident #3, dated 01/11/16, revealed the following in part: Incident Report, dated 01/10/16, by S5LPN: Type of Injury: Laceration, Hematoma, Abrasion .Head Involvement-Yes. Objective Description of Incident: resident was found outside medical records door in the grass & mud with w/c (wheelchair) turned over next to her. She was lying on her R side & had no socks or shoes on. Place of Incident: Outside Was person involved taken to hospital? Yes. By Whom: EMT. On 1/10/16 at 8:50 a.m. Was first aid administered? Yes. Where & by whom: Room & warmed up. 1/10/16 at 8:10 a.m. Typed Notes, dated 01/10/16, by S2DON: 08:15-Received a call from S5LPN informing me that Resident #3 was found outside this morning lying on the ground with her wheelchair turned over beside her and the timeframe for which she went outside was unknown. I asked if she was ok and was told by S5LPN yes, but she is cold and was covered in mud and the staff are cleaning her up now and trying to warm her up . I questioned if her husband had been advised and S5LPN stated that he was present and had just walked up when she was being brought inside. I informed S5LPN that I was on my way. 0835-I placed a call to S1ADM and informed him that I was in route to the facility because Resident #3 was found outside and that the timeframe of just how long she had been outside was unknown. S1ADM informed me that he was also coming in to assist. 0845-I arrived at the facility to the skilled unit and immediately was met by S5LPN. She informed me that Resident #3 was in her room and that she was very cold. I immediately went to Resident #3 ' s room to assess her. Resident #3 was lying in her bed with multiple blankets covering her body and was yelling out frequently. She was very cold to the touch with multiple bruises noted to extremities and to right forehead area. I instructed S5LPN to call 911 right away because she was not stable and needed to be transported to the ER (emergency room ) immediately via ambulance. 0855-Spoke with Resident #3 ' s husband at this time about the need to transport Resident #3 to the hospital right away by ambulance. Resident #3 ' s husband was in complete agreement. Security advised that ambulance was in route to facility. 0900-(Ambulance Company) arrived to the unit at this time. Resident #3 was secured to the transport stretcher and left the facility. 0910-S5LPN questioned at this time on events that occurred. 0925-I notified the IT (Information Technology) department at this time with a request to check the video footage from the hall camera near the exit where Resident #3 was found from the hours of 5:30 p.m. to 8:00 a.m. on 1/09/2016 thru 1/10/2016 for a resident in a wheelchair leaving out the door. 0950 (Name of Information Technologist) returned call at this time with the following information: On the evening of 1/9/2016 at approximately 10 minutes to 6 pm a female resident in a wheelchair entered the hallway unattended and proceeds to the exit door, after a couple of minutes the resident exited the door and no sign of resident was seen again until daylight the next morning at which time the wheel chair could be seen lying next to the resident on the ground, the resident remains in this position until approximately 7:57 am when several nursing staff members are seen running outside to assist the resident . Handwritten Notes: Review of a handwritten note completed by S5LPN in the investigation documentation revealed the following: On Saturday 01/09/16, I saw Resident #3 in the dining room for dinner with her husband. After dinner, her husband walked her out of the dining room at about 5:45 p.m. I then started giving report to oncoming nurse. When I left the shift that night I didn ' t see the resident & we thought she might have gone off with her husband to the apartment. On Sunday, 1/10/16, I was giving a resident medicine, & her sitter then came & told me that someone was outside & on the ground. I went out to assess the resident who was lying on her right side with her w/c turned over next to her. Resident ' s socks & shoes were off & in different areas. We then turned her over on to her back & she started screaming & was very cold. We picked her up & brought her inside to warm up. When being brought inside, her husband showed up. DON (Director of Nursing) notified, EMT ' s (Emergency Medical Technicians) notified, M.D. (Medical Doctor) notified, ER (emergency room ) given report, & resident left building at approximately 9:30 a.m. Review of a handwritten note completed by S11LPN, dated 01/10/16, at 6:08 p.m., revealed the following: On 01/09/16 at 5:50 I was receiving report from S5LPN & the Security Personnel stopped by and stated The Resident in RM (Resident #3 ' s room) was not in her room . S5LPN stated to the security guard at that time that Resident #3 was with her husband in the apartment. I had not assumed care of Resident #3 at this time at 10:15 p.m. I received report form S6LPN and was told in report that Resident #3 was in the apartment with her husband . Review of a handwritten note completed on 01/11/16 by S6LPN revealed the following: Received report from off going nurse at 2 p.m. on 01/09/16, all residents were accounted for at this time. I took Resident #3 ' s B/P at approximately 5:15 pm while she was in the activity room. I gave her her night meds at approximately 5:40 p.m. in the dining room where Resident #3 was eating supper with husband. I gave report to on coming nurse at 10 p.m. Review of a handwritten note completed on 01/11/16 by S12CNA revealed the following: On 01/09/16 I assisted rooms 30-37 with care up until after dinner. Everybody in my section was accounted for up until after dinner I noticed Resident #3 wasn ' t in her room or the activity room so I reported it to the nurse on duty (S5LPN) and she informed me that she was with Resident #3 ' s husband at their apartment. When the next shift came on I gave report and told the next shift that she still had not returned back to the skilled unit. Review of a handwritten note completed on 01/10/16 by S13CNA revealed the following: At around 7:00 p.m. on 1/9/16 I received report from S8CNA and S12CNA on the back hall. Regarding Resident #3, I was told that she was with her husband in their apartment, and that she wasn ' t back on SKU. I also asked the S5LPN about it. First she confirmed that Resident#3 was with her husband. I spoke to her a 2nd time before she left the facility if we should be concerned that Resident #3 wasn ' t back yet. S5LPN had said that it should be OK since she was with her husband. I was up and down the hall frequently throughout the night. I would have noticed if Resident #3 had come back. A review of the Ambulance Service Report, dated 01/10/16, and completed by Emergency Technician, revealed the following: Narrative History Text: Per nursing staff Pt. had been found outside at Approx. (approximately) 7:40 AM this morning and that they did not know how long she had been outside Pt. must have gotten into her wheelchair and went out the side door-we don ' t know Staff could not answer when Pt. was last seen acting normal. Pt. in bed on ambulance arrival covered in blankets. Pt. extremely cold to touch, extremities cyanotic looking. Multiple bruising in various stages of healing noted to Pt. ' s extremities. Light abrasion noted to Pt. ' s knees and forehead. Pt. was not shivering at this point indicating low core body temperature. Pt. nose appeared either cyanotic from cold or bruised, bruising noted to forehead from center to right temporal area. Pt. placed on monitor covered with warm blankets and transported in warm unit without further incident. Pt. care turned over to staff. A review of the acute care hospital Emergency Department notes, dated 01/10/16, revealed the following: admitted : 1/10/2016 Notes by ER Physician: Chief Complaint-Patient presents with Cold Exposure. Pt. Brought in per Ambulance Service from nursing facility, patient was found outside on the ground, not sure how long she was outside, was found about 07:30 this am. Patient noted to have multiple bruising to body. HPI (History of Present Illness) comments: [AGE] year-old female presented to the emergency department with complaints of altered mental status and hypothermia. Per EMS (Emergency Medical System) she was found outside of her nursing home this morning. They ' re unsure how long she was out there. They brought her inside and apparently tried to warm her up there. When they saw no improvement EMS was called at that time to bring her to the hospital. They noted that she normally talks, but is not talking. She is just moaning or screaming out. She was found to have multiple bruises on her body. They state that she is generally wheelchair-bound, and they ' re unsure of how she got outside. Initial Vitals: 01/10/16 0945-B/P (Blood Pressure) 89/68 mmHG (millimeters of Mercury), Pulse: 46, Resp (Respirations): 14, Temp: 80.6 Degrees F (Fahrenheit) (27 Degrees Celsius). Physical Exam: She appears distressed (yelling out/moaning, not responding to commands or speaking, but does react by moaning when you walk up to her, she looks at you and tracks). HENT (Head, Ear, Nose, and Throat): Head: .and is yelling out. Abrasions to mouth, .bruise to right side of temple/scalp. Skin: Multiple bruises and abrasions to extremities. Clinical Impression: A central line was placed in the ED on 01/10/2016 at 3:28 p.m. per ER Physician. The primary encounter [DIAGNOSES REDACTED]. Left Lower Lobe Pneumonia, Hypotension. On 01/13/16 at 2:25 p.m. an interview was conducted with S9CNA. She stated she worked the 7A-7P shift at the facility on 01/09/16. She stated the last time she saw Resident #3 was during dinner and in the activities room between 5:00 p.m. and 6:00 p.m. S9CNA further stated she heard S12CNA asking S5LPN where Resident #3 was and S5LPN responded by stating Resident #3 was with her husband going to take a nap in his apartment. On 01/13/16 at 2:10 p.m. an interview was conducted with S8CNA. She stated she worked at the facility on 01/09/16 from 7a.m.