Every finding on record at Congregational Home, Inc.

Number of residents sampled: 61Number of residents cited:Based on observation, interview and record review, the facility did not ensure food was prepared, and served, in a sanitary manner. This was observed with the dish machine and the facility's 3 compartment sink which has the potential to affect all 61 Residents that reside at the facility.* The facility did not ensure the facility kitchen dish machine was functioning to sanitize dishware.*The facility did not ensure proper procedure for sanitization of dishes involving the 3-compartment sink.Findings include:The facility's Dish Machine policy and procedure dated 1/24/25 documents: . Dietary Supervisor will routinely log Dish Machine Temperatures to assure proper sanitizing of dishes in the Dish Machine Temp Log.1.Staff will monitor dish machine temperatures throughout the dishwashing process.2.Staff will record dish machine temperatures for the wash and rinse cycles at each meal.3.Staff will be trained to report any problem with the dish machine or temperatures to the Culinary Director as soon as they occur.4.The Culinary Director will promptly assess any dish machine problem and take action to immediately assure proper sanitation of dishes. The facility's Manual Cleaning and Sanitizing with 3 Compartment Sink, policy and procedure effective 1/5/24 documents: . 5. [NAME] washing, rinsing, and sanitizing procedure is conducted in the following sequence:a. The sink is cleaned before each useb. Spray, scrape, or soak item before washingc.1st sink: Equipment and utensils are thoroughly washed in the first sink in a detergent solutiond.2nd sink: Equipment and utensils are rinsed free from detergent with clean, hot water.e.3rd sink: Remains emptyf. Equipment and utensils are sent through the dish machine for final washing and sanitizing.(dish machine temperatures are monitored per dish machine operational requirements standard).Note: Dish machine related issues or concerns need to be reported immediately to on-duty supervisor. On 7/29/2025, at 9:17 AM, Surveyor observed the dish machine process. Surveyor observed the 2 front gages on the front of the dish machine. The gage to the left for rinse reads at 130 and has not moved. The gage to the right for wash also reads at 130 and has not moved. The back gage for final rinse reads 150. Surveyor observes staff continue to push dishes through the dish machine while Surveyor and Director of Nutritional Services (DNS)-H observe the process. Surveyor asked DNS-H what the correct temperatures of the dish machine should be. DNS-H stated the wash should be at 150 and the rinse should be about 148-150. DNS-H confirmed the dish machine is a high temperature dish machine. Surveyor requested the manufacturer's guidelines for the dish machine.At this time, Surveyor also observed dishes in the 3-compartment sink. Surveyor requested a test strip be done in the sanitizer sink. Surveyor and DNS-H observed each of the 3 sinks had water with dishes in them. DNS-H did a test strip of the 3rd compartment sink which DNS-H confirmed is the sanitizer sink. The test strip read at 0. DNS-H stated the water must have been sitting for a while. DNS-H stated it should read between 200-400.On 7/29/2025, at 2:54 PM, Surveyor reviewed the dish machine manual which documents:High temp dish machineAllow machine to come to temperatureWash Recommended 150 degreesPumped Rinse Recommended 160 degreesFinal Rinse Recommended 180-195 degreesSurveyor notes the temperatures of the dish machine being run in the morning were not within the manufacturer's specifications.On 7/30/2025, at 8:28 AM, Surveyor and Director of Plant Operations (DPO)-K observed the dish machine together. DPO-K explained the 2 gages in the front. DPO-K confirmed that wash should be at 150, rinse at 160, and the final rinse temperature should be 180-195 degrees. DPO-K confirmed the facility dish machine is a high temp machine. Surveyor explained to DPO-K the 2 temperature gages were stuck at 130 and did not get any higher and the final rinse was at 150 when Surveyor observed the dish machine on 7/29/25. DPO-K stated they should have stopped and waited until the temperature got up to where it should be. DPO-K always recommends for them to run a couple of empty trays until the temperature reaches the required temperature. DPO-K stated yesterday the facility had a water leak which they were fixing. DPO-K stated there is 1 water heater which runs to the kitchen. The guys may have shut the valve off and that is why there was a problem with the temperature of dish machine.On 7/30/2025, at 9:30 AM, Surveyor requested to see the dish machine operation again. DNS-H stated yesterday they should have run 6 empty trays first. Surveyor observed 5 empty trays run through the dish machine. The 6th tray, Surveyor observed the wash was at 150, rinse at 160, and final rinse at 180. DNS-H explained DNS-H completed an in-service and had everyone sign off on the procedure for the dish machine. The in-service reminded employees if the temperature is below the manufacturer guidelines to stop using the machine immediately and to notify the supervisor on duty immediately and wait for further instruction on how to proceed.On 7/30/2025, at 11:00 AM, DNS-H informed Surveyor DNS-H must have been nervous yesterday for the 3-compartment sink when DNS-H used a test strip in the 3rd compartment. DNS-H stated they do not use the 3rd compartment of the sink, only the 1st and 2nd for scrubbing. Surveyor interviewed Dietary Aide (DA)-I who stated DA-I scrubs everything and then takes to the dish machine and runs the dish machine for it to be sanitized. DA-I will disassemble items if need be. DA-I stated only use the test strips for the sanitizer-buckets in the kitchen.On 7/30/2025, at 1:04 PM, DNS-H provided in-service forms completed 7/29/25 on the topic of the dish machine malfunction procedure. The in-service reminded employees if the temperature is below the manufacturer guidelines to stop using the machine immediately and to notify the supervisor on duty immediately and wait for further instruction on how to proceed.On 7/31/2025, at 10:22 AM, Surveyor arrived in the kitchen to observe the dish machine again. Maintenance/Repair Technician (MRT)-J was observed running empty racks through the dish machine. MRT-J stated MRT-J had run 6 empty racks through. The current temperatures were wash at 153 degrees, rinse at 155 degrees, and final rinse temperature is at 185 degrees. MRT-J stated, they should have called us right away when it was at 130 degrees the other day. MRT-J stated that 1 heater was shut down to work on and when the valve was opened up it was accidently mixed with cold and hot water which should not have happened.On 7/31/2025, at 10:32 AM, DNS-H informed Surveyor the dish machine company has been called for repair. Surveyor asked DNS-H what the plan is to wash the breakfast dishes. DNS-H stated they will need to wash everything by hand. DA-I started setting up the sinks, drained and cleaned first and refilled.DA-I filled the sanitizer sink and did a test strip. The test strip read at 500. Surveyor asked DA-I where the test strip should be at. DA-I stated between 200 and 300. DA-I stated will have to wait and let it sit and retest.DNS-H confirmed DNS-H and Surveyor observed the dish machine not working correctly on 7/29/25 and not knowing how many dishes had been cleaned at the wrong temperature which DNS-I agreed with.On 7/31/2025, at 11:15 AM, DNS-I confirmed they do not use a secondary system to check the temperatures of the dish machine.DA-I did another test strip which reads at 400. DA-I was in the process of putting dishes in the sanitizer sink and taking out at the time of the 2nd test strip.DNS-H confirmed for Surveyor the employees are using the rinse (gage in the front expected at 160 degrees) for the recorded temperatures on the daily temperature log on a daily basis.On 7/31/2025, at 12:02 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A about the dish machine not getting to correct temperature and the 3- compartment sink not at the right Parts per Million(ppm). NHA-A stated maintenance must have bumped up the hot water so looking at that right now in regard to the 3-compartment sink. NHA-A understands the concern of sanitization procedures in the kitchen.On 7/31/2025, at 1:10 PM, Assistant Director of Nutritional Services (ADNS)-L explained that ADNS-L spoke to Dish Machine Representative (DMR)-M who informed ADNS-L the front rinse gage doesn't have to reach 160 because it is a holding tank. ADNS-L was told by DMR-M to run the digital test plate to verify the temperature. ADNS-L informed Surveyor the kitchen was unaware they had a digital test plate to run through the dish machine to verify temperatures and found it a drawer. ADNS-L verified they have not been using the digital test plate to check on a regular basis the temperature of the dish machine. ADNS-L verified the temperature they are recording on a daily basis is the temperature from the rinse gage on the front of the dish machine. The temperature that DMR-M stated to ADNS-L doesn't matter what the temperature is because it is a holding tank. Surveyor shared that then this would be the incorrect temperature they are recording. ADNS-L showed Surveyor the current digital test plate verified the temperature at 162 degrees.On 7/31/2025, at 1:17 PM, Surveyor spoke with DMR-M via telephone. DMR-M explained to Surveyor the 2 front gages the free rinse, the water temperature in the tank, is constantly heating and cooling, fluctuating, and the wash is always heated, and the hot water in the back should be 180 to185. DMR-M explained the front rinse is just there to keep the water warm, and from being polluted. DMR-R informed Surveyor the facility should be recording temperatures from the back gage which is the final rinse. DMR-M explained the digital test plate will record the temperature of the sanitizing spray. DMR-M has been working with facilities on what temperature they should be monitoring and recording. DMR-M again confirmed the final rinse should be at a minimum of 180 and that is what the facility should be monitoring and recording for proper sanitization of dishes.Surveyor reviewed July's facility temperature log of the dish machine again. Per DMR-M, the facility should be recording the back gage, the final rinse temperature which should be a minimum of 180. The following temperatures documented would be reflective of the dish machine temperatures not reaching the minimum sanitization guideline of 180:22 days at 177 degrees for the 10 AM dish machine temperature.2 days at 175 degrees for the 10 AM dish machine temperature.7/14 temperatures were documented at 170 degrees for the 10 AM dish machine temperature and 176 degrees for the 1:15 PM dish machine temperature.7/20/25 temperatures were documented at 165, 171,179 degrees for the 3 meals.7/26/25 the 6:15 PM dish machine temperature is blank. The 10 AM dish machine temperature is 177 degrees.7/29/25 the 6:15 PM dish machine temperature is blank. The 10 AM dish machine temperature is 177 degrees.Surveyor notes per the facility the expectation was for staff to record the front rinse gage temperature. However, along with DNS-H, Surveyor observed the front gage rinse temperature only reached 130 degrees which would be below the 160 degrees. Per DMR-M, the facility should have been recording the back gage final rinse temperature with a minimum of 180. With DNS-H, Surveyor observed the back final rinse gage reach 150 degrees.The temperature of the dish machine did not reach the correct temperature for correct sanitization of dishes. The facility was not recording the correct gage temperature as the facility confirmed to Surveyor the expectation was to record the front gage rinse temperature. The facility did not have a formal secondary system in place to check the temperature of the dish machine for the correct sanitization of dishes. At time of exit, NHA-A expressed understanding of the concerns and provided no further information.

Number of residents sampled:8 of 12Number of residents cited:Based on interview and record review, the facility did not ensure admission and annual comprehensive Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 8 (R38, R47, R48, R49, R53, R66, R79, and R91) of 12 residents reviewed for late MDS assessments.*R38's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R47's Annual MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R48's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R49's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R53's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R66's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R79's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.*R91's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/30/2025.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The admission assessment is a comprehensive assessment for a new resident . that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA or an SCPA has been completed since the most recent comprehensive assessment was completed. The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s) (Care Area Assessment) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than 14 days after the ARD (ARD + 14 calendar days). This date may be the same as the MDS completion date, but not earlier than.1.) R38 was admitted to the facility on [DATE]. Per the RAI Manual, R38's admission MDS assessment must be completed by 7/17/2025. On 7/30/2025, R38's admission MDS assessment was In Progress and not completed.2.) R47's Annual MDS assessment dated [DATE], per the RAI Manual, must be completed by 6/27/2025. On 7/30/2025, R10's Annual MDS assessment was In Progress and not completed.3.) R48 was admitted to the facility on [DATE]. Per the RAI Manual, R48's admission MDS assessment must be completed by 7/28/2025. On 7/30/2025, R48's admission MDS assessment was In Progress and not completed.4.) R49 was admitted to the facility on [DATE]. Per the RAI Manual, R49's admission MDS assessment must be completed by 7/14/2025. On 7/30/2025, R49's admission MDS assessment was In Progress and not completed.5.) R53 was admitted to the facility on [DATE]. Per the RAI Manual, R53's admission MDS assessment must be completed by 7/22/2025. On 7/30/2025, R53's admission MDS assessment was In Progress and not completed.6.) R66 was admitted to the facility on [DATE]. Per the RAI Manual, R66's admission MDS assessment must be completed by 7/15/2025. On 7/30/2025, R66's admission MDS assessment was In Progress and not completed.7.) R79 was admitted to the facility on [DATE]. Per the RAI Manual, R79's admission MDS assessment must be completed by 7/3/2025. On 7/30/2025, R79's admission MDS assessment was In Progress and not completed.8.) R91 was admitted to the facility on [DATE]. Per the RAI Manual, R91's admission MDS assessment must be completed by 7/29/2025. On 7/30/2025, R91's admission MDS assessment was In Progress and not completed.In a phone interview on 7/30/2025, at 11:34 AM, Surveyor asked MDS Coordinator-C how many MDS Coordinators the facility had and who completes the MDS assessments. MDS Coordinator-C stated MDS Coordinator-C is the only full time MDS Coordinator at the facility. MDS Coordinator-C stated MDS Coordinator-C cannot keep up with all the assessments anymore, so MDS Coordinator-C is teaching another Registered Nurse (RN) the process. MDS Coordinator-C stated MDS Coordinator-C was currently on vacation and another nurse that is part of their pool nurses is covering for MDS Coordinator-C during this time. MDS Coordinator-C stated the facility has been trying to find someone for the position and they just found someone that is willing to try it. MDS Coordinator-C stated MDS Coordinator-C is concentrating on getting the Medicare MDS assessments done so the quarterly MDS assessments are on the back burner. MDS Coordinator-C stated MDS assessments are late and due to lack of assistance with the MDS Coordinator position, MDS Coordinator-C is not able to address all the assessments timely. MDS Coordinator-C agreed multiple MDS assessments are late in completing and transmitting them.On 7/30/2025, at 2:58 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concerns with incomplete or late MDS assessments for R38, R47, R48, R49, R53, R66, R79, and R91. Surveyor provided NHA-A a detailed list of the timing of the MDS assessments and the concern with the status of each MDS assessment.

Number of residents sampled:6 of 12Number of residents cited:Based on interview and record review, the facility did not ensure admission, quarterly, and discharge Minimum Data Set (MDS) assessments were completed and transmitted in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 6 (R24, R47, R61, R79, R81, and R88) of 12 residents reviewed for late MDS assessments.*R24's Discharge Return Not Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R47's Annual MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R61's Quarterly MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R79's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R81's Discharge Return Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R88's Quarterly MDS assessment dated [DATE] was not transmitted by the specified timeframe.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) (Care Area Assessments) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than day 14. The care plan completion date (item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar days). Transmission Date No Later Than: Care Plan Completion Date + 14 calendar days. (The Quarterly assessment) MDS must be transmitted (submitted and accepted into iQIES) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). The Entry tracking record is the first item set completed for all residents. Must be completed within 7 days after the admission/reentry. Must be submitted no later than the 14th calendar day after the entry (entry date (A1600) + 14 calendar days). OBRA Discharge assessments consist of discharge return anticipated and discharge return not anticipated. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days).1.) R24 was discharged from the facility on 6/6/2025. Per the RAI Manual, R24's Discharge Return Not Anticipated MDS assessment must be completed by 6/20/2025 and transmitted by 7/4/2025. R24's Discharge Return Not Anticipated MDS assessment was completed on 7/26/2025, 22 days late, and had not been transmitted at the time of survey on 7/30/2025.2.) R47's Annual MDS assessment dated [DATE], per the RAI Manual, must be transmitted by 7/11/2025. On 7/30/2025, R47's Annual MDS assessment had not been transmitted at the time of survey.3.) R61's Quarterly MDS assessment dated [DATE], per the RAI Manual, must be transmitted by 7/17/2025. On 7/30/2025, R61's Quarterly MDS assessment had not been transmitted at the time of survey.4.) R79 was admitted to the facility on [DATE]. Per the RAI Manual, R79's admission MDS assessment must be transmitted by 7/24/2025. On 7/30/2025, R79's admission MDS assessment had not been transmitted at the time of survey.5.) R81 was discharged from the facility on 5/14/2025. Per the RAI Manual, R81's Discharge Return Anticipated MDS assessment must be completed by 5/28/2025 and transmitted by 6/11/2025. R81's Discharge Return Anticipated MDS assessment was completed on 5/30/2025, 2 days late, and had not been transmitted at the time of survey on 7/30/2025.6.) R88's Quarterly MDS assessment dated [DATE], per the RAI Manual, must be transmitted by 7/18/2025. On 7/30/2025, R88's Quarterly MDS assessment had not been transmitted at the time of survey.In a phone interview on 7/30/2025, at 11:34 AM, Surveyor asked MDS Coordinator-C how many MDS Coordinators the facility had and who completes the MDS assessments. MDS Coordinator-C stated MDS Coordinator-C is the only full time MDS Coordinator at the facility. MDS Coordinator-C stated MDS Coordinator-C cannot keep up with all the assessments anymore, so MDS Coordinator-C is teaching another Registered Nurse (RN) the process. MDS Coordinator-C stated MDS Coordinator-C was currently on vacation and another nurse that is part of their pool nurses is covering for MDS Coordinator-C during this time. MDS Coordinator-C stated the facility has been trying to find someone for the position and they just found someone that is willing to try it. MDS Coordinator-C stated MDS Coordinator-C is concentrating on getting the Medicare MDS assessments done so the quarterly MDS assessments are on the back burner. MDS Coordinator-C stated MDS assessments are late and due to lack of assistance with the MDS Coordinator position, MDS Coordinator-C is not able to address all the assessments timely. MDS Coordinator-C agreed multiple MDS assessments are late in completing and transmitting them.On 7/30/2025, at 2:58 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concerns with incomplete or late MDS assessments and transmissions for R24, R47, R61, R79, R81, and R88. Surveyor provided NHA-A a detailed list of the timing of the MDS assessments and the concern with the status of each MDS assessment.

Number of residents sampled:2 of 12Number of residents cited:Based on interview and record review, the facility did not ensure quarterly Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 2 (R61 and R88) of 12 residents reviewed for late MDS assessments.*R61's Quarterly MDS assessment dated [DATE] was completed after the specified timeframe.*R88's Quarterly MDS assessment dated [DATE] was in progress and not completed by 7/4/2025 as specified in the RAI 3.0 User's Manual.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days).1.) R61's Quarterly MDS assessment dated [DATE], per the RAI Manual, must be completed by 7/3/2025. R61's Quarterly MDS was completed on 7/26/2025, 23 days after it was due to be completed.2.) R88's Quarterly MDS assessment dated [DATE], per the RAI Manual, must be completed by 7/4/2025. On 7/30/2025, R88's Quarterly MDS assessment was In Progress and not completed.In a phone interview on 7/30/2025, at 11:34 AM, Surveyor asked MDS Coordinator-C how many MDS Coordinators the facility had and who completes the MDS assessments. MDS Coordinator-C stated MDS Coordinator-C is the only full time MDS Coordinator at the facility. MDS Coordinator-C stated MDS Coordinator-C cannot keep up with all the assessments anymore, so MDS Coordinator-C is teaching another Registered Nurse (RN) the process. MDS Coordinator-C stated MDS Coordinator-C was currently on vacation and another nurse that is part of their pool nurses is covering for MDS Coordinator-C during this time. MDS Coordinator-C stated the facility has been trying to find someone for the position and they just found someone that is willing to try it. MDS Coordinator-C stated MDS Coordinator-C is concentrating on getting the Medicare MDS assessments done so the quarterly MDS assessments are on the back burner. MDS Coordinator-C stated MDS assessments are late and due to lack of assistance with the MDS Coordinator position, MDS Coordinator-C is not able to address all the assessments timely. MDS Coordinator-C agreed multiple MDS assessments are late in completing and transmitting them.On 7/30/2025 at 2:58 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concerns with incomplete or late Quarterly MDS assessments for R61 and R88. Surveyor provided NHA-A a detailed list of the timing of the Quarterly MDS assessments and the concern with the status of each MDS assessment.