-7 p.m. She stated she was helping to care for Resident #3 on 01/09/16. She stated the last time she saw Resident #3 was with her husband eating dinner in the dining room at dinner at 5:30 p.m. She further stated she saw Resident #3 ' s husband push her to the activity room in her wheelchair after dinner. She stated she went to Resident #3 ' s room around 6 p.m. and she wasn ' t there. S8CNA stated she asked S5LPN where Resident #3 was and S5LPN told her Resident #3 was with her husband. S8CNA further stated around 6:30 p.m.-6:45 p.m. she asked S5LPN again where Resident #3 was and S5LPN told her that Resident #3 was with her husband. She stated it was not normal for Resident #3 to be gone off the unit with her husband. S8CNA stated she asked S5LPN twice where Resident #3 was because it was not normal for Resident #3 to be off of the unit with her husband. On 01/13/16 at 2:45 p.m. a telephone interview was conducted with S5LPN. She stated she had worked at the facility for 2 ½ years and was familiar with Resident #3. She stated she worked at the facility on 01/09/16 from 6 a.m.-6 p.m. She was asked to explain the events that occurred during her shift on 01/09/16 regarding Resident #3. She stated the last time she saw Resident #3 on her shift 01/09/16 was around 5:45 p.m. when her husband was pushing her in wheelchair to the activity room. She stated S8CNA asked her where Resident #3 was twice between 6:00 p.m. and 6:45 p.m. and she told her that Resident #3 was with her husband. She stated when she returned to work at 5:45 a.m. on 01/10/6, she thought it was odd that Resident #3 was still not in the facility because she never stayed at her husband ' s apartment overnight. S5LPN further stated no staff member attempted to call the husband and no staff member checked in or outside the facility for Resident #3. On 01/14/16 at 11:35 a.m. a telephone interview was conducted with S6LPN. She stated she had worked at the facility through a agency for 4-5 months. She stated her first shift as a full time employee for the facility was the 2 p.m.-10 p.m. shift on 01/09/16. She was asked to explain the events that occurred on 01/09/16. S6LPN stated she was assigned to Resident #3 that day. She stated Resident #3 was eating in the dining room in her wheelchair with her husband around 5:30 p.m. She stated she administered Resident #3 her medications at that time. She stated that was the last time she saw Resident #3 for her shift. She further stated S5LPN told her Resident #3 was with her husband in his apartment. She stated she did not see Resident #3 for the rest of her shift. She stated around 7:00 p.m. S13CNA asked her where Resident #3 was. She stated she told S13CNA that Resident #3 was with her husband in his apartment, because that was reported to her by the previous nurse caring for her. She was asked if she attempted to contact the husband to ensure the resident was with him and she stated, No . On 01/13/16 at 3:20 p.m. an interview was conducted with S11LPN. She stated she worked for a agency and worked the 6:00 p.m. to 6:00 a.m. shift on 01/09/16. She stated she received report on Resident #3 at 10:00 p.m. from S6LPN. She was told Resident #3 was with her husband in his apartment. She stated from 10:00 p.m. to 6:00 a.m. she was the only nurse in the facility. She stated she did not see Resident #3 from 10:00 p.m. to 6:00 a.m. during her shift. She further stated she never attempted to call Resident #3 ' s husband to find out if she was with him. On 01/14/16 at 10:20 a.m. an interview was conducted with Resident #3 ' s husband. He stated he lived on the independent living side of the facility. He was asked to recall the events on 01/09/16 and 01/10/16 regarding Resident #3. He stated he ate dinner with his wife and then took her to the activity room a little before 6:00 p.m. and he left her there with 2 CNA ' s present. Resident #3 ' s husband further stated he always notified staff when he took Resident #3 out of the facility and he always brought her back before dark. He stated he never took her outside of the facility for more than 30 minutes at a time. He stated Resident #3 had never stayed overnight with him in his apartment since she was admitted to the skilled nursing unit. He stated no one attempted to call him between 6:00 p.m. on 01/09/16 and the time he saw her around 8:00 a.m. on 01/10/16. On 01/13/16 at 10:45 a.m. an interview was conducted with S2DON. She was asked about the incident which occurred with Resident #3 on 01/10/16. She stated she received a phone call around 8:00 a.m. from S5LPN informing her Resident #3 was found outside lying on the ground with her wheelchair turned over beside her. She stated at that time no one knew how long Resident #3 had been outside. She stated Resident #3 was found with multiple bruises on her body and was hypothermic. She stated Resident #3 was immediately sent to the emergency room . She was asked if staff attempted to find Resident #3 between 6:00 p.m. on 01/09/16 and 8:00 a.m. on 01/10/16. She stated No . She stated the nurses should have called Resident #3 ' s husband to see if she was with him. She further stated the nurses should have checked the facility to try to locate Resident #3 as soon as they discovered she was not on the skilled unit.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents when the facility failed to ensure 2 of 2 Staffing Agency's (agency a, agency b) used by the facility, were trained through orientation and on-going sessions on issues related to abuse prohibition practices. This had the potential to affect all 21 residents residing in the facility. Findings: Review of the contract between Staffing Agency a and the facility with an effective date of 06/07/09 revealed the following in part: (name of staffing agency) a shall assign qualified Registered Nurses (Staff), Licensed Practical Nurses (Staff) and Certified Nursing Assistants (Staff) to Client to provide clinical and professional services on a temporary basis through contract on per diem assignments. Therefore, in consideration of the mutual considerations and agreements set forth in the Agreement, and for good and valuable consideration, the adequacy and receipt of which are acknowledged, Client and (name of staffing agency) a agree as follows: Terms of Agreement: This agreement commences on the effective date and automatically renews annually, unless terminated earlier as provided in this agreement. Section 3. B.: Client agrees to coordinate and provide orientation to its policies, procedures and all applicable safety guidelines to (name of staffing agency) a assigned. The first eight (8) hours of Client orientation are non billable. Review of the contract between Staffing Agency b and the facility with an effective date of 05/18/06 revealed the following in part: 3. Assignments, Training and Policies and Procedures: f. Health Care Center (facility) shall provide written information to Agency for the purpose of orienting Staff by Agency and shall address relevant Health Care Center policies and methods of delivering care. When Staff first commences work at Health Care Center, Health Care Center shall provide Staff with information about the location of emergency exits, how to call an emergency, the locations of the emergency charts and other information that Health Care Center requires Staff to know. On 01/13/16 at 1:15 p.m., an interview was conducted with S11LPN at the nurses station. She stated she worked for Staffing Agency a and worked in the facility as needed over the last year. She was asked what type of training had she received from the facility and she stated, None. She was asked if she received any recent in-service training from the facility and she stated, No. She stated the facility had never given her any type of orientation or training and she did not know what the facility policies were in a crisis. She stated she could not remember if she had ever received any training for abuse by the staffing agency. She stated a lot of times agency staff worked by themselves in the facility and they don't know what the facility policies are. She stated, I just do what I would do when working at another nursing home. On 01/13/16 at 3:20 p.m., an interview was conducted with S11LPN. She stated she worked for Staffing Agency a and worked throughout the last year, mostly in the assisted living area. She was asked to explain the training and orientation she had received prior to working with residents in this facility. She stated she had never received orientation or training on the skilled nursing unit and did not know what their policies were. She stated following an incident that occurred during her shift on 01/09/16, when a resident was missing and not assessed the entire night shift, was the first time anyone had ever in-serviced her on anything at the facility. She stated she did not recall ever having abuse training. On 01/14/16 at 11:35 a.m., an interview was conducted over the phone with S6LPN. She stated she was recently employed by the facility and her first shift was on 01/09/16 evening shift. She stated prior to that she had worked for Staffing Agency a for several months on the skilled nursing unit in the facility. She stated while working as an agency nurse she had not received orientation, training, in-services, review of policies, or dementia and abuse training by the facility. She stated she did not think the agency had provided any abuse training. On 01/14/16 at 12:15 p.m., an interview was conducted with S3MDS. She stated she was an LPN and did a lot of the staff training. She was asked if she had ever trained agency staff and she stated, No. She stated she did not have any documentation of agency staff ever receiving any type of training by the facility. On 01/14/16 at 3:30 p.m., an interview was conducted with S4LPN. She stated she was working on the skilled nurse unit to assist S2DON. She stated she was new to the unit, so she had not trained any agency staff. She was asked what type of training Staffing Agency a and b provided to the nurses the facility used to staff the unit. She stated she would call and speak with the representatives at the nurse staffing agencies the facility had a contract with. She verified they used staffing from both agencies on a regular basis. On 01/14/16 at 4:10 p.m., an interview was conducted with S2DON. She was asked what type of training did the facility provide to agency staff prior to working with residents on the skilled nurse unit. She stated they did not train agency staff, if the staff happened to be on the unit while an in-service was being conducted they would attend at that time. She stated the facility did not check with the agency to see what type of training the agency staff had received prior to working with them. She was asked specifically about abuse training and she stated she would not know if any of the agency staff would have received abuse training. She stated they trusted the staffing agency was doing that. She verified both staffing agencies covered shifts on the skilled nurses unit frequently and sometimes the only nurse present was agency staff. On 01/14/16 at 4:30 p.m., an interview was conducted with S4LPN. She stated when she spoke with a representative from Staffing Agency b, she was told the agency did not provide any type of training to their employees. She stated when she spoke to a representative at Staff Agency a, they did provide skills training but the agency was not able to provide documentation that abuse training had been done. On 01/14/16 at 4:45 p.m., S1ADM was made aware that agency staff had not received abuse training by the agency or the facility prior to working with residents on the skilled nurse unit. He stated he was made aware of that today and would make sure that was corrected immediately.

Based on record reviews, observations and interviews the facility failed to review and revise the comprehensive plan of care for 1(#16) of 4 (#16, #15, #38 and #39) sampled residents who were assessed to have a high risk for falls. This failed practice resulted in an actual harm for Resident #16 when the resident experienced 8 documented falls with injury out of a total of 23 falls since 03/12/15. Resident #16 was admitted to hospital on [DATE] with preoperative [DIAGNOSES REDACTED]. On 08/09/15 the resident had a Left-sided mini front temporal parietal craniotomy for evacuation of acute Subdural Hematoma. Findings: A review of the clinical record revealed Resident #16 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 07/21/15, revealed the following: Section C (Cognitive Patterns) - the resident had a BIMS (Brief Interview for Mental Status) Score of 15 - which indicated that he was cognitively intact. Section G (Functional Status) - the resident required limited assistance with one person physical assist with bed mobility, and transfer. He required extensive assistance with one person physical assist with locomotion on and off the unit, dressing, toileting and personal hygiene. He required physical help in part of bathing activity with two person physical assist. He required supervision with oversight, encouragement or cueing and set up help only with eating. He required staff assistance to stabilize with balance in walking, turning around while walking, moving on and off toilet and surface-to-surface transfer. His mobility devices consisted of a walker and wheelchair. Section O (Special Treatments, Procedures, and Programs) - he received oxygen therapy, Speech, Occupational and Physical Therapy. A review of the Fall Risk Assessment, dated 1/29/15, 2/6/15, 3/12/15, 4/25/15, 5/7/15 and 7/21/15, revealed a total score from 18-20 which indicated the resident was a High Risk for fall. Review of the Interdisciplinary Care Plan dated 04/25/15 revealed the following documentation: Problem/Need Statement- Potential for falls due to History of Falls multiple falls, Debility, Dementia Goal: The Resident will have no falls with injury with a target date of 07/25/15. -Ongoing monitoring for falls; with implementation of appropriate intervention as needed. -Resident will have no falls with injury with a target date of 07/25/15. Approaches: -PT/OT evaluation as needed. -PT/OT treatment 5 X per week if picked up by therapy. -Assist resident with transfers with extensive assistance using a wheelchair. -Assist resident with ambulating with caregiver providing extensive assistance using a roll walker. -Provide verbal cues for proper pacing and energy conservation techniques. -Place call light within reach at all times. -Remind resident to use call light when attempting to ambulate or transfer. -Maintain a clutter-free environment in the resident's room. Non slip footwear when OOB. -When resident is in bed, place all necessary personal items within reach. -Monitor for toileting needs Q 2 hours and PRN. -Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize. -Fall risk assessment per protocol. Implement the following safety precautions: blank. -On 03/12/15 - increase monitor for toilet needs Q (every) 1 to 2 hours and PRN. Offer to place a urinal at bedside. Place visual cues in room to remind resident to call and wait for assistance . -On 05/17/15 - encourage resident to ride at a slower speed setting on scooter. Remind staff to place resident in center of bed and encourage resident to use pillow for comfort alongside as edge of bed to prevent resident from rolling out. -On 06/08/15 - staff to check temperature in room on each round and offer to assist with adjustments to prevent resident from getting up and attempting to change it. Continue to remind resident to call and wait for assistance. Continue to monitor toileting Q 1 to 2 hours and offer assist PRN. Continue to encourage to call and wait for assistance. Place fall mat at bedside. Continue all above interventions. Continue all above interventions, encourage use of urinal, bed in low position, wheels locked, call light in place, monitor every 1 to 2 hours and PRN, call light in place, visual cues to remind resident to call for assistance. Continue care plan above, bring resident to bathroom after lunch daily. Check resident on morning rounds and offer assistance with getting up. Continue care plan as above. Continue with care plan as above with offer assistance on all rounds with clothing, air conditioner, urinal, bedding . etc. Continue care plan, continue increase supervision with increase to 30 minutes to 1 hour and PRN. Continue all care plan intervention. Fall on 06/01/15- Offer toileting resident to bathroom prior to bedtime on rounds. Fall on 06/03/15- Offer to bring resident to bathroom on rounds between 0100 & 0200 p.m. daily Fall on 06/05/15- Continue to monitor Q (every) 1 to 2 hours and PRN. Fall on 06/05/15- Offer to assist resident on morning rounds with dressing, getting out of bed prior to breakfast. Place pillows alongside of bed to provide comfort and prevent from rolling out of bed. Fall on 06/07/15- Remind resident to move to center of bed to prevent falling out, and to call and wait for assistance. Care plan documentation revealed on: 06/15/15 for fall on 06/14/15 - Continue all care plan interventions and add increase supervision from Q (every) 1 to 2 hours and PRN to Q 30 minutes to 1 hour and PRN. 06/29/15 for fall on 06/28/15 - Talk to family on scooter safety, also talk with resident on the need to let staff know when he is going outside on scooter so that staff can increase supervision while outdoors. Encourage resident to comply with safety concerns of staff for his well- being. Staff to remain with resident when he wants to go . 