Number of residents sampled:4Number of residents cited:1Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R35) of 4 Residents reviewed for falls.*On 5/28/25, Certified Nursing Assistant (CNA)-N rolled R35 away from CNA-N during incontinence cares and R35 rolled off the bed and onto the floor. Findings Include:The facility's Safe Resident Handling, policy and procedure modified 8/21/19 documents: .F. If only one person assisting Resident should be rolled towards caregiver vs away from them. Call for extra assist as needed.R35 was admitted to the facility on [DATE] with diagnoses of Paroxysmal Atrial Fibrillation (Irregular, rapid heart rate that causes poor blood flow), Hypothyroidism (underactive thyroid), Essential Hypertension (chronic condition of persistently high blood pressure), Chronic Kidney Disease (progressive damage and loss of function in the kidneys), Chronic Respiratory Failure (long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Vascular Dementia (brain damage caused by multiple strokes), and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R35 has an activated Health Care Power of Attorney (HCPOA).R35's Quarterly Minimum Data Set (MDS) completed 6/5/25 documents R35's Brief Interview for Mental Status (BIMS) score to be 8, indicating R35 demonstrates moderately impaired skills for daily decision making. R35 has no range of motion impairment. R35's MDS documents R35 is dependent on staff for activities of daily living, mobility, and transfers. R35's MDS also documents R35 has had 2 or more falls prior to admission or prior assessment with no injury.R35's Morse Fall Scale assessment completed 5/8/25, documents R35's score to be 14 indicating R35 is at moderate risk for falls.R35's Morse Fall Scale assessment completed 6/5/25, documents R35's score to be 18, indicating R35 is at high risk for falls.Surveyor observed R35's bed in the low position, directly next to the wall on the right side of the bed.On 7/30/2025, at 1:12 PM, Surveyor reviewed the facility's post fall report for R35's incident on 5/28/25. The following is documented:CNA-N had R35 roll towards the wall so incontinence cares could be done, and R35 rolled too far and fell into the crack between the bed and the wall. CNA-N tried to catch R35, but it didn't work. R35 did not sustain an injury. A new intervention of assist of 2 for bed mobility was implemented for R35. Surveyor notes as of 6/3/25, R35's Visual/Bedside Kardex Report document was updated to require 2 staff assist for bed mobility.On 7/31/2025, at 7:39 AM, Surveyor interviewed CNA-F. CNA-F stated for a 1 person assist, CNA-F will roll Resident away if the bed is directly next to the wall when providing incontinence cares, if there is nothing on the other side of the bed, will roll the Resident towards CNA-F.On 7/31/2025, at 7:45 AM, Surveyor interviewed CNA-E who stated they would roll the Resident away and hold with their left hand and wipe with right hand because CNA-E is right-handed and then roll back towards CNA-E for a Resident that is assist of 1.On 7/31/2025, at 9:29 AM, Nursing Care Manager (NCM)-D informed Surveyor the expectation of staff providing incontinence care to a resident that required assist of 1 staff was to roll the Resident towards one-self. On 7/31/2025, at 9:41 AM, Surveyor interviewed CNA-G who stated they would roll a Resident toward CNA-G when providing incontinence care if the resident required assist of 1. On 7/31/25, at 11:53 AM, Director of Nursing (DON)-B stated the expectation is to roll a Resident toward the caregiver when providing incontinence care for a Resident requiring assist of 1. DON-B believes R35 slid between the wall and the bed. DON-B stated CNA-N started cleaning R35 towards CNA-N but pushed R35 away to finish cleaning. DON-B is not sure if the bed was completely against the wall and R35 slid down, or CNA-N didn't lock the brakes on the bed when providing cares. DON-B stated DON-B re-educated CNA-N only, not all nursing staff. Surveyor shared the concern of R35 rolling from bed to the floor due to CNA-N rolling R35 away from CNA-N when providing incontinence cares. DON-B understands the concern of CNA-N not providing adequate assistance to avoid R35 from rolling from bed to floor.

Based on interviews and record review, the facility did not ensure that 1 (R1) of 1 allegations of neglect were reported to the State Survey Agency within the required reporting timeframe. On 11/25/24, R1 and R1's spouse (Spouse-N) filed a grievance with Social Worker (SW)-D regarding a care concern that occurred on 11/22/25. The grievance was investigated, and the written results and plan were given to R1, and Spouse-N. On 11/28/24, Spouse-N sent an email to SW-D, during the Thanksgiving holiday weekend, stating that R1 and Spouse-N believes that the incident that occurred on 11/22/24 was neglectful and abusive. Facility staff did not report the allegation of neglect to the State Agency until 12/2/24, when SW-D returned from the holiday weekend. Findings include: The facility's policy dated 11/26/24, titled, Abuse, documents, in part: [Name of facility] prohibits mistreatment of residents including: . Neglect . Residents (and resident representatives) will be educated regarding their rights specific to grievances, complaints, incidents, and facility procedures to investigate and resolve these issues . Upon learning of an incident, [Name of facility] will take the necessary steps to protect the resident from further incidents of misconduct or injury. [Name of facility] will thoroughly investigate all alleged violations and report as required to the Division of Quality Assurance (DQA) in a timely manner . It is the policy of [Name of facility] that abuse allegations (abuse, neglect, exploitation or mistreatment, .) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, . are reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency .). The facility's undated facility policy titled, Grievance Policy and Guideline, documents, in part: [Name of facility] is committed to providing a safe and secure environment free of poor customer service or abuse. If a resident or resident representative is unhappy with any service treatment, or care within the [Name of facility], they are encouraged to discuss their concerns personally and promptly with their Social Worker/Grievance Officer, or Nurse Supervisor for quick resolution . Grievance officers are our Social Workers and can be seen in person or contacted by name at [phone number], or at below email address during regular business hours . The grievance report concern form should be completed and delivered to the Grievance Officer/Social Worker, or a designee/Nurse Supervisor in their absence. All effort will be made to resolve your grievance concern promptly within that same day. R1 was admitted to the facility on [DATE] with a diagnoses that includes Multiple Sclerosis, Demyelinating Disease of Central Nervous system, and Spastic Hemiplegia. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents R1's cognition is intact. R1 is responsible for self. Surveyor reviewed the Facility Reported Incident (FRI) submitted to the State Agency by the facility on 12/2/24. The summary documents, in part: On 11/25/24, [SW-D] received a concern from [R1] and [Spouse-N] regarding an interaction with [Licensed Practical Nurse (LPN)-O] on 11/22/24 at approximately 11:30 PM. This involved [LPN-O] coming in to inform [R1] that staff were running late to assist with getting [R1] to bed, but they would be there soon .The incident was investigated and felt to be a customer service concern. [LPN-O] apologized to [R1] and [Spouse-N] on the evening of 11/25/24 and a copy of the concern form was reviewed with and given to [R1] and [Spouse-N]. On Monday 12/2/24, after the holiday weekend, [SW-D] received an email indicating that [Spouse-N] was not satisfied with the apology and [Spouse-N] feels that [LPN-O's] actions on 11/22/24 were a violation of rights as well as neglectful and abusive . On 2/4/25 at 12:05 PM, Surveyor interviewed R1 and Spouse-N. Spouse-N indicated that an email was sent to SW-D on 11/28/24 outlining why R1 and Spouse-N believed LPN-O was neglectful and abusive. Spouse-N provided Surveyor a copy of the email sent to SW-D on 11/28/24. On 2/5/25 at 9:08 AM, Surveyor interviewed Social Services Director (SSD)-G, who prepared and submitted the facility FRI to the State Agency. Surveyor asked when the email mentioned in the FRI was sent to the facility. SSD-G stated that it was sent over the holiday weekend. SSD-G stated that they inform residents to speak with nursing, supervisors or staff with concerns so that concerns can be addressed in time. Surveyor asked if anyone covers incoming emails. SSD-G stated no but indicated that residents are made aware of who to reach out to (supervisors and staff) so they can share concerns timely. SSD-G stated staff would then reach out to SSD-G and Nursing Home Administrator (NHA)-A. Surveyor asked for the facility's copy of the email mentioned in the FRI. SSD-G stated that the email was sent to SW-D and that SW-D would have a copy. On 2/5/25 at 9:14 AM, Surveyor interviewed SW-D. Surveyor asked SW-D for the facility's copy of the email that was mentioned in the facility FRI. SW-D stated SW-D would look for the email and get back to Surveyor. On 2/5/25 at 9:40 AM, SW-D returned to Surveyor and stated that after doing some digging SW-D did not find the email sent by Spouse-N. SW-D stated that SW-D has to delete emails after 30 days. SW-D stated SW-D does not have a copy of the email. Surveyor asked when the email was sent. SW-D stated that SW-D does not recall when it was sent, but does remember reading the email on Monday, 12/2/24. On 2/5/25 at 1:05 PM, Surveyor informed NHA-A and Director of Nursing (DON)-B of the concern that an allegation of neglect was sent by email over a holiday weekend and was not reported to the State Agency within the required time frame. NHA-A stated that NHA-A does not require staff to answer emails if they are not working. Surveyor informed NHA-A that the facility needs a process to address potential abuse/neglect concerns when they are brought forward to the facility. No additional information was provided as to why the facility did not ensure that R1's allegation of neglect was reported to the State Survey Agency within the required reporting timeframe.