06/30/15 for fall on 06/30/15 - Offer to bring resident to bathroom before lunch on rounds. Encourage resident to bathroom before lunch on rounds. Encourage resident to come to activity room or nurses station for closer supervision. 07/06/15 for fall on 07/03/15 - Encourage resident and family to always notify and use staff when assistance is needed for transfer. 07/06/15 for fall on 07/04/15 - Fall mat at bedside, half-side rail in use, check resident placement in bed on rounds and move to center of bed if needed. Encourage use of body pillow to assist in prevent resident from rolling out of bed. 07/06/15 for fall on 07/01/15 - Continue care plan interventions, continue to offer to bring resident to bathroom Q 1 to 2 hours, keep urinal at bedside, continue to encourage resident to call and wait for assist. 07/10/15 for fall on 07/09/15 - Continue care plan, interventions, continue increased supervision to 30 minutes intervals. Continue to reorient to call light system and need to call and wait for assist with all transfers, visual cues in room to remind resident to call for assist. 07/31/15 for fall on 07/30/15 - Continue to increase supervision. Continue to offer assist with bathroom Q 1 hour and PRN. 08/08/15 for fall on 08/07/15 - Continue all care plan interventions. Continue to encourage to call and wait for assistance. Continue to increase supervision. 08/08/15 for fall on 08/08/15 - Use lift on resident or 2 person assist for all transfers. A review of the plan of care dated 04/25/15 and the updated plan of care dated 07/21/15 revealed no new interventions in place and updated after a fall on 05/23/15 and 07/30/15. A review of the care plan indicated that the resident would be supervised every 1 - 2 hours starting on 03/12/15. Further review revealed on 06/15/15- indicated there was an increased supervision from Q 1 to 2 hours and PRN to Q 30 minutes to 1 hour and every 30 minutes. On 08/26/2015 at 12:08 p.m., an observation of Resident #16 with S4MDS,RN revealed no floor mat in the resident's room by his bed. S4MDS, RN said there was supposed to be a floor mat by his bed. On 08/26/2015 at 12:27 p.m., an interview was conducted with the resident's daughter- in- law. She said she visited the resident frequently, and the other family members visited the resident daily. She said she never saw a floor mat on the floor by the resident since resident had frequent falls. She said today was the first time she saw a mat placed on the floor. She said she just quit her job and now she had more time to come and sit with her father in-law. On 08/26/2015 at 12:36 p.m., an interview was conducted with Resident #16. When asked if he had a floor mat by his bed, he said no. He said he never had a floor mat by his bed. On 08/26/2015 at 2:00 p.m., an interview was conducted with the resident's daughter-in-law. She said after the surgery on 08/09/15, her father in-law had a decline in activities of daily living with two person assist. She said her father in-law was using adult briefs since he was not able to go to the bathroom on his own. She also said her father in-law had a decline in appetite after the surgery. On 08/26/2015 at 4:26 p.m. an interview was conducted with S11CNA. She said the resident needed total assistance with all ADLs (activities of daily living). S11CNA said she assisted with the resident with his ADLs. She said she checked on the Resident #16 every 2 hours. S11CNA said before the surgery on 08/09/15, she did not offer the resident the bedside commode or urinal because he was still ambulatory and able to get out of his bed with assistance and use the bathroom on his own. She said the resident wears an adult brief now after the surgery. She said she had never seen a floor mat on the resident's floor. She said before the surgery she was not instructed to check the resident every 30 minutes. On 08/26/2015 at 4:49 p.m., an interview was conducted with S14CNA. She said she assisted the resident with all ADLs, with one person assist. She said she checked the resident every 2 hours and when he used the call light. She said the resident tried to get up without assistance or using the call. S14CNA said she was told to keep an eye on the resident. She said after the surgery the resident had briefs on with 2 person assist with all ADLs. S14CNA said now the resident had to be fed. She said resident's appetite was fair. She said she went in the resident's room to assist another staff to turn the resident. S14CNA said she said she could not recall when the last time she saw a floor mat by the resident's bed. On 08/26/2015 at 5:15 p.m., an interview was conducted with S10LPN. She said the resident had frequent falls. She said to increase supervision, she had to remind the resident to use the call light to ask for help. On 08/26/2015 at 5:26 p.m., an interview was conducted with S7LPN. He said the nursing staff would monitor the resident throughout the day. S7LPN said he had never seen a floor mat by the resident's bed. He said the resident had frequent falls. S7LPN said to increase supervision, he constantly orientated the resident to use the call light and to ask for help for any of his needs. S7LPN said to increase supervision of the resident the family was encouraged to get a private sitter. S7LPN said when Resident #16 was first admitted he was independent and tried to get around on his own. He said the resident refused to use the call light to ask for help when he needed to use the bathroom. On 08/27/2015 at 8:34 a.m., an interview was conducted with S2 DON. She said she did not have a fall protocol. She said the staff communicated with notes and incidents reports about the resident if the resident had frequent falls. On 08/27/2015 at 8:50 a.m., an interview was conducted with S16CNA. She said Resident #16 was 1 person assist and was using his walker or wheelchair to move around. S16CNA said the resident fell mostly during the evening and night shifts. S16CNA said the CNA from the previous shift would provide shift report to her about the care for each resident in the rooms she would have for the day. She said she was told to check on the resident every 45 minutes to an hour. S16CNA said Resident #16 would use the call lights and screamed for help. She said the resident would get up and would not wait for staff to come to help him. She said on 2 occasions she saw the resident would already be on the floor when she came to his room. On 08/27/2015 at 9:33 a.m., an interview was conducted with Resident #16's family member. She said she was sitting with the resident overnight. She said in the past the resident knew to use the call light by his bed or chair to call for help or screamed for help when he needed to go to the bathroom. She said the resident could not wait for the staff to come and so he got out of bed or wheelchair and went to the bathroom on his own. She said the resident had to use the bathroom quickly. On 08/27/2015 at 9:38 a.m., an interview was conducted with S6LPN. She said the staff communicated via daily reports and she also oversaw the CNA working on the hall to be sure they were taking care of Resident #16, and answering the call lights. She said the resident would use the call light sometimes when he asked for help and other times he did not. She said the resident was 1 person assist with ADLs before the surgery, and now the resident was a two person assist with total assistance. She said the resident got up and walk by himself a lot of times and had to be reminded constantly to use the call light. She said to increase supervision the staff was reminded to check on the resident every hour. She said there was an order from the physician to ask the family to get sitter. On 08/27/2015 at 9:49 a.m., an interview was conducted with