Based on interview and record review, the facility did not ensure that 1 (R1) of 1 residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R1 informed surveyor that R1 does not always receive help from facility staff to complete stretches/range of motion (ROM) exercises 2 times a day as indicated in R1's Certified Nursing Assistant (CNA) Kardex. Facility staff do not document when stretches/ROM exercises are completed. R1 has a diagnosis of Multiple sclerosis with spasticity. R1 does not have a care plan with measurable goals and interventions related to spasticity and ROM. Findings include: The facility policy dated 2/22/24, entitled, ROM and/or Mobility, documents: Purpose/policy statement: Policy explanation and compliance guidelines: it is the policy of the [name of facility] to promote independence and quality of life by maintaining or improving a resident's quality of life. Policy: 1. Residents who are unable to ambulate independently may be assessed by the nurse and/or therapist for a walking or ROM program. 2. The walking or ROM program is added to the Kardex. 3. Use appropriate assistive device(s) per Kardex. 4. Information will be provided on the Kardex for communication to the staff. R1 was admitted to the facility on [DATE] with diagnosis that includes Multiple Sclerosis, Demyelinating Disease of Central Nervous system, Osteoporosis, Spastic Hemiplegia, Muscle weakness and Chronic Pain Syndrome. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents R1's cognition is intact. R1 uses a wheelchair for mobility. R1 is dependent for toileting, lower body dressing, and transfers. On 2/4/25 at 11:35 AM, Surveyor interviewed R1. R1 informed surveyor that R1 is supposed to receive help from facility staff in completing stretching/ROM exercised 2 times a day. R1 stated that R1's care plan states that staff should complete the stretching/ROM exercises 2 times a day, but staff do not always perform the stretching/ROM exercises 2 times a day. R1 pointed to the wall in R1's sitting area. Surveyor observed a sign on the wall with detailed instructions indicating how staff should perform stretches/ROM exercises in the afternoon daily. R1 then pointed to the wall in R1's bedroom area. Surveyor observed a sign on the wall with detailed instructions indicating how staff should perform stretches/ROM exercises in the morning daily. Surveyor reviewed R1's Comprehensive Care Plan and did not locate documentation regarding stretching/ROM exercises. R1's progress note dated 10/17/24 documents: New orders received from resident's Neurologist, [MD-H], for PT [evaluation] and treat for spasticity. Order comments state: Daily Therapy for ROM. R1's physician order dated 10/17/24 documents, [Physical Therapy (PT) Evaluation] and Treatment per plan of care. Surveyor noted R1 started PT on 10/29/24. R1's PT visit note dated 11/14/24 documents, in part: . Most of session was spent verbally going over and finalizing stretching program for [R1]. Final program to consist of knee flexion in supine and sitting, sitting at sit to stand, dorsiflexion stretch with band, and with manual pressure. R1's PT visit note dated 11/20/24 documents, in part: . Most of session was spent verbally going over stretching program with [R1]. [R1] tolerates all of these exercises well. Laminated copy posted in [R1's] room and copies given to nursing staff and social worker . R1's PT visit note dated 12/2/24 documents, in part: . Most of session spent observing CNA-E completing stretches and providing cues as needed. PT spoke to head of nursing, [Nursing Care Manager-C], about care plan. [Nursing Care Manager-C] has printed out plan for staff to complete . R1's CNA Kardex documents: Mobility- stretches to be done in the A.M. and stretches to be done on P. M. shift; see attached. Attached to the CNA Kardex is the detailed instructions signs that are posted in R1's room. The signs document: Morning Stretches. Bending [R1's] knee: Lift [R1's] leg into the air and put your elbow under [R1's] knee. Use that arm to pull [R1's] knee towards [R1's] head and push down on [R1's] foot with the other arm to bend [R1's] knee. It is much easier to bend [R1's] knee this way. Do this 10 times on [R1's] right, 10 times on [R1's] left, and then 10 times on the right again as that leg is tighter. Sitting in sit to stand: Let [R1] sit in the sit to stand with [R1's] knee bent for 5 minutes before transferring to the commode. This helps stretch [R1's knees and work on core strength. Afternoon Stretches. Stretching [R1's] ankle and foot: Straighten [R1's] knee. Use your forearm to bend [R1's] ankle. This will stretch out [R1's] ankle and the bottom of [R1's] foot. This will also make it easier on your hands. Using band to stretch out [R1's] ankle and foot: Put the middle opening of the band around the end of [R1's] foot. [R1] will hod the ends of the band and pull up. You will need to hold [R1's] ankle to keep her from lifting [R1's] whole leg up. Surveyor reviewed R1's electronic medical record. Surveyor did not locate any documentation indicating the stretches/ROM exercises were being completed by staff. On 2/4/25 at 11:31 AM, Surveyor interviewed CNA-E, who was mentioned in the PT visit note on 12/2/24. CNA-E indicated that stretches/ROM exercise instructions are in R1's CNA Kardex. CNA-E stated CNA-E completes R1's stretches/ROM exercises when CNA-E is working. Surveyor asked where CNA-E would document that stretches are being completed. CNA-E indicated facility staff do not document that the stretches/ROM exercises are completed but indicated that instructions are on the CNA Kardex, so staff know what to do. Surveyor asked if CNA-E has instructed other CNA's on how to complete the stretches/ROM exercises. CNA-E stated yes. CNA-E stated that some CNAs are scared to do the stretches/ROM exercises. On 2/4/25 at 2:34 PM, Surveyor interviewed CNA-M. Surveyor asked where CNA-M would find if stretches/ROM exercises needed to be completed on a resident. CNA-M stated it would be on the care card/CNA Kardex. Surveyor asked where CNA-M would document that stretches/ROM exercises are documented completed. CNA-M stated they are not documented in the electronic medical record. On 2/4/25 at 4:05 PM, Surveyor interviewed CNA-F. Surveyor asked when R1's stretches/ROM exercises are completed. CNA-F stated that the first shift CNA's will do the stretches/ROM exercises. Surveyor asked if any are completed on 2nd shift. CNA-F stated I don't know. CNA-F stated that CNA-F will raise R1's legs to put lotion on R1's legs. Surveyor asked where Surveyor would find documentation that stretches/ROM were completed. CNA-F indicated that the CNA Kardex has the information CNA-F needs to care for R1. CNA-F indicated that R1 will let you know what R1 wants and needs and will tell you what has and has not been completed. On 2/4/25 at 2:10 PM, Surveyor interviewed Nursing Care Manager-C. Surveyor asked who completes stretches/ROM exercises for R1. Nursing Care Manager-C stated that CNAs do them. Nursing Care Manager-C indicated nurses can do them as well, but usually the CNA completes them. Surveyor asked where staff document that the stretches/ROM exercises are completed. Nursing Care Manager-C stated they are not documented as completed but that they are part of the care plan. Nursing Care Manager-C stated that Nursing Care Manager-C supposed that they should be documented. Nursing Care Manager-C stated that the facility does not have a restorative program and if a resident has instructions on the care card/CNA Kardex, that is what the CNA should do. Surveyor asked how Nursing Care Manager-C knows stretches are being completed. Nursing Care Manager-C stated that R1 will tell Nursing Care Manager-C if they are not being completed. Nursing Care Manager-C stated that in the past, R1 has told Nursing Care Manager-C that a facility CNA was not completing the stretches/ROM exercises with R1. Nursing Care Manager-C addressed the situation with that CNA and completed education. Nursing Care Manager-C again stated R1 would tell someone if they are not being completed. Surveyor noted Nursing Care Manager-C indicated in the interview that stretches were not always completed as documented in the CNA Kardex. On 2/5/25 at 10:06 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked who is responsible for completing stretches/ROM exercises. DON-B stated that the PT will set up a program and CNAs will complete the stretches/ROM exercises as directed by the PT. DON-B indicated that the facility does not have a restorative program, but they follow PT instructions. Surveyor asked where the stretches/ROM exercises are documented. DON-B indicated that staff do not document if the stretches/ROM exercises are completed. Surveyor asked how DON-B would know if stretches/ROM exercises are being completed for R1. DON-B stated that R1 will tell staff if they are not being completed. Surveyor informed DON-B of the concern that R1 is stating that R1 is not always getting help with stretches/ROM exercises as directed in the CNA Kardex and there is no documentation indicating that the stretches/ROM exercises are being completed. Surveyor asked if R1's stretches/ROM of exercises should be included in the comprehensive care plan with measurable goals and other interventions. DON-B stated that it should be care planned. Surveyor informed DON-B that R1 does not have a care plan with measurable goals regarding R1's stretches/ROM exercises for spasticity. On 2/5/25 at 1:05 PM Surveyor informed Nursing Home Administrator (NHA)-A of the concern R1 informed Surveyor that stretches/ROM exercises are not always completed as indicated on the CNA Kardex. There is no documentation indicating that the stretches/ROM exercises are being completed as indicated on the CNA Kardex. There is no comprehensive care plan with measurable goals regarding R1's stretches/ROM exercises. No additional information was provided as to why the facility did not ensure R1 received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Based on observation, record review, and interview, the facility did not ensure that 1 (R2) of 2 residents reviewed received adequate supervision and asssitive devices to prevent accidents. * R2 suffered falls that were not thoroughly investigated, with fall interventions and revisions to the fall care plan post fall review & IDT (interdisciplinary team) not implemented. Findings include: The facility's policy titled, Falls and modified 4/3/23 under Policy documents To follow the intent of HFS 132 and Federal regulations F323 sic (F689) Congregational Home will provide an environment that is free from hazards over which the facility has control and will provide appropriate supervision to each resident to prevent avoidable falls. Under Procedure documents 10. The Charge Nurse caring for the resident that has fallen will complete the following forms: * Skilled Nursing Fall Incident Form A note from appropriate licensed and direct care staff providing care to the resident prior to fall and any witnesses if applicable. * With head trauma the Charge Nurse will complete Evaluation if the resident will require further medical work up and be transported to the Hospital emergency room . * Head Trauma Craniotomy Check Flow Sheet will be initiated with all unwitnessed falls. 11. The Charge Nurse will initiated an intervention help reduce risk of future falls. 12. The Charge Nurse will update POC (plan of care) and the CNA (Certified Nursing Assistant) Care Plan. 13. The Nurse Care Manager/RN (Registered Nurse) Supervisor on duty at time of fall will review all Charge Nurse follow up and documentation including: *Care plans. *Nursing notes. *And assure the new intervention/s and any ongoing interventions to prevent future falls are appropriate. 1.) R2's diagnoses includes unspecified dementia severe with psychotic disturbances, anxiety disorder, epilepsy, atrial fibrillation, hypertension, and depressive disorder. The Falls CAA (care area assessment) dated 6/28/24 documents under the analysis of findings for nature of problem/condition: Morse fall scale score of 19, High risk for falls. Hx (history) of 2 recent falls. See delirium, cognitive, communication, pain CAA for details. Dx (diagnosis) of new seizures, vascular dementia. BIMS (brief interview mental status) score 3/15. Less and less awareness of safety, ability limitations, non ambulatory. Full body lift for transfers up in Broda chair. PRN (as needed) oxycodone medication therapy. Polyneuropathy see NP (Nurse Practitioner) note 6/10/24. Under the Care Plan Considerations section it documents: Newly assigned to hospice. Ongoing decline in mobility & strength, cognitive communication skills. Potential for falls. Goal is for comfort. No falls, injury. Nursing to anticipate and assist with mobility and ADL (activities daily living) deficits, monitor for safety 1:1 PRN (as needed), encouraging to be in a more supervised area. Bed canes for bed mobility, confusion and forgetful. Ensure has hearing aids. Thick full mat to side of bed. Dycem to recliner. Gripper socks. Check and change for incontinence cares. See falls care plan. The Quarterly MDS (minimum data set) with an assessment reference date of 9/13/24 has a BIMS score of 3 which indicates that R2 has severe cognitive impairment. R2 has fallen since prior assessment with 2 or more falls, no injury and 2 or more with injury (except major). The Quarterly MDS with an assessment reference date of 12/13/24 has a BIMS score of 3 which indicates severe impairment. R2 is assessed as being dependent for toileting hygiene, roll left & right, & chair/bed to chair transfer. R2 is assessed as always incontinent of urine and bowel. R2 has fallen since prior assessment with 2 or more falls, no injury and 2 or more with injury (except major). R2's fall care plan initiated 6/1/24 and revised 9/27/24 documents the following interventions: *Continue interventions on the at risk plan initiated 6/1/24. *For no apparent acute injury, determine and address causative factors of the fall, initiated 6/1/24. *New Intervention post fall on 6/3/24: When resident is up out of bed to be in Broda chair for safety precautions, initiated 6/3/24. *New Intervention post fall on 6/25/24: Increased frequency of check and change to: Check and Change every 2 hours and as needed, initiated 6/25/24. *New Intervention post fall on 6/26/24: Staff to perform safety checks on resident every 30 minutes for safety measures and fall prevention, initiated 6/26/24. *New Intervention post fall on 7/1/24: Staff to follow residents current toileting plan: Staff to check and change resident every 2 hours and PRN (as needed), initiated 7/9/24 & revised 2/4/25. *State X-ray to left post UWF (unwitnessed fall) on 7/1/24 d/t (due to) raised red firm area of skin to top of left foot. X-Ray Impression Left Foot: No acute abnormality is seen involving the left foot, initiated 7/1/24. *New Intervention post fall on 7/3/24: Reviewed residents current behavioral medication with [Name] psych NP (Nurse Practitioner). Updated psych NP regarding resident continued anxiety/agitation/restlessness with frequent attempts made by resident to get up out of Broda chair resulting in fall. Reviewed Behavioral medication regimen with [Name] psych NP with new orders obtained on 7/3/24 for: Depakote 250 mg (milligrams) BID (twice daily) along with new orders for CBC (complete blood count) & CMP (comprehensive metabolic panel) on 7/8/24, initiated 7/3/24. *Ensure Broda chair is slightly reclined when resident is in Broda chair, initiated 7/24/24. *New Intervention Post fall on 7/24/24: Ensure Broda chair is slightly reclined when resident is in Broda chair, initiated 7/24/24. *New Intervention post fall on 7/24/24: If resident becomes restless have staff first check if resident needs her briefs changed. Resident is frequently restless when her briefs are soiled or when she has to have a BM (bowel movement), initiated 7/25/24. *Intervention 7/29/24: Educated activities staff if resident becomes restless during an activity please notify nursing staff so resident can be toileted. If resident becomes restless have staff first check if resident needs her briefs changed. Resident is frequently restless when her briefs are soiled or when she has to have a BM (bowel movement). Staff also educated when resident is up in Broda chair to be slightly reclined d/t Broda chair wasn't reclined on 7/29/24 when fall occurred, initiated 8/9/24. *New Intervention 8/5/24: Nursing staff educated on importance of reading resident care cards at the start of every shift to make sure all interventions are being followed appropriately, initiated 8/5/24 and revised 2/4/25. *Thick fall mat on side of bed when occupied and unattended, initiated & revised 9/4/24. *Intervention post fall on 9/11/24: Reviewed psychotropic medication regimen at behavioral health meeting with [Name] psych NP on 9/12/24 with new & changed psychotropic medications orders obtained per psych NP to decrease residents current behaviors including decreased anxiety/agitation with decreased falls r/t (related to) restless behaviors, initiated 9/12/24. *Monitor/document/report PRN x (times) 72h (hour) to D for s/sx (signs/symptoms): Pain, bruises, Changes in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation, initiated 9/11/24 & revised 9/27/24. *Neuro-checks x (times) Q15min (every 15 minutes) x 4, Q1hr x 4, Q4 hrs x 4, Q8 hrs x 4 per facility protocol, initiated 9/11/24 & revised 9/27/24. *Vital signs x 15 min x 4, 1 hr x 4, Q4 hrs x 4, Q8hrs x 4 per facility protocol, initiated 9/11/24 & revised 9/27/24. The Broda Operating Manual Centric Tilt Semi Recliner provided to Surveyor on 2/5/25 by DON (Director of Nursing)-B under the section 2.5 Hazards for 2.5.1 Position of Chair - Danger of Falling documents After a resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. R2's incident note dated 7/22/24 at 11:03 a.m. and written by LPN (Licensed Practical Nurse)-P documents: Date, Time and Location of Fall: 7/22/24 at 0750 (7:50 a.m.) in the common TV area on west hall. Vitals, including POX (pulse oximetry), Blood Sugar and Orthostatic BP (blood pressure): BP: 148/91, P (pulse): 103, R (respirations) 16, POX: 93% RA (room air), T (temperature): 97.4. Describe the fall: Writer was called to the common TV area on west hall d/t (due to) resident slid out of her Broda chair on to the floor in front of her chair. Were there any injuries? If so, describe: No injuries noted. Date/Time/Name of Physician Update: 7/22/24, 0830 (8:30 a.m.) [Name] NP. Date/Time/Name of Family update: 7/22/24 0800 (8:00 a.m.) [Name] daughter POA (power of attorney). R2's fall on 7/22/24 was not thoroughly investigated as there was no CNAs (Certified Nursing Assistant) statements on the post fall report . There were no statements as to who last saw R2 or what was R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up did not indicate whether prior interventions were in place at the time of the fall. The facility implemented a new intervention of ensure Broda is slightly in the reclining position. R2's fall care plan was not revised with this intervention until 7/24/24 after R2 had another fall. In addition, according to the manufacturers information recommend the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward. There is no documentation as to the tilt of R2's Broda chair prior to the fall. R2's incident note dated 7/24/24 at 23:39 (11:39 p.m.) written by LPN-R documents Date, Time and Location of Fall: 7/24/24, 2015 (8:15 p.m.), [NAME] unit bird lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: See charted vitals. Describe the fall: Unwitnessed fall. Resident attempted to self transfer out of her Broda chair without staff assistance and fell on to the floor. Were there any injuries? If so, describe: No. Date/Time/Name of Physician Update: 7/24/24, 2044 (8:44 p.m.), [Name] Hospice. Date/Time/Name of Family update: 7/24/24, 2055 (8:55 p.m.) [Name] POA. R2's fall on 7/24/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw R2 or what was R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of R2's Broda chair. New interventions included in the post fall report documents If resident becomes restless have staff first check if resident needs her briefs changed. Resident frequently restless when briefs soiled or when needs to have BM. Ensure Broda chair is slightly reclined when resident is up in Broda chair for safety. The intervention of checking R2's incontinence product was placed on the fall care plan until 7/29/24, five days later and the intervention of reclining R2's Broda chair was recommended after R2's fall on 7/22/24. R2's post fall report was not signed by the Nurse Manger until 8/6/24 and DON (Director of Nursing)-B did not sign this report until 8/19/24. R2's incident note dated 7/29/24 at 15:19 (3:19 p.m.) written by LPN-Q documents Date, Time and Location of Fall: 7-29-24 1130 in TV room on west. Vitals, including POX, Blood Sugar and Orthostatic BP: 137/66, 97.2, 76, 18, 925. Describe the fall: resident slid out of chair to the floor during activities. Were there any injuries? If so, describe: no injuries. Date/Time/Name of Physician Update: 7-29-24 1225 (12:25 p.m.) [Physician name]. Date/Time/Name of Family update: 7-29-24 1225 (12:25 p.m.) [POA name]. R2's post fall report and IDT incident follow up for R2's fall on 7/29/24 documents R2's Broda chair wasn't reclined according to R2's plan of care when R2's fall occurred. There is no documentation as to whether other prior interventions were in place at the time of R2's fall. R2's post fall report was not signed by the Nurse Manger until 8/9/24 and DON (Director of Nursing)-B did not sign this report until 8/19/24. R2's incident note dated 8/5/24 at 15:38 (3:38 p.m.) written by LPN-J documents Date, Time and Location of Fall: 8/5/2024, 1430 (2:30 p.m.), canary lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: 132/74, 76, 16, 97.9, BG= (blood glucose equals) 118, 97%. Describe the fall: unwitnessed fall in canary lounge from Broda chair to the floor. Were there any injuries? If so, describe: no injuries. Date/Time/Name of Physician Update: [Name] NP. Date/Time/Name of Family update: [POA name], 8/5/2024, 1530 (3:30 p.m.). R2's post fall report 8/5/24 and IDT incident follow up dated 8/26/24 for R2's fall on 8/5/24 includes documentation of Resident with frequent falls occurring d/t (due to) resident attempting to get up out of her Broda chair without any staff assistance at shift change resulting in an unwitnessed fall occurring Resident is supposed to be with a staff member at shift change and is not supposed to be left alone, unwitnessed fall occurred d/t resident being left alone at shift change and resident attempted to self transfer out of her Broda chair resulting in an unwitnessed fall occurring. Surveyor noted R2's CNA (Certified Nursing Assistant) Visual/Bedside Kardex Report as of 7/24/24 under the safety section includes *At shift change someone needs to be with resident. Resident not to be left alone at shift change. R2's post fall report was not signed by the Nurse Manger until 8/26/24 and DON (Director of Nursing)-B did not sign this report until 9/3/24. R2's incident note dated 9/11/24 at 23:06 (11:06 p.m.) written by LPN-R documents Date, Time and Location of Fall: 9/11/24, 1910 (7:10 p.m.), [NAME] unit Bird Lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: See charted vitals. Describe the fall: Resident found by staff sitting upright on the floor next to her Broda chair. Were there any injuries? If so, describe: Bump/hematoma to left side of forehead. Date/Time/Name of Physician Update: 9/11/24, 1950 (7:50 p.m.), On call physician [Name] with [medical group]. Date/Time/Name of Family update: 9/11/24, 2111 (9:11 p.m.), [Name] POA. R2's fall on 9/11/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw R2 or what was R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of R2's Broda chair. R2's incident note dated 10/7/24 at 20:13 (8:13 a.m.) written by LPN (Licensed Practical Nurse)-J documents Date, Time and Location of Fall: 10/7/2024, 2000 (8:00 p.m.), [Room number]. Vitals, including POX, Blood Sugar and Orthostatic BP (blood pressure): 136/74 84 20 97.3 97%. Describe the fall: resident rolled from bed to mat on floor then from mat to floor. Were there any injuries? If so, describe: no injuries. Date/Time/Name of Physician Update: 10/7/2024 [name of medical group]. Date/Time/Name of Family update: 10/7/2024, 2030 (8:30 p.m.) [Name]. R2's post fall report & IDT incident follow up for 10/7/24 documents an intervention of Encourage nursing staff to monitor patient more frequently and toilet in between every 2 hour rounds. R2's fall care plan was not revised to include this intervention. R2's incident note dated 10/24/24 at 17:55 (5:55 p.m.) written by LPN-J documents Date, Time and Location of Fall: 10/24/24, 1700 (5:00 p.m.), west dining room. Vitals, including POX, Blood Sugar and Orthostatic BP: 100/52, 97.9, 16, 67, 97%. Describe the fall: resident slid out of Broda chair and onto Broda foot rest. Were there any injuries? If so, describe: no injury. Date/Time/Name of Physician Update: 10/24/24 [Physician name] 1715 (5:15 p.m ). Date/Time/Name of Family update: 10/24/24, [POA name], 1715 (5:15 p.m.). R2's fall on 10/24/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw R2 or what was R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of R2's Broda chair. The post fall report and IDT incident follow up documents an intervention of provide activities for resident to do independently. R2's fall care plan was not revised to include this intervention. The Nurse Manager & DON-B did not sign the post fall report until 1/12/25. R2's incident note dated 11/9/24 at 07:32 (7:32 a.m.) written by LPN-T documents Date, Time and Location of Fall: 11/9/24 @ (at) 0418 (4:18 a.m.) Canary Lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: T-96.8, P-69, R-16, B/p-145/75, POX 98% RA, BG-120. Describe the fall: Unwitnessed Fall/slide out of Broda chair. Hit head on leg of table. Neuro check negative. ROM WNL. Tenderness to top of head. Were there any injuries? If so, describe: yes; 1.0 cm (centimeter) x 1.0 cm round wound to top of scalp; cleansed et Band-Aid applied. Date/Time/Name of Physician Update: 11/9/24 @ [physician name] [medical group name]. Date/Time/Name of Family update: 11/9/24 @ 0729 am POA/[name]. R2's fall on 11/9/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw R2 or what was R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of R2's Broda chair. The IDT incident follow up documents an intervention of Resident will be monitored more frequently while awake and when in bed for safety. R2's fall care plan was not revised to include this intervention. R2's incident note dated 11/24/24 at 04:04 (4:04 a.m.) written by RN-I documents Date, Time and Location of Fall: 11/24/24 at 04:04 (4:04 a.m.) in dining room, slid out of Broda chair. Vitals, including POX, Blood Sugar and Orthostatic BP: VSS 97.7-86-18 BP 156/86 lying, & 141/86 sitting. SPO2 95% RA, blood glucose at 131. Describe the fall: Resident fell in dining room area, slid out of Broda chair, sitting upright on buttocks on floor. RN [Name] down to assess, AROM (active range of motion) to all extremities WNL (within normal limits), PERLA (pupils equal, round and reactive to light and accommodation) Neuro check negative. Client whimpering intermittently while being hoyer lifted off the floor with 3 staff. No injury noted. Anxiety with confusion. Were there any injuries? If so, describe: None. Date/Time/Name of Physician Update: Call to [Name] hospice spoke with [hospice name] representative [name], about fall without injury. He will have RN from [hospice name] return call this morning sometime. Date/Time/Name of Family update:. R2's post fall report for fall on 11/24/24 at 4:04 a.m. documents R2 was being watched by [name of staff] who stepped into a room in dining room area. R2's fall care plan was not revised to include the new intervention of not to be left alone in Broda chair if restless agitated follow all nurse directives. All shift to follow this directives. R2's incident note dated 11/24/24 at 12:42 (12:42 p.m.) written by Graduate RN-S documents Date, Time and Location of Fall: 11/24/24 11:52 (11:52 p.m.) Commons area. Vitals, including POX, Blood Sugar and Orthostatic BP: T 97.7, P 84, R 16, BP 137/75, O2 (oxygen) 94% RA. Describe the fall: Unwitnessed. Pt (patient) was found c (with) back against couch. Were there any injuries? If so, describe: No apparent injuries noted. ROM (range of motion) of all extremities WNL (within normal limits). Reported soreness to btx (buttocks). Date/Time/Name of Physician Update: 11/24/24 12:15 [Name] Hospice. Staff nurse contacting [medical group name]. Date/Time/Name of Family update: 11/24/24 12:23 Daughter [name]. R2's fall on 11/24/24 at 11:52 p.m. was not thoroughly investigated as there are no statements included in the post fall report as to who last saw R2 or what was R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of R2's Broda chair. On 2/5/25, at 7:10 a.m., Surveyor observed R2 dressed for the day in a Broda chair slightly reclined back sleeping in the lounge area with the bird aviary. At 7:18 a.m. Surveyor observed R2 is now awake. At 7:28 a.m. R2 continues to be sitting in a Broda chair in the lounge area. R2 removed the blanket off and has moved her feet off the Broda foot rest. CMA (Certified Medication Assistant)-U approached R2, covered R2 with the blanket and moved her feet back onto the foot rest. At 7:35 a.m. RN-L approached R2 asking if she was hot as R2 had taken off one of her blankets and tucked the hoyer sling on the right side back in. Surveyor observed R2 continued to be sitting in the Broda chair in the lounge with the bird aviary until 8:23 a.m. when CNA (Certified Nursing Assistant)-V wheeled R2 out of the lounge area into the dining room and placed R2 at a table. On 2/5/25 at 9:37 a.m., Surveyor observed R2 continues to be sitting in the Broda chair at a table in the dining room. At 9:38 a.m. R2 is wheeled into the lounge area from the dining room. At 9:40 a.m. a Life Enrichment staff member asked R2 if she wanted a warm blanket telling R2 let me put music on and then will get you a blanket. Music was placed on and then at 9:41 a.m. the Life Enrichment staff member wheeled R2 out of the lounge down the hall and returned back to the lounge with a blanket on at 9:43 a.m. At 9:48 a.m. CNA-V wheeled R2 out of the lounge and into R2's room. CMA-U wheeled a hoyer lift in. Surveyor observed CNA-V & CMA-U transfer R2 into bed using the hoyer lift. At 9:54 a.m. CNA-V informed R2 she was going to pull her pants down. Surveyor observed CNA-V provide incontinence care to R2 who was incontinent of urine & bowel. After cares were provided, CNA-V and CMA-U transferred R2 back into the Broda chair, CNA-V tucked the sling into the Broda chair and remade R2's bed. R2 was then wheeled into the lounge. On 2/5/25, at 10:08 a.m., Surveyor asked CNA-V if she got R2 up this morning. CNA-V replied R2 was up when she came in. Surveyor asked CNA-V what time her shift starts. CNA-V replied 6:30 a.m. CNA-V explained to Surveyor hospice usually comes in Monday & Wednesday and they get R2 washed & dressed. Surveyor asked CNA-V how often R2 is to be changed. CNA-V replied every two hours, if she is fussy then know to change her as she may be wet or pooped. Surveyor asked if R2 is suppose to be checked & changed every two hours and was up already when she got here why wasn't R2 checked & changed earlier. CNA-V informed Surveyor she was busy and breakfast came at 8:30 or 8:45 a.m. Surveyor noted CNA-V wheeled R2 into the dining room at 8:23 a.m. the approximate time R2 should have been checked & changed. On 2/5/25, at 10:38 a.m., Surveyor asked RN-L to explain their fall process. RN-L informed Surveyor a RN has to do the post fall assessment and the resident is not moved until a RN assesses the resident. Vital signs & Neuro checks are completed, the doctor, family & NHA are notified. An incident report is filled out, anyone working with the resident fills out a statement, and a picture is drawn of what they see. Surveyor inquired if the fall is discussed as a team. RN-L informed Surveyor she believes the unit manager is involved but is not sure who is involved as she is not. Surveyor asked how the CNA's are notified of changes to a resident's care plan. RN-L informed Surveyor the Kardex is updated and also stays on the 24 hour report board to be communicated through report. Surveyor asked who revises the care plans. RN-L informed Surveyor the Unit Manager and as a RN she can update the care plan. On 2/5/25, at 11:14 a.m., Surveyor asked NCM (Nurse Care Manager)-K to explain their fall process. NCM-K informed Surveyor no one touches the resident until a RN assesses the resident, Neuro checks, range of motion, and vital signs are obtained. The physician and family are notified. An incident report is filled out by the nurse assigned to the resident and this is brought to morning meeting where they go over the report as the IDT. Surveyor asked if staff statements are obtained. NCM-K informed Surveyor they are on the incident report. Surveyor asked if they look to see if prior interventions were in place at the time of the fall. NCM-K replied I do. Surveyor inquired who updates the care plan. NCM-K replied she does or any other manager. Surveyor informed NCM-K since 7/3/24, R2 has had 14 falls. Surveyor informed NCM-K there are multiple falls where the post fall assessment and/or IDT follow up doesn't indicate when R2 was last seen, what she was doing or whether prior interventions were put into place. R2's care plan was not always revised to include interventions. NCM-K informed Surveyor she was not the manager during this time and its hard for her to respond. NCM-K informed Surveyor there were two different managers before her and they are no longer with the facility. NCM-K informed Surveyor she is responsible at this point and will make sure the care plans are updated. Surveyor then informed NCM-K R2 has a fall intervention that she should be checked and changed every two hours and this didn't occur this morning. NCM-K informed Surveyor if she is to be checked and changed every two hours this should happen. On 2/5/25, at 1:00 p.m., during the meeting with NHA (Nursing Home Administrator)-A and DON-B Surveyor asked how should a residents Broda chair be positioned. NHA-A replied depends and explained if they are eating upright, leaving the table or relaxing a little titled back. S urveyor informed NHA-A & DON-B R2's falls weren't thoroughly investigated as there are no staff statements as to who last saw R2, what was R2 doing and whether prior interventions were in place at the time of the fall. R2's fall interventions were not always followed and the care plan was not always revised to include new interventions. No additional information was provided as to why R2's falls were not thoroughly investigated, with fall interventions and revisions to the fall care plan post fall review & IDT (interdisciplinary team) not implemented.

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed for the development of an individualized plan of care with interventions to promote healing, prevent infection and prevent new pressure injuries from forming. This was observed with 1 (R34) of 3 residents reviewed with pressure injuries and at risk for the development of pressure injuries. *R34 was assessed at high risk for the development of pressure injuries. Despite this, the facility did not initiate a turning or repositioning schedule for R34. On 11/7/23, R34 was noted to have developed a suspected deep tissue injury to the right heel. The facility did not individualize R34's care plan related to their pressure injury, conduct weekly wound assessments consistently or discuss risks versus benefits related to repositioning with R34 or R34's representative. Findings include: R34 was admitted to the facility on [DATE] with diagnoses of a femur fracture and chronic kidney disease. R34's Braden Scale for Predicting Pressure Sore risk assessment dated [DATE] documented a Braden score of 12, indicating R34 was at high risk for pressure injuries. R34's Admission MDS (Minimum Data Set) assessment dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 13, indicating R34 was noted as cognitively intact in regards to daily decision making. R34's Admission MDS indicated that R34 requires substantial to maximum assistance with mobility and repositioning. R34's MDS also indicated the facility did not initiate a repositioning or turning schedule upon R34's admission to the facility. The MDS assesses R34 to not have any issues with the rejection of care. R34's Quarterly MDS assessment dated [DATE] documented that R34 had a suspected deep tissue injury to the right heel which required daily wound treatments. The MDS assesses R34 to not have any issues with the rejection of care. On 4/29/24 at 1:20 PM, Surveyor noted R34 sitting in a recliner chair in their room. R34 was observed to be wearing gripper socks and was observed with their feet resting directly against the recliner's foot rest. On 4/30/24 at 11:10 AM, Surveyor noted R34 sitting in a recliner chair in their room. R34 was observed wearing gripper socks and was observed with their feet resting directly against the recliner's foot rest. On 4/30/24 at 1:15 PM, Surveyor noted R34 sitting in a recliner chair in their room. R34 was observed wearing gripper socks and was observed with their feet resting directly against the recliner's foot rest. Surveyor reviewed R34's medical record including physician orders, progress notes, and care plans. Surveyor noted R34's skin integrity care plan with initiation date of 10/27/23 documents, The resident has potential/actual impairment to skin integrity related to fall resulting in injury. R34's care plan interventions included: Encourage good nutrition and hydration in order to promote healthier skin, educate resident/family/caregivers of causative factors and measures to prevent skin injury and follow facility protocols for treatment of injury. Surveyor did not note any revisions to R34's skin integrity care plan when R34 developed a suspected deep tissue injury to their right heel on 11/15/23. R34's Electronic Medical Record (EMR) documents the following wound measurements to R34's right heel: -11/15/23: Suspected deep tissue injury to the right heel measuring 2.8 x 2.9 cm (Centimeters). - 11/22/23: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 11/29/23: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 12/6/23: Suspected deep tissue injury to the right heel measured 3 x 3 cm. - 12/13/23: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 12/27/23: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 1/3/24: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 1/25/24: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 1/31/24: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 2/7/24: Suspected deep tissue injury to the right heel measuring 3 x 3 cm. - 3/20/24: Suspected deep tissue injury to the right heel measuring 2 x 2 cm. - 3/27/24: Suspected deep tissue injury to the right heel measuring 2 x 2 cm. - 4/3/24: Suspected deep tissue injury to the right heel measuring 2 x 2 cm. - 4/17/24: Suspected deep tissue injury to the right heel measuring 1.5 x 1.5 cm. - 4/24/24: Suspected deep tissue injury to the right heel measuring 1.5 x 1.5 cm. The facility's Skin/Wound Documentation Guidelines policy and procedure with an initiation date of 7/5/11, documents: The facility will complete through assessments and documentation of pressure ulcers arterial ulcers, venous ulcers, diabetic ulcers, surgical/nonsurgical wounds, significant skin tears and other wounds as indicated following Clinical Practice Guidelines. On 5/1/24 at 10:30 AM, Surveyor interviewed DON (Director of Nursing)-B regarding R34's pressure injuries. Surveyor asked DON-B what the facility's policy is for assessing wounds, including pressure injuries. DON-B responded that weekly assessments should be conducted for pressure injuries. DON-B told Surveyor that the facility's unit managers are responsible for conducting weekly pressure injury assessments. Surveyor asked which unit manager would be responsible for conducting R34's weekly pressure injury assessments. DON-B told Surveyor that R34's unit manager was terminated by the facility recently due to not performing their job duties, including weekly wound assessments and documentation of weekly wound assessments. Surveyor asked DON-B if a resident with a pressure injury should be on a turning and repositioning schedule. DON-B responded that R34 often refuses to be repositioned and refuses the use of offloading heel boots for pressure relief. Surveyor asked DON-B whether or not a resident who has frequent refusals of care or repositioning should have a comprehensive care plan in place to address resident's refusal of care. DON-B responded, Yes, they probably should. Surveyor asked DON-B if risk versus benefits of refusals of pressure relieving devices was ever discussed with R34 or their representative. DON-B told Surveyor they would look into this to see if they could find any documentation regarding risk versus benefit education with R34. On 5/1/24 at 12:45 PM, DON-B informed Surveyor that she could not find any additional information related to R34's pressure injury. On 5/1/24 at 2:10 PM, Surveyor conducted interview with NHA (Nursing Home Administrator)-A and DON-B. Surveyor shared concerns related R34's development of a facility acquired unstageable pressure injury, lack of repositioning schedule, lack of care plan updates and lack of documentation related to alleged refusals of repositioning and use of pressure reducing devices from R34 or their representative. No additional information was provided by the facility as to why R34 was comprehensively assessed for the development of an individualized plan of care with interventions to promote healing, prevent infection and prevent new pressure injuries from forming.

Based on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 serving kitchens. *Cook-J was observed preparing food for residents while not wearing a beard hair restraint. *Server- L was observed walking around the kitchen in areas where food is prepared for residents while not wearing a beard hair restraint. *Server-K was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. This deficient practice has the potential to affect 61 of 61 residents who eat and receive their meals from the main serving kitchen. Findings include: 1. Hair Restraints The facility's policy did not have a last revision date, and titled: Employee Sanitary Practices documents, Policy: All employees will: 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. On 04/29/2024 at 09:06 AM, during the initial tour, Surveyor observed Server-L unloading clean dishes from the dishwasher conveyor belt without wearing a beard hair restraint. Surveyor observed Cook-J walking around the kitchen where food is prepared for residents, without wearing a beard hair restraint. On 04/30/24 at 10:33 AM, Surveyor observed Cook-J, preparing vegetables for a resident meal without wearing a beard hair restraint. On 04/30/24 at 10:34 AM, Surveyor observed Cook-J using a blender while preparing food for a resident meal, without wearing a beard hair restraint. Surveyor also observed Cook-J walk through the kitchen where food is prepared for residents, without wearing a beard hair restraint. On 04/30/24 at 10:36 AM, Surveyor observed Server- L on the clean side of dish washing station, gathering clean dishes without wearing a beard hair restraint. On 05/01/2024 at 10:24 AM, Surveyor observed Cook-J not wearing a beard hair restraint while walking through the kitchen where food is prepared for residents. On 05/01/2024 at 10:16 AM, Surveyor informed Certified Dietary Manager (CDM)-I of above findings. CDM-I informed Surveyor they are waiting for the order of beard restraints to come in and have been substituting beard restraints with hair nets. CDM-I informed Surveyor that the expectation of staff is to always have hair/beards completely covered. On 05/01/24 at 10:24 AM, While Surveyor was leaving the kitchen, Surveyor heard CDM-I instruct Cook-J and Server-L to put beard hair restraints on. On 05/01/2024 at 03:02 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the above findings. 2. Food Handling The facility's policy with no last revision date, and titled: Employee Sanitary Practices documents, Procedure: 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready to eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 04/30/24 at 11:56 AM, Surveyor observed Server-K serving food from the main steam table that serves all the food residents eat. Surveyor observed Server-K, wearing gloves on both hands, touch the counter and their pants with gloved hands, then grab a ready to eat country fried steak with her gloved hands and place the steak on a plate for residents to eat. Surveyor noted that Server-K did not wash her hands or change her gloves after touching non-sanitized food surfaces and prior to touching ready to eat food. On 04/30/24 at 11:58 AM, Surveyor observed Server-K go into the freezer while wearing gloves on both hands and grab a metal cart covered with a plastic bag and pull it into the kitchen area. Surveyor then observed Server-K remove the plastic covering from cart and return to the serving line. Server-K was then observed to grab ready to eat country fried steak while wearing the same gloves and placed it onto a plate for a resident to eat. Surveyor noted that Server-K did not wash her hands or change her gloves after touching non-sanitized food surfaces and prior to touching ready to eat food. On 04/30/24 at 12:01 PM, Surveyor observed Server-K wearing gloves on both hands, touch the counter and pick up a plate lid with both gloved hands. Surveyor then observed Server-K grab ready to eat country fried steak and place it on a plate for a resident to eat. Surveyor noted that Server-K did not wash her hands or change her gloves after touching non sanitized food surfaces and prior to touching ready to eat food. On 05/01/2024 at 10:16 AM, Surveyor informed CDM-I of above findings. CDM-I informed Surveyor that the expectation of staff is that gloves are to be changed in between tasks with proper hand washing. On 05/01/2024 at 03:02 PM, NHA-A and DON-B were informed of the above findings. No further information was provided as to why the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 serving kitchens. 49845

Based on observations, record review and interviews, the facility did not ensure that 1 (R59) of 15 residents reviewed had an individualized comprehensive plan of care. *R59 has bed canes on his bed and has a foley catheter. R59 did not have a comprehensive plan of care with individualized interventions to address the use of bed canes or a foley catheter. Findings Include: Surveyor reviewed the facility's Comprehensive Care Plan policy and procedure dated effective 3/15/18 and noted the following applicable documentation to R59 not having care plans in place for R59's foley catheter and the use of bed canes: .Policy: To develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights that include measurable outcomes and timeframes to meet a Resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Goal: Promote care for a Resident that will attain or maintain the Resident's highest practicable physical, mental and psychosocial wellbeing. STANDARD PRACTICE/PROCEDURE: Interdisciplinary team(IDT) will develop and implement a person-centered comprehensive care plan to meet the Resident's preferences and goals and address the Resident's medical, physical, mental and psychosocial needs. This includes, but is not limited to: . Using an assessment process to determine the Resident's clinical condition, cognitive and functional status and use of services. . Using assessment findings to determine areas of weakness, risk, or need and determining if a care plan and interventions are needed for that area. . Establishing goals that have measurable objectives, interventions, and timeframes. . Identifying what is important to each Resident with regard to daily routines and preferred activities, and having an understanding of the Resident's life before coming to reside in the facility. . Completing the care plan with a Resident centered approach that focuses on the Resident as center of control and supports the Resident in making his or her own choices. Process: IDT will assess Resident and determine needs based on Resident's medical, physical, mental and psychosocial wellbeing. Comprehensive care plan will be created and implemented per stated guidelines. Resident needs and preferences will be communicated to staff via the use of care plans, orders, verbal communication, CNA care plans, etc. Resident needs and goals will be reviewed routinely and changes to the care plan made as needed by the Resident. Communication with the Resident and representative, if applicable will be ongoing. R59 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Bladder, Chronic Kidney Disease Stage 3, Anxiety Disorder, and Restlessness and Agitation. R59 is currently his own person. Surveyor reviewed R59's Admission Minimum Data Set(MDS) dated [DATE] which documents R59's Brief Interview for Mental Status score to be 13, indicating R59 is cognitively intact for daily decision making. R59's Admission MDS also documents R59 has no range of motion impairments, requires supervision for upper body dressing, substantial/maximum assist for lower body dressing, dependence for all transfers and partial/moderate assistance for sit to lying movements. On 4/29/24 at 9:46 AM, Surveyor observed R59 sleeping in bed. R59 was observed to have bed canes on both side of the bed and a foley catheter hanging off the bed. On 4/29/24 at 12:36 PM, Surveyor reviewed R59's electronic medical record. In review of R59's comprehensive care plan, Surveyor was not able to locate a care plan with interventions to address R59's bed canes and foley catheter. Surveyor noted that R59 had a 48 hour baseline care plan that did not document that R59 utilized bed canes for mobility and only documents that R59 has a foley catheter but did not address R59's foley catheter interventions and or goals of care. On 5/1/24 at 8:09 AM, Surveyor interviewed Nursing Care Manager(NCM-D) whom is responsible for completing R59's comprehensive care plans. NCM-D confirmed that there is no documentation for the use of bed canes or a foley catheter for R59. NCM-D confirmed that there should be a care plan in place for the use of R59's bed canes and R59's foley catheter. On 5/1/24 at 11:23 AM, Surveyor shared the concern that R59 did not have a care plan for the use of bed canes and foley catheter with Director of Nursing(DON-B). DON-B confirmed that R59 should have both care plans in place. No further information was provided as to why R59's did not contain the care/services to be furnished with goals, desired outcomes, and interventions in order for R59 to attain or maintain the highest practicable physical well being.