S4MDS, RN. She said she was responsible for the care plan for Resident #16 and she updated the resident's MDS. She said after the nurses completed the incident and accident reports which included the falls, S2DON would review the care plan after every fall and made recommendations to prevent further falls. She said the staff was told to check on the resident every 30 minutes to 1 hour during the night and offered bathroom assistance during the 07/15/15 in-service. S4MDS, RN said the CNAs were asked to check the resident as often as a possible. She said to increase supervision the family was asked to provide a sitter. She said the staff and CNA communicated with any new staff who would be assigned to that resident. She said S2DON updated all falls and made appropriate changes to the care plan after every fall. On 08/27/2015 at 12:15 p.m., an interview was conducted with S2DON. She said she did not have a CNA supervisor. She said she was responsible for making sure the resident's plan of care and new interventions were implemented to prevent falls. On 08/27/2015 at 1:40 p.m., an interview was conducted with S3MDS, LPN. She said she did not have any documentation of the CNAs checking on Resident #16 every 30 minutes to an hour after the in-service was conducted on 07/15/15. She verified that there was no documentation that nursing staff checked on the resident every 2 hours after each fall unless the resident had neuro-checks initiated. On 08/27/2015 at 2:17 p.m., an interview was conducted with S2DON. She said to increase supervision she had an in-service with the CNAs and nursing staff to check on Resident #16 every 30 minutes to an hour on 07/15/15. S2DON said she had requested the family to provide a sitter. She said S4MDS, RN completed the care plan and when there was a fall she would implement a new care plan for the resident. S2DON acknowledged that she failed to review, revise and evaluate the effectiveness of the care plan to prevent further falls and accident hazards for Resident #16.

Based on observation, interviews and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 (#16) of 4 residents (#16, #38, #39, #15) who were reviewed for accident hazards/falls. This failed practice resulted in an actual harm for Resident #16 when the resident had experienced 8 documented falls with injury out of a total of 23 falls since 03/12/15 and there was no increase supervision for the resident. On 08/09/15 the resident was admitted to hospital with preoperative [DIAGNOSES REDACTED]. On 08/09/15 had a Left-sided mini front temporal parietal craniotomy for evacuation of acute Subdural Hematoma. Findings: Review of the facility Quality Assurance Fall Prevention Program revealed the following documentation: Purpose: To prevent and reduce the incidence of falls and injury. Guidelines: 1. A Fall Risk Assessment is performed by the charge nurse on each admission within 24 hours. 2. Fall Risk Assessment are performed quarterly on all residents 3. The room of all new admissions is inspected by the Director of Nursing to ensure that there no environmental hazards. All resident rooms are checked weekly. 4. Staff members are informed daily of those residents at risks for falls. 6. Care plans are completed and updated by nursing on a quarterly basis and more frequently as need dictates. 10. D.O.N. completes the IDT post-fall assessment form and makes recommendations to prevent further falls. 11. Following every fall nursing completes an Incident Report and nurses note entry for that fall. Alert charting is initiated and continued for 72 hours. Neuro-checks performed in the event of head injury per protocol. A review of the clinical record revealed Resident #16 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 07/21/15, revealed the following: Section C (Cognitive Patterns) - the resident had a BIMS (Brief Interview for Mental Status) Score of 15 - which indicated that he was cognitively intact. Section G (Functional Status) - the resident required limited assistance with one person physical assist with bed mobility, and transfer. He required extensive assistance with one person physical assist with locomotion on and off the unit, dressing, toileting and personal hygiene. He required physical help in part of bathing activity with two person physical assist. He required supervision with oversight, encouragement or cueing and set up help only with eating. He required staff assistance to stabilize with balance in walking, turning around while walking, moving on and off toilet and surface-to-surface transfer. His mobility devices consisted of a walker and wheelchair. Section O (Special Treatments, Procedures, and Programs) - he received oxygen therapy, Speech, Occupational and Physical Therapy. A review of the Fall Risk assessment dated [DATE], 2/6/15 3/12/15, 4/25/15, 5/7/15 and 7/21/15 revealed a total score from 18-20 which indicated the resident was a High Risk. Review of the Resident Incident Report 03/12/15 revealed the following: Date/Time: 03/12/15 at 4:30 a.m.; Incident Type: Fall with head injury; Type of Injury: Skin tear, Abrasion, Laceration - superficial; Location: Resident room; Activity at time: From bed w/o assistance. Narrative of incident and description of injuries: - Call to room by CNA. Resident found on the floor next to bed . left temple, nickel sized size wound. Left elbow 3X3 wound. Left back hand dime sized wound. Soreness to right shoulder/arm. Physician Notified: Yes; Taken to hospital for evaluation. No documentation of 72 hours neuro-checks initiated after a fall with head injury. Review of the Incident Fall Investigation Form: Resident's Mental State: Dementia was documented. Review of the Fall Scene Investigation Report dated 03/12/15 revealed the following documentation: Resident lost their balance; Found on the floor (unwitnessed) in resident room; Attempting self-transfer; Alone and unattended. What appears to be the initial root cause (s) of the fall? Non compliance with safety protocol. Did not use call light for assistance. Describe initial interventions to prevent future falls: Safety protocol. Review of the Incident Fall Investigation Form dated revealed the following documentation: Dated of injury: 03/12/15; Type of injury: Skin tear, Abrasion, Laceration Was resident responding to bowel or bladder emergency? - yes; Resident attempt to get up unassisted and fell to the floor. Resident hit the call light staff went into room resident was on the floor . attempted to transfer from bed to wheelchair without assistance. Did not use call light. Nurse account of occurrence: Resident attempt to get up unassisted and fell to the floor. Recommendations: Increase monitoring to Q (every) 1 to 2 hours and PRN. Offer to place urinal at bedside. Review of IDT Post Fall assessment dated [DATE] revealed the following documentation: Physical limitations: Weak with unsteady gait Care Plan Decision: Increase monitoring to Q (every) 1 to 2 hours and PRN. Offer to place urinal at bedside. Review of Resident Incident Report dated 05/07/15 revealed the following documentation: Date/Time: 05/07/15 at 12:16 a.m.; Incident Type: Fall w/no head injury; Type of injury: None apparent; Location: Resident room; Activity at time: From bed w/assist Narrative of incident and description of injuries: - found on floor next to bed . back to bed with assistance x1. Review of Skilled Nursing Unit SNU Non-Employee Incident Report dated 05/07/15 revealed the following documentation: Objective Description of Incident: Found resident on floor. States: I slipped out of bed. Reposition and side rails up. Call light in reach & reorient resident to use it for . and all transfers or ADLs. Physician notified: Yes Taken to hospital: No Review of Fall Scene Investigation Report dated 05/07/15 revealed the following documentation: Resident lost balance, slipped, lost strength/appeared to get weak in resident room; Found on floor (unwitnessed); Resident room; Attempting to self-transfer; Rolling/sliding out of bed; Alone and unattended. What did the resident say they were trying to do just before the fell ? Take a leak. What appears to be the initial root cause (s) of the fall? Resident did not use call light as instructed. Describe initial interventions to prevent future falls: Reoriented to safety protocol. Review of Incident Fall Investigation Form dated 05/07/15 revealed the following: Resident' s Mental State: Dementia was documented. Nurse account of occurrence: Resident slide out of bed. Tried to use the bathroom unassisted and slide to floor. Recommendation: Place visual cues in room to remind resident to call and wait for assistance with transfers and ADLs (Activities of Daily Living). Review of IDT Post Fall assessment dated [DATE] revealed the following documentation: Physical limitations: Weakness, unsteady gait. Care Plan Decision: Place visual cues in room to remind resident to call and wait for assistance with transfers and ADLs. Review of SNU Non-Employee Incident Report dated 05/17/15 at 8:15 a.m. revealed: Objective Description of incident: Stated he was in his electric scooter and forgot it only had 3 wheels and turned too fast and slid out of it, landed on the floor on his bottom. No injuries noted. Physician notified: Yes Taken to hospital: No Review of Fall Scene Investigation Report date 05/17/15 revealed the following documentation: Scooter tilted while turning; Found on the floor (unwitnessed); Resident room, Hallway; Slide out; Alone and unattended. What did the resident say they were trying to do just before they fell ? Riding his electric scooter. Review of the Incident Fall Investigation Form dated 05/17/15 revealed the following documentation: Resident's Mental State: Dementia was documented. Resident account of occurrence: resident reports forgetting that his scooter only has 3 wheels . moved too fast and slid off. Recommendation: Encourage resident to use a slower speed sitting on scooter. Review IDT Post Fall assessment dated [DATE] revealed the following documentation: Physical limitations: weak Care Plan Decision: Encourage resident to use a slower speed setting on scooter. Review of Departmental Notes dated 05/17/15 at 4:03 p.m. revealed resident was found sitting on floor with legs out in front of him and arms at sides next to his scooter. Stated he forgot the scooter only had 3 wheels and said he turned too fast and it tilted and he just slid out. Stated he didn't hurt anything or hit his head . no injuries noted from fall. Reminded resident to go slow when on scooter especially when turning. Review of Departmental Notes dated 05/18/15 at 12:27 a.m. Resident is alert and oriented to person, place, and time. He is frail, debilitated and oxygen dependent. He required limited assistance with toileting, bed mobility and transfers, and is able to feed himself with setup help .He is a fall risk, and did fall off of his scooter this AM. No obvious trauma from fall . A review of Resident Incident Report dated on 05/21/15 at 3:30 p.m. revealed the following: Date/Time: 05/21/15 at 3:30 a.m.; Incident Type: Fall with head injury; Type of Injury: Abrasion; Location: Resident room; Activity at time: From bed w/o assistance. Narrative of incident and description of injuries: - Resident stated he was going to turn his air conditioner and lost his balance, landed on left knee, and bumped his head on the bed rail. No bruising or lump to left side of head. Brush burn looking abrasion on left knee not open or bleeding. Physician Notified: Yes via fax Exam by Physician: No; Taken to hospital: No No documentation of neuro-checks initiated after the fall for 72 hours. Review of Incident Fall Investigation Form dated 05/21/15 revealed: Resident's Mental State: Dementia was documented. Date of injury: 05/21/15. Type of injury: Bump to head, abrasion to knee. Nurse account of occurrence: Resident attempt to adjust temp (temperature) controls on a/c (air conditioner) unit and lost balance and fell . Recommendations: Staff to offer assistance with adjusting room temperature controls of air conditioner unit to prevent resident from attempting to adjust temp and falling. Review of IDT Post Fall assessment dated on 06/08/15 revealed the following: Physical limitations: Unsteady gait, decreased muscle coordination. Care Plan Decision: Staff to check with resident on rds (rounds) & offer assist with adjusting temp of a/c (air conditioner) unit. A review of SNU Non-Employee Incident Report dated on 05/23/15 revealed the following: On 05/23/15 at 4:40 a.m. - Resident got up with walker to go to bathroom. Stated became dizzy fell , hitting head on floor. Type of injury: Hematoma Physician notified: Yes, via fax First aid administered: Ice bag to head. Taken to hospital: No Neuro-check completed. Review of Skilled Nursing Unit fax to physician date 05/23/15 revealed the following documentation: Message: FYI Named resident got up by himself to go to bathroom and fell (again) resulting in hematoma size of golf ball to right side top of head . Review of Departmental Notes dated 05/23/15 at 12:05 p.m. revealed the following documentation: .small hematoma to left side of head. Resident refused earlier in shift to go to hospital for evaluation. Review of Nursing/therapy communication form dated 05/26/15 revealed the following: Recommendations: Patient on therapy case load, encourage pt.(patient) to use call light and not to ambulate/toilet without assistance. Review of SNU Non-employee Incident Report dated 05/23/15 revealed the following: On 05/23/15 at 5:00 p.m. - Called to room per CNA. Observed resident sitting on floor . stated: I'm on floor; I just slipped OOB (out of bed); no complaint of pain/discomfort noted. Review of Fall Scene Investigation Report dated 05/23/15 revealed the following documentation: Resident slipped OOB (out of bed); Found on floor (unwitnessed); Resident room, Rolling out; Alone and unattended. What did the resident say they were trying to do just before they fell ? Resident was lying in bed asleep. What appears to be the initial root cause (s) of the fall? Resident was close to edge of bed. Describe initial interventions to prevent future falls: Center resident to middle of bed. Review of Incident Fall Investigation Form dated 05/23/15 revealed the following: Resident's Mental State: Dementia was documented. Resident account of occurrence: Resident reports that he rolled out of the bed. Recommendations: Place resident in center of bed, offer to place pillows for comfort along side of bed. Review of the IDT Post Fall Assessment date 05/25/15 revealed the following documentation Physical limitations: Weak with unsteady gait. Care Plan Decision: Encourage resident to move to center of bed to prevent possible rolling out, offer to place pillows for comfort along side of bed. Review of Departmental Notes dated 05/24/15 at 12:05 a.m. revealed a late entry for 5:00 p.m., revealed the following: Called to room per CNA. Observed resident sitting on floor smiling. Stated, I am fine, I just slipped OOB (out of bed). Departmental Notes entry dated 05/24/2015 at 10:59 p.m. revealed a late entry for 5:00 p.m. revealed the following: Acute issue/Fall charting. Observed resident sitting on side of bed. Oxygen @ 3LPM/NC in progress. O2 sats 95%-96%. Resident stated, I'm SOB. I can't breathe; I'm very sick. VS- T-100.1/Temporal; P-79; R-18; BP- 150/60; PERRLA. Mild coarseness heard to upper lobes posteriorly with diminished breathe sounds. Appeared somewhat anxious and shaky . Resident was transported to hospital via ambulance. Departmental Notes entry on 05/26/15 at 3:02 p.m. - Resident arrives back to SNU against protocol from hospital. His head to toe assessment was done. Purple/black bruise to Right side of head is noted from fall . Review of SNU Non-Employee Incident Report dated 05/29/15 revealed the following: On 05/29/15 at 13:52 - Patient was observed lying on floor in room between wheelchair and bed on left side. Stated he blacked out Call light was on when nurse and aide observed patient .skin tear to left elbow and right thumb. Type of injury: skin tear Physician notification: Yes Taken to hospital: No First aid administered: dressing to left elbow and right thumb. Review of Fall Scene Investigation Report dated 05/29/15 revealed the following: Resident lost his balance; Found on the floor (unwitnessed); Resident room; Attempting self-transfer; Alone and unattended. What did the resident say they were trying to do just before they fell ? Resident stated he blacked out. Denies trying to transfer. What appears to be the initial root cause (s) of the fall? Patient continues to attempt unassisted transfers. Review of SNU Non-Employee Incident Report dated 06/01/15 revealed the following: On 06/01/15 at 12:40 p.m. - Staff reports finding resident sitting up on bathroom floor. Alert and oriented. Resident stated: I was going to the bathroom and fell before I made it. Physician notified: Yes Taken to hospital: No Review of Incident Fall Investigation Form dated 06/01/15 revealed the following documentation: Resident account of occurrence: States, I was going to the bathroom & fell before I made it. Nurse account of occurrence: Resident got up, unassisted and attempted to go to bathroom and fell . Recommendation: Continue to monitor for toilet needs Q 1 to 2 hours and PRN. Continue to encourage to call and wait for assistance. Place urinal at bedside and encourage use. Review of IDT Post Fall assessment dated [DATE] revealed the following: Physical limitations: Weakness & unsteady gait, uncoordinated movements. Care Plan Decision: Cont. (continue) care plan, offer to bring resident to bathroom after lunch time meal. Continue increase monitoring. Review of SNU