Based on observations, staff interview and record review, the facility did not ensure the environment remained as free of accident hazards as possible for 1(R 36) of 1 residents reviewed for falls. R36 fell in the facility on 3/29/24 and 4/22/24 from R36's recliner. R36's falls were not thoroughly investigated and R36's plan of care was not updated to prevent future falls with person-centered interventions. Findings Include: Surveyor reviewed the facility's Falls policy and procedure dated as modified 4/3/23 regarding R36's two falls and noted the following: Procedure: 1. Upon admission licensed nursing staff will complete the NSG Admit/Readmit Screener 2. Upon admission, quarterly, with a significant COC, licensed nursing staff will complete the 'Morse Fall Scale' form 3. Staff will review: .Cognitive skills .History of falls .Ambulation .Transfer ability .Medications .Diagnosis .And have the ability to add additional safety points if there is a condition or behavior which may escalate a Resident's safety risk 4. The Resident will then receive a score which correlates to level of safety risk. .0-24=low risk 25-44=moderate risk 45+higher=high risk 6. An individualized plan of care to prevent falls will be initiated 8. The Residents' Plan of Care will be monitored and evaluated and approaches, interventions, and goals will be modified as indicated on an ongoing basis. 9. When a Resident falls, the Charge Nurse and RN supervisor of Nurse Care Manager will be called to assess and provide immediate and ongoing direction. 10. The Charge Nurse caring for the Resident that has fallen will complete the following forms: .Skilled Nursing -Fall Incident Form .A note from appropriate licensed and direct care staff providing care to the Resident prior to fall and any witnesses if applicable. 11. The Charge Nurse will initiate an intervention to help reduce risks of future falls. 12. The Charge Nurse will update the Plan Of Care and CNA Care Plan. 13. The Nurse Care Manager/RN Supervisor on duty at time of fall will review all Charge Nurse follow-up and documentation including: .Care plans .Nursing notes .And assure the new intervention/s and any ongoing interventions to prevent future falls are appropriate. 16. Daily, all falls that occur in the Skilled Nursing will be individually reviewed at the Interdisciplinary(IDT) Meeting. .The IDT may review the current fall, history of falls, the Resident's physical and cognitive abilities, and current interventions for the Residents' plan of care and assign responsibilities to facilitate new interventions as indicated. R36 was admitted to the facility on [DATE] with diagnoses of Pathological Fracture, Pelvis, Mixed Incontinence, Localized Edema, Other Abnormalities of Gait and Mobility, Malignant Neoplasm of Thyroid Gland, Parkinson's Disease and Cognitive Communication Deficit. Surveyor reviewed R36's Admission Minimum Data Set(MDS) dated [DATE] documents R36's Brief Interview for Mental Status(BIMS) score to be a 15, indicating that R36 is cognitively intact for daily decision making. R36's Admission MDS documents that R36's range of motion is impaired on 1 side lower extremity and, no range of motion and impairment on upper extremities, substantial/max assist required for toileting, upper/lower dressing, transfers on/off toilet, and chair/bed to chair transfers. R36 is also documented as requiring partial/moderate assist for mobility. R36's fall risk admission assessment dated [DATE] did not determine and document if R36 is low, moderate, or high risk for falls. The assessment also instructs to alert for fall with significant injury in the Resident care profile under special instructions. Surveyor noted that R36 did not have a documented Morse Fall Scale completed as documented in the facility Fall policy and procedure. R36's fall care plan is documented as initiated on 3/13/24. R36's falls care plan documents: Problem:The resident is High, Moderate, Low risk for falls r/t (related to) Deconditioning, Gait/balance problems, Weakness, management of displaced pathologic fracture 2/2 metastatic follicular thyroid carcinoma of the right iliac bone, pain management; Goal: The resident will be free of falls through the review date; Intervention: Anticipate and meet the resident's needs. Date: 3/13/24 Intervention: Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date: 3/13/24 Intervention: Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Date: 3/13/24 Intervention: Bed canes to aid R36 in self positioning. Date: 3/13/24 Intervention: Encourage R36 to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Date: 3/13/24 Intervention: Physical therapy(PT) evaluate and treat as ordered or as needed. Date: 3/13/24 Intervention: Monitor for safety. Date: 3/13/24 Intervention: R36 needs a safe environment with: even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach. Date: 3/13/24 R36's CNA (Certified Nursing Assistant) care card dated 5/1/24 documents: R36 is not to be left alone on toilet/in bathroom due to fall risk-remain within arms reach of Resident. Keep bed in low position when unattended. R36 has had 2 falls in the facility both from R36's recliner. R36's Electronic Medical Record(EMR) incident note dated 3/29/24 documents: Incident Note - Falls Date, Time and Location of Fall: 3/29/24, 4:00 PM Resident's room Vitals, including POX (pulse oximetry), Blood Sugar and Orthostatic BP: BP 130/68 T (temperature) 97.7 P (pulse) 61 R (respirations) 18 POX 92% Describe the fall: Resident found by CNA passing by room lying on her R (right) side in front of her recliner. Resident was attempting to pick up puzzle pieces from the floor when she lost her balance. Neurological checks initiated, resident denied headache, VSS (vital signs stable) Were there any injuries? If so, describe: Raised area/bump to R side of head Bruising and increased pain to R (right) shoulder - X-ray ordered and results pending Date/Time/Name of Physician Update: 3/29/24 @ 1630, NP(nurse practitioner), assessed resident Date/Time/Name of Family update: 3/29/24 @ 1640, daughter updated Position: RN (Registered Nurse) Created By: Registered Nurse(RN-M) R36's Post Fall Report dated 3/29/24 documents: R36 was found by CNA-N laying on right side in front of recliner. CNA-N was assigned to R36 and stated that CNA-N was passing linen and saw R36 on the floor. It is documented R36 was toileted at start of shift, but Surveyor does not know what time that is. R36 was instructed to use the call light for assistance. The report does not document if R36's call light was on at the time of the fall or if there was any device in the recliner. R36's care plan was not updated at this time. Surveyor was unable to located any Interdisciplinary(IDT) meeting notes to review R36's fall. R36's EMR incident note dated 4/22/24 documents: Incident Note - Falls Date, Time and Location of Fall: 4-22-24 7:50 PM Vitals, including POX, Blood Sugar and Orthostatic BP: T 97.9 P 59 R 18 B/P 109/59 pulse ox 91% RA BS 161 Describe the fall: Resident observed sitting on buttocks on floor in front of lounge chair, no bleeding or bruising noted, denies pain, able to move extremities without difficulty, cran (cranium) check negative, up to w/c with assist of 3. Were there any injuries? If so, describe: No injury noted Date/Time/Name of Physician Update: 4-22-24 2010 T NP NNO (No New Orders) Date/Time/Name of Family update: 4-22-24 daughter Position: RN Created By: RN-O R36's Post Fall Report dated 4/22/24 documents: R36 was found sitting on floor next to recliner and reports did not hit head. The report has no documentation from any staff that would have last seen her and what cares provided. It is documented R36 was toileted before supper but Surveyor does not know what time that is. The report does not document why R36 would have been attempting to get out of the recliner. The report does not document if R36's call light was on at the time of the fall or if there was any device in the recliner. R36's care plan was not updated at this time. Surveyor was unable to located any Interdisciplinary(IDT) meeting notes to review R36's fall. On 5/1/24 at 11:47 AM, Surveyor informed Director of Nursing (DON-B) that R36's 2 fall reports were incomplete and that both falls were from the recliner but no intervention(s) were put into place after each fall to prevent future falls. DON-B understands the concerns that a thorough investigation was not completed for both falls and acknowledged that there were no care plan updates as a result of each fall from the recliner. DON-B informed Surveyor that there should have been a new intervention(s) implemented after each of R36's falls. On 5/1/24 at 1:38 PM, Surveyor was provided documentation that the Interdisciplinary Team(IDT) met on 5/1/24 to review R36's falls and implemented a new intervention of putting a sign up reminding R36 to use call light for assistance when needed. No additional information was provided as to why the facility did not ensure that R36 had updated interventions in place to prevent accidents after experiencing two falls from the recline.

Based on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, did not have evidence the risks and benefits of bed rails were discussed with the Resident and/or resident representatives and that informed consent was obtained prior to installation for 2 (R59 and R1) of 4 residents reviewed for repositioning bars. *R59 did not have a physician's order for the use of bed canes or a care plan in place for the use of bed assist bars. There is no documentation that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R59. *R1 does not have an assessment that was updated quarterly that documented that the risks and benefits of bed rails were discussed with the Resident and/or Resident representatives and that informed consent was obtained prior to the installation of half bed rails. R1 did not have any evidence that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R1. Findings Include: Surveyor reviewed the facility's Bed Rails policy and procedure dated effective 1/1/23 and noted the following documentation applicable to R59 and R1: .STANDARD PRACTICE/PROCEDURE: Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed assist bars. Appropriate alternative approaches are attempted prior to installing or using bed assist bars. After completion of bed assist bar use assessment form, if bed assist bars are used, the facility ensures correct installation, use, and maintenance of the bed assists bars along with follow up assessments. Policy Explanation and Compliance Guidelines: Resident Assessment 1. As part of the Resident's comprehensive assessment, the following components will be considered when determining the Resident's needs, and whether or not the use of bed assist bars meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms b. Height and weight c. Sleep habits d. Medication(s) e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely i. Cognition j. Communication k. Mobility(in and out of bed) l. Risk of falling 2. The Resident assessment must include an evaluation of the alternatives that were attempted to prior to the installation or use of a bed assist bar and how these alternatives failed to meet the Resident's assessed needs. 3. The Resident assessment must also assess the Resident's risk from using bed assist bars. Informed Consent 4. Informed consent from the Resident or Resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed assist bars. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. 5. The information that the facility should provide to the Resident, or Resident representative includes, but not limited to: a. What assessed medical needs would be addressed by the use of bed assist bars b. The Resident's benefits from the use of bed assist bars and the likelihood of these benefits c. The Resident's risks from the use of bed assist bars and how these risk will be mitigated d. Alternatives attempted that failed to meet the Resident's needs and alternatives considered but not attempted because they were considered to be inappropriate 6. Upon receiving informed consent, the facility will obtain a physician's order for the use of specified bed assist bar Appropriate Alternatives 7. The facility will attempt to use appropriate alternatives prior to installing or using bed assist bars. Alternatives include, but are not limited to: a. Trapeze bar for use with repositioning b. [NAME] or wheelchair next to bed for use with repositioning and/or transfers until mobility improves c. Two staff when appropriate for repositioning and/or transfers until mobility improves 8. Alternatives that are attempted should be appropriate for the Resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed assist bar was considered. Assessment of the Resident, the bed, the mattress, and bed assist bar for entrapment risk(which would include ensuring bed dimensions are appropriate for Resident size/weight) and risks and benefits were reviewed with the Resident or Resident representative, and informed consent was given before the installation or use. Installation and Maintenance of Bed assist bars 11. The facility will continue to provide necessary treatment and care to the Resident who has bed assist bars in accordance with professional standards of practice and the Resident's choices. a. Direct care staff will be responsible for care and treatment in accordance with the plan of care. b. The nurse manager in collaboration with therapy will complete reassessments in accordance with the facility's assessment schedule. For long term Residents not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/bed assist bar. c. The IDT will make decisions regarding when the bed assist bar will be used or discontinued, or when to revise the care plan to address any residual effects of the bed assist bar. 1) R59 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Bladder, Chronic Kidney Disease Stage 3, Anxiety Disorder, and Restlessness and Agitation. R59 is currently his own person. Surveyor reviewed R59's Admission Minimum Data Set(MDS) dated [DATE] documents R59's Brief Interview for Mental Status(BIMS) score to be 13, indicating R59 is cognitively intact for daily decision making. R59's Admission MDS also documents that R59 has no range of motion impairments, requires supervision for upper body dressing, substantial/maximum assist for lower body dressing, is dependent for all transfers, requires partial/moderate assist for sit to lying movement and substantial/max assist for lying. On 4/29/24 at 9:46 AM, Surveyor observed R59 sleeping in bed. R59 was observed to have bed canes on both sides of the bed. On 4/29/24 at 12:36 PM, Surveyor reviewed R59's electronic medical record(EMR). Surveyor was unable to locate a care plan with interventions to address the use of bed canes by R59. Surveyor noted that R59 had a 48 hour baseline care plan that did not document that R59 utilized bed canes for mobility. Surveyor noted that R59's current physician orders did not contain a physician's order for R59's bilateral bed canes. Surveyor reviewed R59's bed cane assessment data collection tool dated 3/13/24 and noted there was no documentation that the facility attempted to use appropriate alternatives prior to installing or utilizing bed assist bars for R59. On 4/30/24 12:21 PM, Surveyor interviewed R59 regarding the use of repositioning bars. R59 informed Surveyor that R59 uses the repositioning bars to pull self up in bed. On 5/1/24 at 7:58 AM, Surveyor interviewed Director of Nursing (DON-B) who confirmed there should be a physician's order for R59's repositioning bars. On 5/1/24 at 8:09 AM, Surveyor interviewed Nursing Care Manager(NCM-D) who is responsible for completing R59's comprehensive care plans. NCM-D confirmed that there should be a care plan in place for the use of bed canes by R59 and agreed there is no documentation that R59's were current for the use of bed canes. Surveyor noted that R59 did not have a physician's order for the use of bed canes or a care plan in place for the use of bed assist bars. There is no documentation that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R59. 2) R1 was admitted to the facility on [DATE] with diagnoses of Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Lymphedema, Peripheral Vascular Disease, and Major Depressive Disorder. Surveyor reviewed R1's Annual MDS dated [DATE] that documents R1's Brief Interview for Mental Status score to be a 12, indicating R1 demonstrates moderately impaired skills for daily decision making. R1's Annual MDS also documents that R1 has no range of motion impairment on upper extremities, has impairment on both sides of lower extremities, and that R1 is dependent for toileting, upper and lower body dressing, mobility, and transfers. On 4/29/24 at 10:38 AM, Surveyor observed R1 in bed with half siderails on both sides of the bed. R1 appeared to be in a larger bed. R1 informed Surveyor that R1 uses the half siderails to help boost up self up in bed. On 4/29/24 at 12:38 PM, Surveyor reviewed R1's electronic medical record. In review of R1's comprehensive care plan, Surveyor noted the following care plan for the use of side rails: R1 has an ADL self-care performance deficit due to hypoxia, need for O2 (oxygen), weakness, deconditioning, diagnosis of morbid obesity, impaired mobility/transfers requiring assist of 2 and full body lift, right lower extremity weakness due to CVA; Initiated 5/30/17. Intervention in place for bed mobility: R1 is able to: assist with bed mobility with use of 1/2 bed side rails x 2 to aid in self positioning; Initiated 5/30/17. R1's physician orders dated 5/20/2019, documented an order for the use of bilateral half rails, to check placement and function every shift. Surveyor reviewed R1's most recent bed cane assessment data collection tool dated 1/12/23 and noted that the section documenting history of fear of rolling out bed-for bed cane, history of sliding/falling from bed to floor, bed mobility, aid in safe transfer into/out of bed, assist with independence and repositioning is circled. Surveyor noted it was not completed on a quarterly basis and was not updated to evaluate and assess the need for half siderails. Surveyor noted that there is no documentation that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R1. On 5/1/24 at 11:23 AM, Surveyor informed DON-B that R59 did not have a care plan or a physician's order for the bed canes. DON-B confirmed that R59 should have both a care plan and that a physician order is required for the use of bed canes. Surveyor informed DON-B that R1's bed cane assessment does not reflect that R1 is currently using half side rails. DON-B stated that R1's bed probably came with half side rails but confirmed that a new assessment for the use of half side rails should have been completed. Surveyor also informed DON-B that R59 and R 1 did not have any documentation that the facility attempted to use appropriate alternatives prior to installing or using bed assist bars for R59 and R1. No additional information was provided.

Based on record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1 (R59) of 1 sampled residents receiving hospice services. *R59 was admitted on hospice to the facility on [DATE]. R59 did not have a physician certification of terminal illness and the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider. Findings Include: Surveyor reviewed the facility's hospice services policy and procedure dated effective 3/2/18 documents: PURPOSE/POLICY STATEMENT: It is the policy of the facility to have a coordinated plan of care for any Resident electing to utilize the Medicare hospice benefit. The plan of care will reflect the hospice philosophy as well as the individual's needs and living situation in the facility. STANDARD PRACTICE/PROCEDURE: 1. A Resident may use their Medicare hospice benefit when they have received a physician order for the services and have found to qualify through a hospice agency of their or their representative's choice. 2. Once the chosen hospice agency has completed admission paperwork, the care coordination will begin with the hospice team and facility staff. 3. A care plan will be created which will indicate the responsibilities of the hospice agency. 4. The care plan will include directives for pain and other uncomfortable symptom management. The care plan will also identify the care services which the hospice staff and facility staff will provide in order to be responsive to the individual needs of the Resident. 5. The hospice nurse and facility nurse will communicate with each other when any changes are made to the plan of care. 6. A Resident receiving hospice services will continue to receive all personal cares and SNF services from facility staff as they would receive without the hospice services in place. 7. As outlined in their Resident rights, a Resident continues to have the right to refuse services from the hospice agency as well as the facility. 8. The care plan will be kept in the hospice binder located at the Resident's nurse's station. R59 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Bladder, Chronic Kidney Disease, Stage 3, Anxiety Disorder, and Restlessness and Agitation. R59's Admission Minimum Data Set(MDS) dated [DATE] documents a Brief Interview for Mental Status(BIMS) score to be 13, indicating R59 is cognitively intact for daily decision making. R59's Annual MDS also documents that R59 has no range of motion impairments, requires supervision for upper body dressing, substantial/max assist for lower body dressing, full dependence for all transfers, partial/moderate assist for sit to lying. R59's current physician orders did not have a current physician order for hospice services. On 4/29/24 at 11:18 AM, Surveyor attempted to speak with R59. R59 was very angry about a razor not working and not getting a shave and expressed that R59 has 2 sets of hearing aides and neither work. R59 appeared very frustrated, tearful at times, yelling, and stated they don't do anything for me, can't tell them anything. R59 was observed banging on R59's hearing aid cases. On 4/30/24 at 12:42 PM, Surveyor asked Licensed Practical Nurse(LPN-E) for the location of the hospice binder for R59. LPN-E informed Surveyor, I have no idea. On 4/30/24 at 12:44 PM, Surveyor located R59's hospice binder. Surveyor noted R59's hospice binder contained hospice contacts, an updated plan of care dated 4/23/24, progress note which were not current, and a hospice election form that was signed 2/9/24. Surveyor was unable to locate R59's physician certification for terminal illness in the hospice binder. On 4/30/24 at 3:29 PM, Surveyor spoke with Social Worker(SW-C). Surveyor shared concerns that R59 appeared to be agitated as evidenced by Surveyor's interaction with R59 on 4/29/24. SW-E stated that SW-E hasn't observed R59's agitation but staff have commented that R59 has periods of agitation. SW-C informed Surveyor that there has not been a care conference to discuss behaviors with facility and hospice in attendance. On 5/1/24 at 7:57 AM, Surveyor spoke with Director of Nursing(DON-B) regarding R59 and hospice services. Surveyor explained that the physician certification of terminal illness for R59 is not present in R59's hospice binder. Surveyor also shared that the R59's current physician orders do not contain an order for hospice services. DON-B informed Surveyor that she did not believe there needed to be a hospice order for R59 as R59 was on hospice prior to being admitted to the facility. On 5/1/24 at 9:35 AM, Surveyor was provided the physician certification of terminal illness for R59. On 5/1/24 at 10:11 AM, Admissions Director(AD-F) stated AD-F spoke to the hospice representative and the representative would get the certification filed in R59's hospice binder. On 5/1/24 at 10:40 AM, Surveyor interviewed the Hospice Social Worker(HSW-G). HSW-G informed Surveyor that HSW-G had come in to the facility in the morning and spoken to SW-C. HSW-G informed Surveyor that at the time, R59 had asked to rest. Surveyor shared R59's concerns about getting shaved and getting R59's hearing aides fixed. HSW-G stated that SW-C did not communicate R59's concerns and stated that the hospice team will need to meet to discuss a new plan of care for R59. On 5/1/24 at 11:13 AM, AD-F informed to Surveyor that the Hospice Coordinator(HC-H) stated that the physician certification of terminal illness should have been attached to R59's plan of care but that upon further investigation, it was discovered that the physician certification of terminal illness for R59 had not been attached to R59's hospice binder. On 5/1/24 at 11:25 AM, Surveyor shared the concern with DON-B that R59 did not have a physician order for hospice and that the physician certification of terminal illness for R59 should have been attached to the hospice comprehensive care plan on R59's admission. Surveyor shared that R59's care concerns had not been communicated between the facility and hospice in order to facilitate person-centered interventions in order to meet R59's highest practicable physical and psychosocial well being. DON-B acknowledged the concern and provided no additional information. On 5/1/24 at 12:08 PM, SW-C confirmed to Surveyor that she had not shared R59's hearing aides and not getting shaved concerns with HSW-G after Surveyor had informed SW-C of the above concerns. Surveyor noted that the facility had not designated a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and hospice provider. No additional information was provided as to why the facility did not ensure that R59 had a physician certification of terminal illness and why the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider.

Based on observation, record review and staff interview, the facility did not ensure infection control prevention was implemented with hand hygiene. This was based on 1 (R17) of 1 handwashing observations. The facility did not establish an infection control water plan to prevent Legionella in the facility. This has the potential to effect all 53 residents in the facility. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella and the facility's water system. - Identify where control measures should be applied based on where Legionella could grow and spread - Identify acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met - Include a process to confirm the WMP is being implemented and is effective * R17 had cares performed without hand hygiene to prevent spread of infection. Findings include: 1.) Surveyor reviewed the facility's Water Management Program to Reduce Legionella Growth and Spread dated 2/2023. The Policy and Procedure Section indicates the Team job titles only. This included the Director of Plant Operations, Administrator, Director of Nurses and the Infection Preventionist. There is not an identified staff member name, along with their responsibilities. The facility identifies areas of concern through a flow diagram, however does not identify where control measures should be applied and corrective actions. It does not indicate the process to confirm these corrective actions are effective. The Water Flow Diagram indicates water stagnation in the following areas under Fireside East: the East basement sinks and utility rooms; resident room sinks, showers and tub room; Therapy department, RS resident rooms, showers, and tub rooms, Laundry department. The following areas under Fireside West: resident room sinks, showers, West Tub room; central supply; breakroom; education center. The Control Measure and Corrective Actions include: Daily water temperatures at the water heaters. Check for Hardness of the water twice a month. Quarterly cleaning of the ice machines. There is no documentation for the control measures and corrective actions for the other areas listed in the assessment. On 3/28/23 at 8:51 AM Surveyor reviewed the facility's Water Plan for preventing Legionella with DPO-H (Director of Plant Operations). DPO-H indicated they test the water temperature twice a day at the mixing point. The mixing point then goes out to the resident rooms. They look for 140 degrees Fahrenheit at water heater and check the temperature when going out to the rooms. DPO-H did not have documentation that the water has been at 140 degrees Fahrenheit at the mixing area that included corrective action. DPO-H did not have documentation how the spa rooms and resident rooms are being tested . DPO-H indicated the facility has a full census most of the time. DPO-H indicated when housekeeping cleans they run the water to clean everything. DPO-H did not provide the control measures or corrective action for housekeeping responsibilities. DPO-H did not have any testing information on the Spa rooms. DPO-H feels housekeeping runs the water, however does not have definitive measuring for unoccupied rooms or other areas. The resident rooms and areas on the Unit's were not included in the current policy and procedures. DPO-H indicated they will add this information to the policy and procedure. On 3/29/23 at 8:01 AM Surveyor spoke with DON-B (Director of Nurses) who is also the facility's Infection Preventionist. DON-B indicated they do not have Water Plan Committee meetings. The DPO-H will tell them if there is a water concerns. DON-B will also look further if their is an undiagnosed respiratory concerns. DON-B was not aware of control measure and corrective actions with the water flow in the facility. On 3/29/23 at 2:00 PM Surveyor shared the concerns regarding the Water Plan Program at the facility Exit Meeting with DON-B (Director of Nurses) and Administrator-A. There was no further information provided. 2.) The facility policy, entitled Hand Hygiene, dated 10/25/2019, states: POLICY: Hand hygiene continues to be the primary means of preventing the transmission of infection and controlling cross-contamination between residents and staff. All facility staff will adhere to the CDC hand hygiene guidelines. PROCEDURE: Alcohol based hand rub (ABHR) is the new preferred form of hand hygiene if hands are not visibly soiled. ABHR cannot be used for the following and employees must wash their hands with soap and water: 1. Your hands are soiled with proteinaceous material or visibly soiled with blood or other body fluids. 2. Before eating. 3. After using the restroom. 4. any exposure to spore producing bacterial such as C-diff (clostridium difficile). R17 was admitted to the facility on [DATE] with diagnoses of diverticulitis, colon cancer, frontotemporal neurocognitive disorder, bipolar disorder, depression, rheumatoid arthritis, anxiety, and aphasia. R17's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R17 was severely cognitively impaired per staff interview and needed extensive assistance with bed mobility, transfers, dressing, eating, toileting, and hygiene. R17 was admitted to the facility after falling at an assisted living facility and fracturing their hip. On 3/27/2023 at 1:32 AM Surveyor observed certified nursing assistant (CNA)-G and CNA-J assist R17 to the bathroom. CNA-G had gloves on and removed R17's adult brief and threw it out in the garbage, CNA-G grabbed a new adult brief and put it on R17. CNA-G performed perineal care for R17 and pulled up R17's pants and assisted R17 into wheelchair. CNA-G touched R17's call light and put in R17's reach along with a picture book that was on R17's dresser. Surveyor observed CNA-G did not change disposable gloves after taking off the adult brief for R17 or after completed perineal cares for R17 after R17 used the toilet. CNA-G did not remove gloves and wash hands before pulling R17's pants up or giving R17 the call light and picture book. On 3/29/2023 at 2:10 PM Surveyor informed the Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of observation of CNA-G not changing disposable gloves or performing hand hygiene during and after cares for R17.

Based on observation, record review and staff interview, the facility did not develop and implement a comprehensive person-centered care plan for 3 (R24, R31, and R47) of 14 residents reviewed. -R24, R48 did not have a comprehensive plan of care related to the use of motion sensing alarms. -R31 did not have a comprehensive plan of care addressing the use of anticoagulant medication. -R47 did not have a comprehensive plan of care addressing the use of psychotropic medications. Findings include: The facility's policy and procedure entitled, Comprehensive Care Plan, dated 3/15/2018 was reviewed by Surveyor and documents in part, -The interdisciplinary team will develop and implement a person-centered comprehensive care plan to meet the resident's preferences and goals and address the resident's medical, physical, mental and psychosocial needs. - Using an assessment process to determine the resident's clinical condition, cognitive and functional status and use of services. - Establishing goals that have measurable objectives, interventions and timeframe's. 1) R24's medical record was reviewed by Surveyor. R24's Significant Change in Status MDS (minimum data set) assessment dated [DATE], and Admission MDS on 11/15/22, documents a bed and chair alarm are used daily. R24's Fall Risk Assessment documented on 11/9/22 and 2/25/23 indicates R24 is at high-risk for falls. R24's medical record did not contain an assessment, or plan of care indicating the assessed need and use of the chair and bed alarms. On 3/27/23, at 9:59 AM, Surveyor observed and spoke with R24 in their room. R24 was not able to answer questions appropriately. R24 was dressed, sitting in a wheelchair, and had a chair alarm attached to the back of their shirt. On 3/28/23, at 8:31 AM, Surveyor observed R24 in their wheelchair in the dining room. R24 had a chair alarm attached to the back of their shirt. On 3/29/23, at 10:15 AM, Surveyor spoke with MDS Nurse-I (Minimum Data Set). MDS-I indicated restraint use should be addressed in the care plan. MDS nurse-I stated sometimes there is a note in the care plan that refers staff to look at the CNA (Certified Nursing Assistant) care plan. R24's plan of care was reviewed during this interview. Surveyor noted R24's care plan was not comprehensive and did not identify the use of physical restraints. MDS-I did not have any further information. On 3/29/23, at 10:30 AM, Surveyor spoke with R24's (Unit Manager) UM-C. UM-C indicated they use the alarms as a monitoring tool. UM-C reviewed R24's plan of care during this interview. UM-C indicated they did not know they should include the use of alarms in the care plan. On 3/29/23, at 2:00 PM, Surveyor shared the concerns related to R24's care plan during the daily Exit Meeting with DON-B (Director of Nurses) and Administrator-A. There was no further information provided. 2) R31's medical record was reviewed by Surveyor. R31's Physician Orders indicate Eliquis 5 mg (milligrams) every day for A-fib (Atrial Fibrillation) with a start date of 1/27/21. R31's Quarterly MDS (minimum data set) assessment completed on 3/6/23, and a Annual MDS assessment completed on 6/6/2022, documents daily use of an anticoagulant medication. R31's plan of care was reviewed by Surveyor. There is no indication R31 is receiving an anticoagulant medication, along with interventions to monitor for side effects. Eliquis is a blood thinner and can cause bruising and bleeding per manufactures side effects. On 3/29/23, at 10:15 AM, Surveyor spoke with MDS nurse-I (Minimum Data Set). MDS-I indicated they did not develop a plan of care for this medication. MDS-I indicated the management on the Unit are responsible for creating the care plans. On 3/29/23, at 10:29 AM, Surveyor spoke with the (Unit Manager) UM-C for R31. UM-C stated they did not know the medication needed to be care planned. On 3/29/23, at 2:00 PM, Surveyor shared the concerns with R31's care plan at the daily Exit Meeting with DON-B (Director of Nurses) and Administrator-A. There was no further information provided. 38253 4) R47 was admitted to the facility on [DATE] and had diagnoses that include chronic kidney disease, major depressive disorder, anxiety disorder, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance with anxiety, unsteadiness on feet and weakness. R47's quarterly minimum data set (MDS) dated [DATE] indicated R47 had severely impaired cognition with a brief interview for mental status (BIMS) score of 3: requires extensive assist with all cares; receives antipsychotics and antianxiety medications daily. R47's Physician orders indicate R47 was taking: 1.Zoloft Concentrate (Sertraline HCL)- Give 100mg (milligrams) by mouth in the afternoon for anxiety. Start date of: 11/4/2022 2. Buspirone HCl tablet 10mg- Give 1 tablet by mouth with meals for anxiety three times a day. Start date of: 2/23/2023 3. Risperdal solution (risperidone)- Give 0.5 mg by mouth two times a day for delusions. Start date of: 11/17/2022 R47's Psychotropic Medication use Care Plan was initiated on 3/27/2023. On 3/29/2023, at 1:08 PM, Surveyor interviewed the Director of Nursing (DON)- DON-B replied that care plans should be initiated right away at the start of psychotropic medication use. DON-B replied that unit managers usually initiate the care plans. On 3/29/2023, at 2:40 PM ,Surveyor interviewed Registered Nurse Unit Manager (RNUM)-C. RNUM-C replied that RNUM-C has been in the position as RNUM for 1 1/2 years and was not up on how to do care plan monitoring. RNUM-C replied RNUM-C has started to update residents care plans after speaking with other Surveyors. Surveyor asked RNUM-C if R47's care plan for psychotropic drug use was initiated on 3/27/2023 by RNUM-C. RNUM-C replied that RNUM-C did not know who initiated R47's psychotropic care plan on 3/27/2023 but RNUM-C did not initiate R47's psychotropic medication care plan. On 3/29/2023, at 2:10 PM, Surveyor informed the Nursing Home Administrator (NHA)-A and DON-B Surveyors concern that R47's care plan for psychotropic drug use was not initiated until 3/27/2023. No further information provided at that time. 42037 3) R48 was admitted to the facility on [DATE] with diagnoses of Alzheimers disease, depression and anxiety disorder. R48's Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicates R48 is rarely to never understood. R48's Quarterly MDS dated [DATE] indicates R48 utilizes a sensor floor mat on a daily basis. R48's medical record was reviewed by Surveyor. The medical record did not contain a comprehensive care plan related to usage of sensor floor mat. On 3/27/23, at 10:15 AM, Surveyor observed R48 in their room. R48 was dressed sitting in a recliner chair. R48 was not able to respond appropriately to questions posed by Surveyor. Surveyor noted a sensor floor mat on the floor next to R48's recliner. On 3/28/23, at 7:45 AM, Surveyor observed R48 in bed. R48 had 2 thick floor mats in place with sensor floor mat on top next to bed. On 3/29/23, at 10:10 AM, Surveyor conducted interview with MDS (Minimum Date Set) nurse-I. Surveyor asked MDS-I why R48's sensor floor mat use was not addressed on R48's comprehensive care plan. MDS-I told Surveyor that they are not responsible for care plan updates and that unit managers should be updating care plans. MDS-I did not have any further information to share with Surveyor at this time . On 3/29/23, at 10:40 AM, Surveyor conducted interview with UM (Unit Manager)-C. Surveyor asked who would be responsible for implementing comprehensive care plans. UM-C responded that comprehensive care plans should be initially generated by the resident's MDS and then updated thereafter by nursing staff. Surveyor asked UM-C if a resident has an alarm in usage if that should be addressed on a resident's care plan. UM-C responded Yes. On 3/29/23, at 2:20 PM Surveyor shared concerns with NHA (Nursing Home Administrator)-A and DON (Director of Nurses)-B related to the lack of a comprehensive care plan initiation for R48's sensor floor mat usage. The facility did not provide any additional information at this time.