Non-Employee Incident Report dated 06/02/15 revealed the following: On 06/2/15 at 11:00 p.m. - Resident found on floor next to bed. States: I had to go pee, but I fell . This LPN had attempted to reorient resident. Physician notified: Yes Taken to hospital: No Review of Fall Scene Investigation Report dated 06/02/15 revealed the following documentation: Found on floor (unwitnessed); Resident room; Attempting self-transfer; Alone and unattended. What did the resident say they were trying to do just before they fell ? I had to use the bathroom. What appears to be the initial root cause (s) of the fall? Resident continues to attempt x-fers (transfers) & ambulation without use of call light. Describe initial interventions to prevent future falls: Multiple attempts to reorient to use of call light for any/all needs. Review of Incident Fall Investigation Form dated 06/2/15 revealed the following: Resident's Mental State: Dementia was documented. Resident account of occurrence: States I had to go pee, but I fell . Nurse account of occurrence: Resident was attempting to use unassisted to go to bathroom & slid to floor. Recommendation: Offer to bring resident to bathroom on last round for evening shift prior to placing resident in bed. Review of IDT Post Fall assessment dated [DATE] revealed the following: Physical limitation: Unsteady gait, uncoordinated movements Care Plan Decision: Offer to take resident to bathroom on last round for evening shift prior to placing resident in bed. Review of SNU Non-Employee Incident Report dated 06/03/15 revealed the following: On 06/03/15 at 2:00 a.m.- Resident found on floor next to bed, and states: I forgot to use the call light.; Attempted to reorient to use of call light for any/all transfers. Physician notified: Yes Taken to hospital: No Review of Fall Scene Investigation Report dated 06/03/15 revealed the following documentation: Found on the floor, Resident room; Attempting self-transfer; Alone and unattended. What did the resident say they were trying to do just before they fell ? I needed to go take a leak. What appears to be the initial root cause (s) of the fall? Resident continues to attempt transfers and ambulation with use of call light. Describe initial interventions to prevent future falls: Continued to attempt for reorient to use of call light for any/all needs. Review of Incident Fall Investigation Form dated 06/03/15 revealed the following documentation: Resident account of occurrence: States, I forgot to use the call light. Recommendation: Bring to bathroom between 1 a.m. and 2 a.m. Review of the IDT Post Fall assessment dated [DATE] revealed the following: Physical limitations: Decreased muscle coordination. Care Plan Decision: Bring to bathroom between 1 a.m. and 2 a.m. Review of SNU Non-Employee Incident Report dated 06/03/15 revealed the following documentation: On 06/03/15 at 1400 - Patient was found on floor at 1400. Patient's head was by right lower end of bed, and feet where headed toward HOB (head of bed). Physician notified: Yes, routine Taken to hospital: No Review of Fall Scene Investigation Report dated 06/03/15 revealed the following documentation: Resident noted he slide off bed; Found on the floor; Resident room; Rolling/sliding out of bed; Alone and unattended. What did the resident say they were trying to do just before they fell ? Go to the bathroom. What appears to be the initial root cause (s) of the fall? Non compliance. Describe initial interventions to prevent future falls: Bed alarm? Review of Incident Fall Investigation Form dated 06/03/15 revealed the following: Resident's Mental State: Dementia was documented. Resident account of occurrence: Trying to go to bathroom. Nurses' account of occurrence: Resident attempted to get up and go to bathroom unassisted and fell . Recommendation: Bring to bathroom between 1 p.m. and 2 p.m. Review of IDT Post Fall assessment dated [DATE]: Care Plan Decision: Bring to bathroom between 1 p.m. & 2 p.m. daily. Review of SNU Non-Employee Incident Report dated 06/05/15 revealed the following documentation: On 06/05/15 at 4:10 a.m. - Resident found on floor next to bed. Non-compliance with call light. Resident list of [DIAGNOSES REDACTED]. Physician notified: blank Taken to hospital: blank Review of Fall Scene Investigation Report dated 06/05/15 revealed the following documentation: Resident found on the floor (unwitnessed); Resident room; Attempting self-transfer; Alone and unattended. What did the resident say they were trying to do just before they fell ? Resident stated: pull my pants off and I fell down. Review of a copy of fax from the evening nurse to physician dated 06/05/15 revealed the following documentation regarding multiple falls: Message: Please advise: These falls are getting ridiculous. I spoke to his son and his nephew Re: getting a sitter and they said they are working on it. I have reoriented him to use of call light for any/all needs! (6 falls in 72 hours). Review of Incident Fall Investigation Form dated 06/05/15 revealed the following: Resident account of occurrence: I fell out of bed while trying to pull pants off. Nurses' account of occurrence: Resident was attempting to pull his pajamas bottom off & fell out of bed. Recommendation: Continue to monitor and assess for needs. Review of IDT Post Fall Assessment 06/08/15 revealed the following: Physical limitations: Weak with unsteady gait, uncoordinated movements. Care Plan Decision: Continue to monitor & anticipate needs. Offer to remove all clothing that may be bothersome on rds (rounds). Review of SNU Non-Employee Incident Report dated 06/05/15 revealed the following documentation: On 06/05/15 at 8:00 a.m. - CNA found resident sitting on trash can next to bed. Said he did not fall. Just sat down. No apparent injuries noted; no complained of pain ROM WNL. Physician notified: Yes Taken to hospital: No Review of Fall Scene Investigation Report dated 06/05/15 revealed the following documentation: Resident's mental status: confused; Resident lost their balance; Lost strength/appeared to get weak; Found on the floor (unwitnessed); Resident room; Ambulating, Attempting self-transfer; Alone and unattended; had gripper socks. What appears to be the initial root cause (s) of the fall? Resident doesn't use call button or wait for assistance. Describe initial interventions to prevent future falls: Reminded resident to use call button and wait for assistance. Review of Incident Fall Investigation Form dated 06/05/15 revealed the following documentation: Resident account of occurrence: Trying to get up.' Recommendation: Offer to assist with getting up prior to breakfast on morning rounds. Review of IDT Post Fall assessment dated [DATE] revealed the following documentation: Physical limitations: Weak with unsteady gait. Care Plan Decision: Offer to assist resident with getting up and dressed on morning rds (rounds) prior to breakfast. Review of SNU Non-Employee Incident Report dated 06/07/15 revealed the following documentation: On 06/07/15 at 11:45 p.m. - CNA entered room, noted resident sitting on the floor. Bed was at its lowest level. Resident stated he slid off the mattress onto the floor. Was it necessary to notify physician? -No, non emergency fax Taken to hospital: No Review of Fall Scene Investigation Report dated 06/07/15 revealed Slid off mattress; Found onto floor (unwitnessed); Resident room; Attempting self-transfer; Alone. What did the resident say they were trying to do just before they fell ? Resident stated, He was lying in bed, went to sit up and slid off mattress onto floor. Review of Fall Scene Investigation Report dated 06/07/15 revealed the following documentation: What appears to be the initial root cause (s) of the fall? Resident was unable to make good judgment concerning repositioning and transfer. Describe initial interventions to prevent future falls: 1. Encourage use of call light, 2) Reorient resident to call for assistance, 3) Keep bed at lowest position at all times, 4) Q 1 hour monitoring. Review of Incident Fall Investigation Form dated 06/07/15 revealed the following documentation: Resident account of occurrence: Resident states that he was lying in bed and tried sit up & slid out of bed. Recommendation: Encourage resident to move to center of bed for safety purposes. Review of IDT Post Fall assessment dated [DATE] revealed the following documentation: Physical limitations: decreased muscle coordination. Care Plan Decision: Encourage resident to move to center of bed for safety reasons. Review of SNU Non-Employee Incident Report dated 06/14/15 revealed the following documentation: On 06/14/15 at 1:20 a.m.