Based on observation, interview, and record review, the facility did not ensure residents comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 8 (R109, R24, R31, R50, R19, R17, R46 and R48) of 14 resident record reviews. -R109, R24, R50, R19, R17, and R48 had falls in the facility and their comprehensive plan of care was not revised after the fall assessment. -R31 comprehensive plan of care was not revised to indicate their refusals to wear tubi-grips and socks. - R46 comprehensive plan of care was not revised with antipsychotic medication use. Findings include: The facility policy and procedure for Comprehensive Care Plans dated 3/15/18 was reviewed by Surveyor. The procedure includes: -The interdisciplinary team will develop and implement a person-centered comprehensive care plan to meet the resident's preferences and goals and address the resident's medical, physical, mental and psychosocial needs. -Using an assessment process to determine the resident's clinical condition, cognitive and functional status and use of services. -Establishing goals that have measurable objectives, interventions and timeframe's. - Identifying areas where a resident may refuse treatment or services that professional staff believes may be indicated to assist the resident in reaching his or her highest level of well-being or keep the resident safe. -Establishing, documenting and implementing the care and services that will maintain or attain the resident's highest practicable quality of life. 1) R109's medical record was reviewed by Surveyor. R109 was admitted on [DATE] for rehab services for a hip fracture from a fall in the community. R109 had an Entry Tracking MDS (Minimum Data Set) assessment completed on 3/17/23 and 3/23/23. R109 has not had an Admission MDS completed at this time. The 3/18/23 fall assessment indicates R109 was a sit-to-stand transfer with assist of 2 staff. R109 was transferred with 1 staff assist with the sit-to-stand and a fall occurred during this transfer. R109 was then transferred from the floor with a mechanical lift and 3 staff into bed. R109 was transferred to the hospital for evaluation. R109 returned back to the facility with physician orders for non weight bearing status. Surveyor reviewed R109's plan of care. R109's plan of care documents moderate risk for falls related to chronic back pain, decreased mobility and need for assist date initiated 1/13/2020, and a goal date of 4/18/2023, and a revision date of 3/21/23. R109's plan of care does not document the fall R109 sustained on 3/18/23. R109 has a plan of care for Activity of Daily Living self-care performance, date initiated 2/5/2020 and a goal date of 4/18/2023 and a revision date of 3/21/23. This plan of care indicates R109 requires 1 staff assist with a wheeled walker and gait belt. The plan of care does not accurately identify R109's current transfer and mobility status. On 3/27/23, at 9:20 AM, Surveyor observed and spoke with R109 in their room. R109 was in a recliner with a A-frame between their legs. R109 indicated they were here for rehab due to a fall with fracture and then fell here. R109 indicated they are not walking. On 3/28/23 at 9:27 AM Surveyor spoke with the Administrator-A regarding additional information related to R109 fall on 3/18/23. Administrator-A conducted an investigation into the fall and discovered the CNA (Certified Nursing Assistant) did not follow the plan of care of 2 staff with sit-to-stand. R109 was a 2 staff assist with a sit-to-stand. The plan of care was not followed and resident fell and displaced their hip, which was previously fractured. On 3/29/23, at 10:08 AM Surveyor spoke with MDS-I. MDS-I reviewed R109 plan of care during the interview. The plan of care was not revised to include the fall and transfer status, MDS-I indicated the Nursing Admission Screener has paper baseline care plans, however they were not updated. MDS-I indicated the computer system leaves the old care plans in there. The resident care plans are not resolved when a resident is discharged . MDS-I stated they will use the ones in the system and just revise them. MDS-I stated R109's current plan of care in the electronic record is the ones they are using. MDS-I had no further information as to why R109 plan of care did not identify R109 current transfer status. On 3/29/23, at 2:00 PM, Surveyor shared the concerns related to R109's care plans not being revised during the daily exit meeting with Administrator-A and DON-B (Director of Nurses). No further information was provided. 2) R24 medical record was reviewed by Surveyor. R24 had the following falls per Progress Notes and Post Fall Reports: -2/12/2023, at 3:07 PM, had a fall with no injury. The facility post fall assessment dated [DATE] indicates to continue current plan of care. The follow up fall interdisciplinary note (2 days later) on 2/14/23, at 12:50 PM, indicates all interventions in place met the goal of being effective in preventing injury to the resident. Continue current plan of care. R24 plan of care was reviewed by Surveyor. R24's care plan documents R24 is at a high risk for falls initiated 12/10/2022 with a goal date of 6/13/2023 and revised on 3/21/2022. There is no indication of the fall on 2/12/23, and no revision to the care plan to address the root cause for the fall. On 2/8/2023, at 4:15 PM had a fall with no injury. The follow-up fall interdisciplinary note on 2/9/23 indicates all interventions in place met the goal of being effective in preventing major injury to the resident. continue current plan of care. R24 plan of cares were reviewed by Surveyor. R24 has a high risk for falls indicated 12/10/2022 with a Goal date of 6/13/2023 and revised on 3/21/2022. There is not indication of this fall on 2/8/23, along with any review or revision. -1/18/23 at 5:00 PM had a fall with no injury. There is no follow-up fall interdisciplinary note. There is no care plan documentation on the Post Fall Report from 1/18/23. R24 plan of cares were reviewed by Surveyor. R24 has a high risk for falls indicated 12/10/2022 with a Goal date of 6/13/2023 and revised on 3/21/2022. There is not indication of this fall on 1/18/23, along with any review or revision. -1/11/23 at 10:48 PM had a fall with no injury. The follow-up interdisciplinary note on 1/12/23 indicates to encourage recliner after lunch, to read the paper. R24 plan of cares were reviewed by Surveyor. R24 has a high risk for falls indicated 12/10/2022 with a Goal date of 6/13/2023 and revised on 3/21/2022. There is not indication of this fall on 1/11/23, along with any review or revision. A Fall Risk Assessment conducted on 11/9/22 and 2/25/23 indicates a high-risk for falls. On 3/29/23 at 10:00 AM Surveyor spoke with MDS-I (Minimum Data Set). MDS -I will look at resident care plans when MDS assessment is completed. MDS-I does not update the plan of care with falls. The Falls care plan's are updated at the time of the fall. MDS-I attends stand up meetings where falls are discussed. MDS-I did not identify a designated staff that revises the plan of care On 3/29/23 at 10:34 AM Surveyor spoke with R24 (Unit Manager) UM-C. On 1/12/23 they encouraged the recliner and to read the paper. UM-C may have put that on the assignment sheet and then would put on the care plan. R24 plan of care was reviewed during this interview. UM-C indicated the 1/18/23 fall R24 was weak. They changed them to a sit-to-stand then changed to 1 assist with gait belt in February. UM-C has not added any interventions to the plan of care. The fall on 2/28/23 nothing was changed with the fall care plan interventions. UM-C indicated we couldn't think of anything else to do. The same for the fall on 2/12/23. Nothing was changed for fall interventions. UM-C feels R24 just self transfers. They use an alarm to alert staff that R24 is standing up. UM-C has not been updating the plan of care after falls, along with reviewing or revision of interventions. On 3/29/23 at 2:00 PM Surveyor shared the concerns with R24 plan of care at the facility Exit Meeting with Administrator-A and DON-B (Director of Nurses). No further information was provided 3) R31's medical record was reviewed by Surveyor. R31 is non-interviewable and is dependent on staff for activities of daily living. R31 CNA Kardex dated 3/27/23 indicates tubi-grips to lower extremities and gripper socks on at all times. R31 plan of care was reviewed. R31 has a plan of care for potential/actual impairment to skin integrity initiated date of 4/23/2019 and a Goal date of 5/25/23. This care plan indicates an intervention of tubi-grips on in the AM and off at bedtime for edema, dated 7/19/2020. And an intervention to identify/document potential causative factors and eliminate/resolve where possible dated 4/23/2019. On 3/27/23, at 10:01 AM, Surveyor observed R31 in the common area on the Unit. R31 was sitting in a wheelchair with no foot pedals. R31 had Capri length slacks exposing their lower legs. R31 had regular sneakers on their feet with no socks. They did not have tubi-grips on their legs. Their legs appeared dry. R31 had their head down and was not interviewable at this time. On 3/28/23, at 8:32 AM, Surveyor observed R31 in the dining room. R31 was in a wheelchair with no foot pedals. R31 was wearing sneakers without socks. R31 had Capri length pants and did not have tubi-grips on their legs. On 3/29/23, at 10:27 AM, Surveyor spoke with R31's (Unit Manager) UM-C. UM-C indicated R31 refuses to wear tubi-grips and socks. R31 plan of care was reviewed during this interview. UM-C indicated there is no plan of care related to refusals and R31 has not worn anything on their feet for a long time. UM-C indicated they did not know they should revise the plan of care. On 3/29/23, at 2:00 PM, Surveyor shared the concerns with R31's plan of care at the daily exit meeting with Administrator-A and DON-B (Director of Nurses). No further information was provided. 38253 4) R50 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, ulcerative colitis, glaucoma, and cognitive communication deficit. R50's admission Minimum Data Set (MDS) assessment dated [DATE] documents R50 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12; and required extensive assistance with all activities of daily living. R50's High Risk for Falls Care Plan was initiated on 12/2/2022 with no interventions. Interventions were added to the High Risk for Falls Care Plan on 12/5/2022: -Be sure call light is within reach and encourage the resident to use it for assistance as needed; resident needs prompt response to all requests for assistance. -Ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. -Physical Therapy evaluate and treat as ordered or as needed. On 12/11/2022, at 3:57 AM, in the progress notes, nursing charted the nurse received a call that at 1:15 AM, R50 was found sitting on the floor, scooting out into the hallway. The Post Fall Report for the 12/11/2022 fall at 1:15 AM documented R50 stated they had slid out of bed and moved themselves. The root cause of the fall was R50 trying to get up on own. Nursing stated the incident was an isolated event and no new fall prevention interventions were needed at that time. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because the incident is an isolated event. R50's High Risk for Falls Care Plan was not revised on 12/11/2022 with any interventions to prevent future falls. On 12/14/2022, at 3:30 AM, in the progress notes, nursing charted an incident note for a fall that occurred on 12/13/2022 at 10:55 PM. R50 was found by a CNA sitting outside of R50's room in the hall with R50's back resting on the left side of the door frame as if to be entering the room. The Post Fall Report for the 12/13/2022 fall at 10:55 PM documented R50 stated R50 did not know what they wanted to do prior to the fall. New intervention put in place to help prevent further falls or injury from falls was an alarming floor mat to be placed at bedside. The form indicated the intervention had been implemented and the Care Plan was revised. R50's High Risk for Falls Care Plan was not revised on 12/13/2022 with the new intervention of placing an alarming floor mat at bedside. On 12/14/2022, at 7:21 PM, in the progress notes, nursing charted an incident note for the fall on 12/14/2022 at 6:50 PM. R50 was found sitting in front of the recliner, sitting on the buttocks but had rolled onto the left side. The Post Fall Report for the 12/14/2022 fall at 6:50 PM documented a new interventions put in place to prevent future falls were a floor mat and sensor pad. The sensor pad was to be placed near R50 when in the recliner or wheelchair. The report indicated the Care Plan was revised. R 50's High Risk for Falls Care Plan was not revised on 12/14/2022 with any interventions to prevent future falls. On 12/15/2022, at 6:51 PM, in the progress notes, nursing charted an incident note for a fall on 12/15/2022 at 5:45 PM in R50's room. Nursing charted a medication [NAME] was walking past R50's room and witnessed R50 sliding out of the chair onto the floor. The Post Fall Report for the 12/15/2022, fall at 5:25 PM, documented R50 stated R50 was trying to get out of bed. A new intervention to prevent future falls was a urinalysis with culture and sensitivity order. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because the fall caused by (UTI) increased confusion. R50's High Risk for Falls Care Plan was not revised on 12/15/2022 with any interventions to prevent future falls. On 12/16/2022, at 3:52 AM, in the progress notes, nursing charted an incident note for a fall that occurred on 12/16/2022 at 12:13 AM in R50's room. R50 had an unwitnessed fall from bed onto an alarming sensor floor mat. The Post Fall Report for the 12/16/2022, fall at 12:13 AM, documented R50 had an unwitnessed fall out of bed onto an alarming sensor mat. The root cause of the fall was R50 trying to get up on their own and thinking they were going home. No new interventions were put in place to prevent further falls or injury from falls. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because the resident being evaluated for possible UTI - has symptoms and a urinalysis with culture and sensitivity to be obtained and many interventions are already in place. R50's High Risk for Falls Care Plan was not revised on 12/16/2022 with any interventions to prevent future falls. On 12/17/2022, at 1:33 PM, in the progress notes, nursing charted R50 had a fall that morning with no new injuries noted. The Post Fall Report for the 12/17/2022, fall at 6:39 AM, documented R50 was found sitting on the floor mat next to R50's bed. A potential factor for the fall was impaired cognitive function. The root cause of the fall was R50 wanted to go to the bathroom and could not remember to use the call light for help. New interventions to prevent further falls was 15-minute checks for three days. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because No revision needed. Resident frequently monitored x (times) 3 days. R50's High Risk for Falls Care Plan was not revised on 12/17/2022 with any interventions to prevent future falls. On 12/19/2022 at 12:29 PM, in the progress notes, nursing documented the IDT (Interdisciplinary Team) note for R50's fall on 12/13/2022, at 10:55 PM, six days after the fall occurred. Nursing documented R50 had impaired cognitive function due to Parkinson's Disease with periods of confusion. R50 was forgetful and restless at times and R50 was unable to explain what R50 was attempting to do at the time of the incident. The IDT felt as if placing an alarming floor mat at bedside would be helpful for notifying staff when R50 attempts to get out of bed. R50's High Risk for Falls Care Plan was revised on 12/19/2022 with the following intervention: alarming floor mat placed at bedside or next to recliner to notify staff if R50 attempts to self-transfer. Surveyor noted this intervention had been implemented on 12/13/2022 when referenced after a fall but had not been added to R50's care plan. On 12/22/2022, at 10:04 PM, in the progress notes, nursing charted an incident note for a fall on 12/22/2022, at 5:00 PM, in R50's room. R50 was found sitting on the buttocks in front of the bed. The Post Fall Report for the 12/22/2022, fall at 5:00 PM, documented R50 was found sitting on the buttocks. R50's statement was they did not know what they were doing. New interventions to prevent further falls or injury from falls: No new interventions necessary. Has multiple safety precautions in place. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Resident has multiple safety precautions in place. Fall is due to impaired cognition. On 12/22/2022, at 10:09 PM, in the progress notes, nursing charted an incident note for a fall on 12/22/2022 at 5:20 PM, in R50's room. R50 was found lying on the floor on the back with a cover under the head. The Post Fall Report for the 12/22/2022, fall at 5:20 PM, documented R50 was found lying on the floor on the back with a cover under the head. The root cause of the fall was R50 had impaired cognitive function and decreased safety awareness. New interventions to prevent further falls or injury from falls: No new interventions necessary at this time. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Resident has many safety precautions in place. Surveyor noted R50 had two falls on 12/22/2022 that were twenty minutes apart. No new interventions were identified to prevent future falls. On 12/24/2022, at 7:55 PM, in the progress notes, nursing charted an incident note for a fall on 12/24/2022 at 6:45 PM in R50's room. R50 was found sitting on the buttocks on the right side of the recliner. The Post Fall Report for the 12/24/2022 fall at 6:45 PM documented R50 was found sitting on the buttocks on the right side of the recliner. R50 did not know why R50 was trying to get up. The root cause of the fall was due to neurocognitive disorder and impaired judgement. New interventions put in place to prevent further falls or injury from falls: No new interventions. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Fall due to neurocognitive disorder. Multiple precautions in place for safety. R50's High Risk for Falls Care Plan was not revised on 12/24/2022 with interventions to prevent future falls. .On 1/1/2023, at 7:48 AM, in the progress notes, nursing charted an incident note for a fall on 1/1/2023 at 7:30 AM. R50 was found on the floor. R50 stated R50 had moved their legs around and got onto the floor mat and then onto the floor. The Post Fall Report for the 1/1/2023 fall at 7:30 AM documented R50 was found sitting on the floor near the wheelchair. R50 stated that R50 tried to move the feet off the bed, got on the floor, and then proceeded to scoot across the floor toward the wheelchair. The root cause of the fall was R50 was attempting to self-transfer and ended up on the floor. New interventions put in place to help prevent further falls or injury from falls: No new interventions. Resident has impaired cognitive function and has impaired judgement. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Resident continues to self-transfer. Multiple precautions in place for safety. R50s' High Risk for Falls Care Plan was not revised on 1/1/2023 with any interventions to prevent future falls. On 1/10/2023, at 12:22 PM, in the progress notes, nursing documented an IDT note for the fall on 12/15/2022 at 5:25 PM, twenty-six days after the fall. The IDT determined R50 had a UTI which caused increased confusion that lead to multiple falls. No new interventions were documented on the plan of care. On 1/10/2023 at 1:38 PM in the progress notes, nursing documented an IDT note for the fall on 12/16/2022 at 12:13 AM, twenty-five days after the fall. The IDT determined R50 had a UTI which caused increased confusion and impaired safety awareness due to impaired cognitive functioning. No new interventions were documented on the plan of care. On 1/10/2023, at 2:31 PM, in the progress notes, nursing documented an IDT note for the fall on 12/17/2022 at 6:39 AM, twenty-four days after the fall. R50 was placed on 15-minute checks immediately after the incident. The IDT determined R50 should be placed on 15-minute checks due to impaired cognitive function and the inability to remember to use the call light. This intervention was not added to R50's plan of care. On 1/10/2023, at 2:55 PM, in the progress notes, nursing documented an IDT note for the fall on 12/22/2022 at 5:00 PM, nineteen days after the fall. The IDT determined R50 fell out of bed due to impaired safety awareness related to impaired cognition. No new interventions were documented in R50's plan of care. On 2/2/2023, at 1:55 AM, in the progress notes, nursing charted an incident note for a fall on 2/2/2023, at 1:55 AM. R50 was found sitting with bedding on the floor mat between the bed and the wall. The Post Fall Report for the 2/2/2023, fall at 1:55 AM documented R50 had no statement of what happened or what R50 was trying to do at the time of the fall. The root cause of the fall was the new room arrangement did not have the bed against the wall as in the prior room. The new intervention put in place to help prevent further falls or injury from falls was to move the bed along the wall and to remove the gap on the other side of the bed with a low bed mat and sensor mat. The High Risk for Falls Care Plan was not revised on 2/2/2023 with any interventions to prevent future falls. No documentation was found in R50's medical record to indicate the bed should remain next to the wall to prevent falls. On 2/25/2023, at 6:41 AM, in the progress notes, nursing charted an incident note for a fall on 2/25/2023 at 6:10 AM. R50 rolled out of bed onto the floor mat at bed level with the sensor alarm and pulled a lamp into bed with R50. The Post Fall Report for the 2/25/2023, fall at 6:10 AM, documented R50 pulled a lamp down after rolling onto a high level mat causing a skin tear. The root cause of the fall was restlessness. New intervention put in place to prevent further incidents: No new interventions necessary. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Incident is an isolated event. The High Risk for Falls Care Plan was not revised on 2/25/2023 with any interventions to prevent future falls or injury. On 2/28/2023, at 10:15 AM, in the progress notes, nursing documented an IDT note for the fall on 2/2/2023 at 1:55 AM, the IDT determined the fall was due to severe neurocognitive impairment with forgetfulness and attempts to self-transfer. The IDT determined R50's room should be rearranged to remove the gap to prevent the incident from occurring again. Surveyor noted the High Risk for Falls Care Plan was never revised to indicate the intervention of the room being rearranged. On 3/4/2023, at 3:18 AM, in the progress notes, nursing charted an incident note for a fall the occurred on 3/3/2023, at 11:10 PM. R50 was found resting on the right side on the floor between the closet and the bathroom door. The facility did not complete a post fall report for this fall and did not determine the root cause of the fall or identify interventions to prevent future falls. R50's care plan was not revised after this fall. On 3/8/2023, at 7:25 PM, in the progress notes, nursing charted an incident note for a fall that occurred on 3/8/2023, at 7:20 PM. R50 was found sitting on the buttocks on the floor in R50's room. The facility did not complete a post fall report for this fall and did not determine the root cause of the fall or identify interventions to prevent future falls. R50's care plan was not revised after this fall. On 3/27/2023, at 10:13 AM, in the progress notes, nursing documented an IDT note for the fall on 3/8/2023 at 7:20 PM, nineteen days after the fall. The IDT determined R50 had neurocognitive impairment with impaired judgement and periods of anxiety and restlessness. The IDT felt as if R50 was placed in bed too early and the intervention of placing R50 in bed around 9:00 PM would be implemented. This intervention was documented on R50's High Risk for Falls Care Plan. In an interview on 3/29/2023 at 8:46 AM, Surveyor asked RN Unit Manager (RNUM)-D what the process was for the facility when a resident has a fall. RNUM-D stated the IDT meets daily and they discuss all the incidents that occurred the previous day and Monday includes anything that happened over the weekend. RNUM-D stated if anything is needed to be done right away, the intervention is put in place. Surveyor asked RNUM-D if all interventions are added to the Care Plan. RNUM-D stated that would depend on the circumstance if the Care Plan was updated or not. Surveyor gave RNUM-D an example: if a resident is reaching for a glass of water and falls while reaching, would the Falls Care Plan show an intervention to have the residents water within reach. RNUM-D stated an intervention such as water being put in reach would be put on the Kardex so the CNA staff would know what should be done, but that intervention would not necessarily be in the Falls Care Plan. Surveyor asked RNUM-D how often the Kardex was updated and if there was a history to show when an item was added to the Kardex. RNUM-D stated some resident Kardex's are updated more than others. RNUM-D was not sure if there was a way to see a history of added items to the Kardex. Surveyor shared with RNUM-D the concerns with R50's multiple falls: care plans were not revised with interventions to prevent future falls, and no re-evaluations of current interventions after falls occurred to determine if those interventions were adequate in preventing future falls. RNUM-D provided R50's Kardex to Surveyor. R50's Kardex had the following interventions for safety: -Alarming floor mat to be placed at bedside or when resident is in recliner for safety. -Alarming floor mat(s)- check function every shift. -Clip alarm when in wheelchair. -Do you not leave resident alone on toilet or in bathroom due to fall risk, remain within arm's reach of resident. -Gripper socks on at all times. -keep bed in low position when unattended. -Non alarm floor mat to bedside for safety. -Wide bed. In an interview on 3/29/2023 at 10:00 AM, MDS-I stated the resident's Care Plan is updated and revised with the MDS assessment, either quarterly or with a significant change. MDS-I stated the Fall Care Plan is not updated by MDS-I unless MDS-I was working as a supervisor, and then MDS-I would update the Fall Care Plan. MDS-I stated the Care Plan can be updated by the Unit Manager or the nurse that works on the floor. MDS-I stated staff talk about falls daily at stand up and they go around the table to each Unit Manager to discuss each incident. MDS-I stated voicemail messages are left for Nursing Home Administrator (NHA)-A and DON-B so they know to bring up the fall in morning meeting; sometimes the Unit Manager has not been to their unit before coming to morning meeting so would not be aware of a fall. Surveyor shared the concern with MDS-I of R50's multiple falls with no care plan revisions to address the root cause of the fall. On 3/29/2023 at 2:10 PM, Surveyor shared with NHA-A and DON-B the concerns with R50's falls. R50 had fourteen falls since December 2022. The fall interventions were not reviewed to determine their effectiveness in preventing falls, and no new interventions were implemented to prevent future falls. No further information was provided at that time. 5) R19 was admitted to the facility on [DATE] with diagnoses of posthemorrhagic anemia, gastrointestinal hemorrhage, congestive heart failure, depression, anxiety, and chronic kidney disease. R19's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R19 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and coded R19 as needing extensive assistance with bed mobility and toilet use and total assistance with transferring. R19's Moderate Risk for Falls Care Plan was initiated on 6/29/2022 with the following interventions: -Anticipate and meet the resident's needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Educate the resident, family, caregivers about safety reminders and what to do if a fall occurs. -Follow facility fall protocol. -Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes of possible. Educate resident, family, caregivers, Interdisciplinary Team (IDT) as to causes. -The resident needs a safe environment with even floors free from spills and or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, handrails on walls, and personal items within reach On 7/12/2022 at 3:21 AM in the progress notes, nursing charted an incident note for a fall on 7/11/2022 at 11:17 PM in R19's room. The Post Fall Report for the 7/12/2022, fall at 11:17 PM, documented R19 was seen sliding out of bed. Interventions put in place after the fall were: floor mat to side of bed and gripper socks, and hospice was notified of fall and a request was made for a wider bed. On 7/12/2022, at 3:58 AM, in the progress notes, nursing charted hospice returned their call and stated they would place an order for a wider mattress and nursing informed hospice a safety mat was placed next to R19's bed. On 7/12/2022 at 8:44 AM in the progress notes, nursing documented an IDT note for the fall that occurred on 7/11/2022. The IDT determined new interventions of a non-alarm floor mat next to a low bed and a wider bed would prevent future falls. R19's Bedside Kardex Report had the following interventions listed as of 9/29/2022: -floor mat side of bed. -Gripper socks on when in bed. -Keep bed in low position when unattended. -Non-alarm floor mat to bedside. Surveyor noted the intervention of a wider bed was not added to the care plan or Karadex. On 7/23/2022, at 3:08 PM, in the progress notes, nursing charted an incident note for a fall on 7/23/2022, at 11:45 AM. R19 was found sitting at the side of the bed. The Post Fall Report for the 7/23/2022, fall at 11:45 AM documented R19 slid off the bed and reported to nursing staff R19 did not hit head. The root cause of the fall was bed sheets were too slippery causing R19 to slide off the bed. New interventions to help prevent further falls or injury from falls was to not use hospice provided sheets and a scoop mattress. The section where it asks if the Nursing Care Plan was revised, N/A (not applicable) was circled with no explanation of why. The Moderate Risk for Falls Care Plan was not revised on 7/23/2022 with any interventions, such as not using the slippery sheets provided by hospice and a scoop mattress, to prevent future falls or injury. On 8/8/2022, at 10:48 AM, in the progress notes, nursing documented an IDT note for the 7/23/2022 fall, sixteen days after the fall. The IDT determined R19 was using very slippery s [TRUNCATED]