- found on the floor. Type of injury: Hematoma. There was no documentation of 72 hours neuro-check completed. Review of Fall Scene Investigation Report, dated 06/14/15 revealed the following documentation: Resident lost their balance; Found on the floor (unwitnessed); Resident room; Attempting self-transfer; Alone and unattended. What appears to be the initial root cause (s) of the fall? Resident had unsteady gait/OOB (out of bed) without use of call light. Review of Fall Investigation Form dated 06/14/15 revealed the following: Resident's Mental State: Dementia was documented. Date of injury: 06/14/15. Type of injury: Hematoma Recommendation: Continue with care plan & increase monitoring to 30 minutes to 1 hr (hour) & PRN. Review of IDT Post Fall assessment dated [DATE] revealed the following documentation: Care Plan Decision: Continue care plan and increase monitoring to Q 30 minutes & 1 hr & PRN. Review of Departmental Notes dated 06/14/15 at 3:02 a.m. Late entry 0120- S4MDS nurse walking down front hall, heard someone calling out Called back for CNA to assist in looking down hall to find who. Resident lying on floor, faced down, propped on elbows. Requesting for help to get up, resident voiced being ok. Rolled over to assess; knot on right side above forehead . Assisted to bed. Called son; don't really want to send out .but agrees to do what doctor orders. Called MD on call. Review of SNU Non-Employee Incident Report, dated 06/28/15 revealed the following documentation: On 06/28/15 at 2:45 p.m. - Resident riding scooter (mechanical) did not inform staff he was going outside, fell off of scooter. Review of Departmental Notes entry dated 06/28/15 at 11:41 p.m. revealed the following documentation: Resident was brought to nurses' station by security officer. He was found outside of facility of the ground after falling out of his motorized scooter. He was muddy, upset and said his ribs hurt. He said he bumped his head but it does not hurt. No LOC (loss of consciousness) or change in LOC. No bruising or deformity noted. No trauma noted to patient. Called ambulance and he was transported to ER. He was treated with 2 fractured ribs. Review of Fall Scene Investigation Report, dated 06/28/15, revealed the following: Went 4-wheeling on 3 wheeler through mud and grass; fell off of scooter outside; Outside building on premises; Alone and unattended. What did the resident say they were trying to do just before they fell ? Take a ride. What appears to be the initial root cause (s) of the fall? Riding scooter outside of unit across grass, hit muddy area. Describe initial interventions to prevent future falls: Parked scooter & will talked to family about safety issues with scooter. Review of Incident Fall Investigation Form dated 06/28/15 revealed the following documentation: Resident's Mental State: Dementia was documented. Date of injury: 06/28/15. Type of injury: blank Nurses account of occurrence: Resident got stuck in mud while outside on scooter and turned over. Recommendation: Bring family attention to safety awareness of situation. Staff to go outside with resident and remain with him for safety reasons. Review of IDT Post Fall assessment dated [DATE] revealed the following: Resident's mental status: Dementia was documented. Physical limitations: Weak with uncoordinated movements. Care Plan Decision: Staff to attend resident excursions outside when on scooter for safety reasons. Inform resident and family of safety concerns. Review of SNU Non-Employee Incident Report dated 06/30/15 revealed the following documentation: On 06/30/15 at 11:15 a.m. - Unknown cause of fall. Resident reported ambulating from restroom to bed unassisted. Was it necessary to notify physician: blank Taken to hospital: blank Review of Fall Scene Investigation Report dated 06/30/15 revealed the following documentation: Resident lost balance; Self-reported fall; Resident room and bathroom; Ambulating; Alone and unattended. What did the resident say they were trying to do just before they fell ? Trying to ambulate from bathroom to bed unassisted. Review of Fall Scene Investigation reported dated 06/30/15 revealed the following documentation: Staff reported: I was walking down the hall seen . light on went in his room and he said he had fell and hit his knee. Resident was sitting on his bed . CNA walked to the nurses station and informed nurse of said incident. What appears to be the initial root cause (s) of the fall? Resident ambulating without assistance or assist device. Describe initial interventions to prevent future falls: Reminded resident not to ambulate with assistance and the use of call light. Review of Incident Fall Investigation Form dated 06/30/15 revealed the following: Resident's Mental State: Dementia was documented. Nurse account of occurrence: found sitting on bed, resident reports falling while walking unassisted from bathroom. Recommendation: Offer talking resident to bathroom before lunch on rds (rounds). Offer taking to nurses' station or activity room for closer supervision. Review of IDT Post Fall assessment dated [DATE] revealed the following documentation: Physical limitations: Weak with unsteady gait. Care Plan Decision: Encourage resident to come to activity rm (room) or nurses station for closer supervision, bring to bathroom prior to lunch time meal. Review of SNU Non-Employee Incident Report dated 07/01/15 revealed the following documentation: On 07/01/15 at 2:00 p.m. - Found resident sitting on floor in front of toilet. Stated he was trying to get to the bathroom. Claims he did not hit his head or injured. Type of injury: Abrasion noted on left arm. Physician notified: Yes Taken to hospital: No Immediate treatment and follow-up care: wound cleaned Review of the Fall Scene Investigation Report dated 07/01/15 revealed the following documentation: Resident lost their balance; Found on the floor (unwitnessed); Bathroom; Ambulating; Alone and unattended. What did the resident say they were trying to do just before they fell ? Trying to go to bathroom. What appears to be the initial root cause (s) of the fall? Rises without assist. Describe initial interventions to prevent future falls: Reminded to use call button and wait for assistance. Nurse and CNA round Q (every) 1 hour. Review of SNU Non-Employee Incident Report dated 07/04/15 revealed the following documentation: On 07/04/15 at 1:30 a.m. - Resident was sitting on floo

Based on interviews and record reviews the facility failed to ensure the Quality Assessment and Assurance Committee identified actual quality deficiencies and implement appropriate plans of action for quality of care issues necessary to correct quality deficiencies. Findings: 1. Cross reference with F323 2. Cross reference with F280 Quality Assurance Fall Prevention Program Purpose: To prevent and reduce the incidence of falls and injury. Guidelines: 1. A Fall Risk Assessment is performed by the charge nurse on each admission within 24 hours. 2. Fall Risk Assessment are performed quarterly on all residents. 3. The room of all new admissions is inspected by the Director of Nursing to ensure that there are no environmental hazards. All resident rooms are checked weekly. 4. Staff members are informed daily of those residents at risks of falls. 5. All nursing staff are inserviced on fall prevention. 6. Care plans are completed and updated by nursing on a quarterly basis and more frequently as need dictates. 7. All falls are tracked by the Director of Nursing on a fall Prevention Monitoring Tool. 8. Falls are tracked monthly for time, location and quantity by Director of Nursing. 9. D.O.N. completes a pharmacy post-fall evaluation on every fall. 10. D.O.N. completes the IDT post-fall form and makes recommendations to prevent further falls. 11. Following every fall nursing completes an Incident Report and nurses note entry for that fall. Alert charting is initiated and continued for 72 hours. Neuro-checks performed in the event of head injury per protocol. On 08/27/2015 3:34:40 PM an interview was conducted with S2DON. S2DON stated was the person responsible for the facility's quality assessment and assurance (QAA). She reveaeld the QAA committee identify issues to be addressed by the QAA program. S2DON stated we discuss any high risk issues such as skin, falls, infections. She stated she meets with S3MDS and S4MDS on a daily basis to discuss any issues. She explained the only fall that was discussed in theQAA meeting was related to the staff using a stand up lift instead of a hoyer lift. She stated that fall resulted in a head injury. She stated she completed a track and trend of Resident #16's falls this week in preparation of the QAA committee meeting in the next couple of weeks. She stated she counted 22 falls in a 6 month period for Resident #16. She further explained 4 falls were with head injuries, 1 fall resulted in fractured ribs, and 3 of the falls he sustained skin tears. She stated the time frames where the resident had the most falls were from Thursday to Sunday and were on the night shift. She stated she had an extra CNA at night.