Based on observation, interview, and record review the facility did not ensure residents received adequate supervision to prevent accidents for 6 (R50, R19, R17, R24, R109, and R48) of 6 residents reviewed for falls. R50, F19, R17, R24, R109 and R48 had falls while in the facility that were not investigated to find the root cause of the fall, care plans were not revised with interventions to prevent future falls, and no re-evaluations of current interventions after falls occurred to determine if those interventions were adequate in preventing future falls. Findings include: Review of Guideline for the Prevention of Fall in Older Person by the Journal of the American Geriatrics Society, Volume 49, Issue 5 May 2001 revealed that Incidence rates of falls in nursing homes and hospital are almost three times the rates for community-dwelling person age >65 (1.5 fall per bed annually). Injury rates are also considerably higher with 10% to 25% of institutional falls resulting in fracture, laceration, or the need for hospital care .A key concern is not simply the high incidence of falls in older person but rather the combination of high incidence and a high susceptibility to injury. This propensity for fall-related injury in elderly persons stems from a high prevalence of comorbid diseases (e.g., osteoporosis) and age-related physiological decline (e.g., slower reflexes) that make even a relatively mild fall potentially dangerous .Unintentional injuries are the fifth leading cause of death in older adults (after cardiovascular, neoplastic, cerebrovascular, and pulmonary causes), and falls are responsible for two-thirds of the deaths resulting from unintentional injuries .high-risk groups-such a person with recurrent falls, those living in a nursing home, person prone to injurious falls, or person presenting after a fall-would require a more comprehensive and detailed assessment. The essential elements of any fall-related assessment include details about the circumstances of the fall (including a witness account), identification of the subject's risk factors for fall, any medical comorbidity, functional status and environmental risks . The facility policy and procedure entitled Falls dated 6/2/2017 states the facility will provide an environment that is free from hazards over which the facility has control and will provide appropriate supervision to each resident to prevent avoidable falls. Definition: Fall refers to unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. PROCEDURE: 1. Upon admission licensed nursing staff will complete the NSG (nursing) Admit Readmit Screener. 2. Upon admission, quarterly, with a significant COC (Change of Condition), licensed nursing staff will complete the 'Morse Fall Scale' form. 6. An individualized Plan of Care to prevent falls will be initiated. 8. The residents' Plan of Care will be monitored and evaluated and approaches, interventions, and goals will be modified as indicated on an ongoing basis. 9. When a resident fall [sic], the Charge Nurse and RN (Registered Nurse) supervisor or Nurse Care Manager will be called to assess and provide immediate and ongoing direction. The RN supervisor or Nurse Care Manager will determine if the resident requires emergency evaluation at the hospital for assessment of the injury. 10. The Charge Nurse caring for the resident that has fallen will complete the following forms: Skilled Nursing: Fall Incident Form - a note from appropriate licensed and direct care staff providing care to the resident prior to fall and any witnesses if applicable. 11. With head trauma the Charge Nurse will complete: -Evaluation if the resident will require further medical work up and be transported to the Hospital emergency room . -Head Trauma Craniotomy Check Flow Sheet will be initiated. 12. The Charge Nurse will initiate an intervention to help reduce risks of future falls. 13. The Charge Nurse will update the POC (Plan of Care) and the CNA (Certified Nursing Assistant) Care Plan. 14. The Nurse Care Manager/RN Supervisor on duty at time of fall will review all Charge Nurse follow- up and documentation including: -Care Plans. -Nursing notes. -And assure the new intervention/s and any ongoing interventions to prevent future falls are appropriate. 15. The Nurse Care Manager/RN Supervisor on duty at time of fall will assure completion of all above documentation and provide any additional direction as indicated. 16. Daily (Monday - Friday) all falls that occur in the Skilled Nursing and AL (Assisted Living) areas will be individually reviewed at the Interdisciplinary Meeting. -Interdisciplinary team members may include: Administrator, DON (Director of Nursing), Nurse Managers, Admission Director, Activity Director, SS (Social Service Director, PT (Physical Therapy)/OT (Occupational Therapy), Dietitian and the Plant Operations Manager. -Falls will be recorded in the Risk Management area in PCC (Point Click Care). -This team may review the current fall, history of falls, the resident's physical and cognitive abilities, and current interventions to prevent falls. -This team will verify that new interventions have been initiated, may modify interventions for the residents' plan of care and assign responsibilities to facilitate new interventions as indicated. The facility Head Trauma Craniotomy Check Flow Sheet, as referenced in the facility's Fall policy and procedure, has the following time indicators for when a neurological check should be performed: initial, every 15 minutes for the first hour, every hour for the next four hours, every four hours for the next 16 hours, and every eight hours for the next 32 hours. 1) R50 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, ulcerative colitis, glaucoma, and cognitive communication deficit. R50's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R50 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 and assessed R50 as requiring extensive assistance with all activities of daily living. The MDS assessed R50 as using a bed and chair alarm daily. R50's High Risk for Falls Care Plan was initiated on 12/2/2022 with no interventions. Interventions were added to the High Risk for Falls Care Plan on 12/5/2022: -Be sure call light is within reach and encourage the resident to use it for assistance as needed; resident needs prompt response to all requests for assistance. -Ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. -Physical Therapy evaluate and treat as ordered or as needed. On 12/11/2022, at 3:57 AM, in the progress notes, nursing charted the nurse received a call that at 1:15 AM, R50 was found sitting on the floor, scooting out into the hallway. Nursing charted R50 was able to move arms and legs and was assisted to a standing position with a gait belt and assist of three staff members and moved directly to a wheelchair. Nursing charted R50 had one sock on. Nursing charted R50 had a bowel movement after being up in the wheelchair and then assisted R50 back to bed; R50 continued to try and get up out of bed so was brought to the dining area with staff. Nursing charted suggestions were left for the manager regarding new interventions. Nursing charted R50 was being monitored for safety and had gripper socks on. The physician was notified. On 12/11/2022, at 4:24 AM, in the progress notes, nursing charted an incident note regarding the fall. The fall occurred on 12/11/2022 at 1:15 AM in the resident's room. Vital signs were stable. R50 was observed sitting up in the doorway with feet straight out in front of resident, inching further out of the room. Neurological checks were negative, range of motion was within normal limits, and R50 denied any pain or discomfort. The Post Fall Report for the 12/11/2022 fall at 1:15 AM documented R50 stated they had slid out of bed and moved themselves. The Certified Nursing Assistant (CNA) statement was R50 had been restless all night in bed and was called to the room by the nurse who found R50 on the floor. The nurse statement was R50 had slid out of bed with covers tangled up; R50 had been restless and inched to the room entrance where the nurse discovered R50. R50 had a history of falls prior to admission. R50 had last been toileted on PM shift. R50 was alert, verbal, oriented times two with forgetfulness and restlessness. The root cause of the fall was R50 trying to get up on own. Nursing stated the incident was an isolated event and no interventions were needed at that time. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because the incident is an isolated event. The Nurse Manager signed the Post Fall Report on 12/19/2022, eight days after the fall, and the Director of Nursing (DON) signed the Post Fall Report on 12/22/2022, eleven days after the fall. The High Risk for Falls Care Plan was not revised on 12/11/2022 with any interventions to prevent future falls. On 12/14/2022, at 3:30 AM, in the progress notes, nursing charted an incident note for a fall that occurred on 12/13/2022 at 10:55 PM. R50 was found by a CNA sitting outside of R50's room in the hall with R50's back resting on the left side of the door frame as if to be entering the room. The Registered Nurse (RN) Supervisor was notified. R50 was found to have no apparent injury except for a small pink area along the back of the mid-shoulder which later faded. Range of motion was within normal limits, neurological checks were normal, and R50 denied having any discomfort. Staff assisted R50 into the wheelchair and then into bed. Staff provided cares. Gripper socks were on, and the bed was put in the lower position; staff were checking on R50 after the fall. The Post Fall Report for the 12/13/2022 fall at 10:55 PM documented R50 stated R50 did not know what they wanted to do prior to the fall. The CNA statement was they were with another resident at the time of the fall. The nurse statement reflected the progress note on 12/14/2022 at 3:30 AM. R50 had a history of falls prior to admission and a fall on 12/11/2022. R50 was last changed at 10:15 PM. The root cause of the fall was R50 had periods of confusion and attempts to self-transfer. New intervention put in place to help prevent further falls or injury from falls was an alarming floor mat to be placed at bedside. The form indicated the intervention had been implemented and the Care Plan was revised. The Nurse Manager signed the Post Fall Report on 12/19/2022, six days after the fall, and the DON signed the Post Fall Report on 12/22/2022, nine days after the fall. The High Risk for Falls Care Plan was not revised on 12/13/2022 with any interventions to prevent future falls. On 12/14/2022 at 7:14 PM in the progress notes, nursing charted a nurse found R50 on the floor. Nursing charted R50 stated R50 had slid out of the recliner chair, was able to move all extremities, and denied hitting their head. Nursing charted R50 had a skin tear to the right lower shin and an abrasion to the left lower back. Nursing charted R50 stated R50 just does not want to be here anymore. On 12/14/2022, at 7:21 PM in the progress notes, nursing charted an incident note for the fall on 12/14/2022 at 6:50 PM. R50's vital signs were stable. R50 was found sitting in front of the recliner, sitting on the buttocks but had rolled onto the left side. R50 sustained a skin tear to the right lower shin and an abrasion to the left mid back. The Post Fall Report for the 12/14/2022 fall at 6:50 PM, documented R50 had a 1 cm (centimeter) skin tear to the right lower shin and a red area to the right mid back. (Surveyor noted the progress note charted an abrasion to the left mid/lower back, not the right mid back.) No statements were documented on the report. R50 had a history of falls with several falls due to decreased safety awareness. No interventions were indicated as being in place at the time of the fall. R50 had last been toileted at 7:00 PM. (Surveyor noted the fall occurred at 6:50 PM, prior to R50 being toileted.) The root cause of the fall was decreased safety awareness. New interventions put in place to prevent future falls were a floor mat and sensor pad. The sensor pad was to be placed near R50 when in the recliner or wheelchair. The Care Plan Goal was to prevent injury. The report indicated the Care Plan was revised. The Nurse Manager signed the Post Fall Report on 1/10/2023, twenty-seven days after the fall, and the DON signed the Post Fall Report on 1/10/2023, twenty-seven days after the fall. The High Risk for Falls Care Plan was not revised on 12/14/2022 with any interventions to prevent future falls. On 12/15/2022, at 6:51, PM in the progress notes, nursing charted an incident note for a fall on 12/15/2022 at 5:45 PM in R50's room. R50's vital signs were stable. Nursing charted a medication [NAME] was walking past R50's room and witnessed R50 sliding out of the chair onto the floor. R50 landed on the buttocks and did not hit their head. No injuries were sustained in the fall. The Post Fall Report for the 12/15/2022, fall at 5:25 PM documented R50 stated R50 was trying to get out of bed. The CNA statement was the CNA laid R50 down around 4:00 PM per resident request and did not want dinner. The CNA stated just before R50's tray came, the CNA set R50 up to get R50 to eat and the CNA left the room to get the tray, was gone for less than five minutes, and the nurse medication tech saw R50 slide to the floor. The nurse statement was they heard the alarm go off and went in and saw R50 sliding off the bed. (Surveyor noted the progress note charted R50 had slid out of the recliner and not the bed as per the statements.) R50 had a history of falls with this fall being the third in three days. The call light was within reach, the bed was low, a floor mat was down, and a floor alarm and clip alarm were in place at the time of the fall. No time was entered on the report for the last time R50 had been toileted. Potential factors for the fall were cognition and medical condition change; R50 had impaired cognitive function and possible urinary tract infection (UTI). The root cause of the fall was a possible UTI. A new intervention to prevent future falls was a urinalysis with culture and sensitivity order. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because the fall caused by (UTI) Increased confusion. The Nurse Manager signed the Post Fall Report on 1/10/2023, twenty-six days after the fall, and the DON signed the Post Fall Report on 1/10/2023, twenty-six days after the fall. The High Risk for Falls Care Plan was not revised on 12/15/2022 with any interventions to prevent future falls. On 12/16/2022, at 3:52 AM, in the progress notes, nursing charted an incident note for a fall that occurred on 12/16/2022 at 12:13 AM in R50's room. R50 had an unwitnessed fall from bed onto an alarming sensor floor mat. R50 was observed to be sitting on the mat, leaning back against the bed. Nursing charted R50's vital signs were stable and did not sustain any injuries but had bruising from previous falls to bilateral lower extremities. The Post Fall Report for the 12/16/2022 fall at 12:13 AM documented R50 had an unwitnessed fall out of bed onto an alarming sensor mat. R50's vital signs were stable. R50 stated they were going home. The CNA statement was the CNA saw R50 on the floor and the floor alarm was going off. The nurse statement was R50 was restless in bed and slid out of bed onto the floor sensor mat. The nurse stated R50 was incontinent at the time. No time was documented of when R50 had last been toileted. R50 had a history of falls with four falls in the last three days, now totaling five falls. Interventions in place at the time of the fall: call light within reach, toileting schedule, low bed, wide bed, sensor floor mat, and R50 had socks on. The root cause of the fall was R50 trying to get up on their own and thinking they were going home. No new interventions were put in place to prevent further falls or injury from falls. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because the resident being evaluated for possible UTI - has symptoms and a urinalysis with culture and sensitivity to be obtained and many interventions are already in place. The Nurse Manager signed the Post Fall Report on 1/10/2023, twenty-five days after the fall, and the DON signed the Post Fall Report on 1/10/2023, twenty-five days after the fall. The High Risk for Falls Care Plan was not revised on 12/16/2022 with any interventions to prevent future falls. On 12/17/2022 at 1:33 PM in the progress notes, nursing charted R50 had a fall that morning with no new injuries noted. Nursing charted cranial checks were started with 15-minute checks for three days. Nursing charted vital signs were stable with no signs or symptoms of infection noted. Nursing charted R50 denied any pain or discomfort with urination, but urgency was noted. Surveyor noted no incident note was documented in the progress notes for any fall occurring on 12/17/2022. The Post Fall Report for the 12/17/2022 fall at 6:39 AM documented R50 was found sitting on the floor mat next to R50's bed. Vital signs were stable an no injury was sustained from the fall. R50's statement was they were trying to go to the bathroom. The CNA did not provide a statement. The nurse statement was See nursing noted. Surveyor did not see a nursing note in R50's medical record for this fall. R50 had a history of falls with falls occurring on 12/14/2022, 12/15/2022, and 12/16/2022. The interventions in place at the time of the fall were: call light within reach, low bed, floor mat, alarming floor mat and a clip alarm. R50 was last toileted at 1:30 AM, five hours prior to the fall. A potential factor for the fall was impaired cognitive function. The root cause of the fall was R50 wanted to go to the bathroom and could not remember to use the call light for help. New interventions to prevent further falls was 15-minute checks for three days. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because No revision needed. Resident frequently monitored x (times) 3 days. The Nurse Manager signed the Post Fall Report on 1/10/2023, twenty-four days after the fall, and the DON signed the Post Fall Report on 1/10/2023, twenty-four days after the fall. The High Risk for Falls Care Plan was not revised on 12/17/2022 with any interventions to prevent future falls. In an interview on 3/29/2023, at 10:00 AM, Surveyor asked MDS-I if someone was on 15-minute checks, where would that information be documented. MDS-I stated some residents have been on 15-minute checks for three to five days and that would be documented on paper, but not in the computer. MDS-I stated, We know if it's not written, it didn't happen. In an interview on 3/29/2023, at 1:12 PM, Surveyor asked Director of Nursing (DON)-B where the 15-minute checks would have been documented. DON-B stated DON-B thought the nurse wrote the note wrong and it should have read cranial checks were to be completed every fifteen minutes. On 12/19/2022, at 12:08 PM, in the progress notes, nursing documented the Interdisciplinary Team (IDT) note for R50's fall on 12/11/2022 at 1:15 AM, eight days after the fall occurred. Nursing documented the IDT met to discuss the incident. R50 stated R50 slid out of bed and moved herself to the door. R50 was forgetful and restless at times. R50 had impaired cognitive function due to Parkinson's Disease. Final interventions after the IDT meeting: the incident was an isolated event and no interventions needed at this time. On 12/19/2022, at 12:29 PM in the progress notes, nursing documented the IDT note for R50's fall on 12/13/2022 at 10:55 PM, six days after the fall occurred. Nursing documented R50 had impaired cognitive function due to Parkinson's Disease with periods of confusion. R50 was forgetful and restless at times and R50 was unable to explain what R50 was attempting to do at the time of the incident. The IDT felt as if placing an alarming floor mat at bedside would be helpful for notifying staff when R50 attempts to get out of bed. R50's High Risk for Falls Care Plan was revised on 12/19/2022 the following intervention: alarming floor mat placed at bedside or next to recliner to notify staff if R50 attempts to self-transfer. Surveyor noted this intervention had been implemented on 12/13/2022 when referenced after a fall. On 12/22/2022, at 10:04 PM, in the progress notes, nursing charted an incident note for a fall on 12/22/2022 at 5:00 PM in R50's room. R50 was found sitting on the buttocks in front of the bed. R50 denied hitting their head and sustained no injuries. R50's vital signs were stable. The Post Fall Report for the 12/22/2022 fall at 5:00 PM documented R50 was found sitting on the buttocks. R50's statement was they did not know what they were doing. The CNA statement was they were not sure why R50 wanted to get up, R50 was toileted prior to the fall, and when asked where R50 was going or what R50 needed, R50 said R50 did not know. The nurse statement was R50 was found sitting on buttock in front of the bed and denied hitting their head. R50 had a history of falls due to self-transfers. The following interventions were in place at the time of the fall: call light within reach, low bed, shoes/gripper socks on, and floor mat in place. R50 had been toileted before dinner. Factors present that attributed to the fall were impaired cognitive function and COVID-19. The root cause of the fall was R50 had impaired safety awareness due to impaired cognitive function. New interventions to prevent further falls or injury from falls: No new interventions necessary. Has multiple safety precautions in place. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Resident has multiple safety precautions in place. Fall is due to impaired cognition. The Nurse Manager signed the Post Fall Report on 1/10/2023, nineteen days after the fall, and the DON signed the Post Fall Report on 1/10/2023, nineteen days after the fall. On 12/22/2022, at 10:09 PM, in the progress notes, nursing charted an incident note for a fall on 12/22/2022 at 5:20 PM in R50's room. R50's vital signs were stable. R50 was found lying on the floor on the back with a cover under the head. R50 did not sustain any injuries. The Post Fall Report for the 12/22/2022 fall at 5:20 PM documented R50 was found lying on the floor on the back with a cover under the head. R50 was unable to explain what R50 was trying to do at the time of the fall. No CNA statement was obtained. The nurse reiterated how R50 was found and that R50 denied pain or hitting the head. R50 had a history of falls. The following interventions were in place at the time of the fall: call light within reach, low bed, shoes/gripper socks on, floor mat, and sensor mat. R50 was toileted prior to dinner. The factor present that attributed to the fall was impaired cognitive function. The root cause of the fall was R50 had impaired cognitive function and decreased safety awareness. New interventions to prevent further falls or injury from falls: No new interventions necessary at this time. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Resident has many safety precautions in place. The Nurse Manager signed the Post Fall Report on 1/11/2023, twenty days after the fall, and the DON signed the Post Fall Report on 1/11/2023, twenty days after the fall. Surveyor noted R50 had two falls on 12/22/2022 that were twenty minutes apart. No new interventions were put in place for either fall. The two fall Post Fall Reports were reviewed and signed by the Nurse Manager and the DON on two different days with no revision of the care plan for either fall. On 12/24/2022, at 7:55 PM, in the progress notes, nursing charted an incident note for a fall on 12/24/2022 at 6:45 PM in R50's room. R50 was found sitting on the buttocks on the right side of the recliner. No injuries were sustained, and vital signs were stable. The Post Fall Report for the 12/24/2022 fall at 6:45 PM documented R50 was found sitting on the buttocks on the right side of the recliner. R50 did not know why R50 was trying to get up. The CNA statement was R50 was toileted and waiting for dinner and the CNA was in the dining room feeding a resident at the time of the fall. The nurse statement was R50 was found on the floor and denied hitting the head and had no complaints of pain. R50 had a history of falls and sliding from the recliner. The following interventions were in place at the time of the fall: call light within reach, shoes/gripper socks on, and an alarming floor mat. R50 was last toileted at 5:15 PM. The root cause of the fall was due to neurocognitive disorder and impaired judgement. New interventions put in place to prevent further falls or injury from falls: No new interventions. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Fall due to neurocognitive disorder. Multiple precautions in place for safety. The Nurse Manager signed the Post Fall Report on 1/15/2023, twenty-two days after the fall, and the DON signed the Post Fall Report on 1/16/2023, twenty-three days after the fall. The High Risk for Falls Care Plan was not revised on 12/24/2022 with any interventions to prevent future falls. On 12/30/2022, at 1:20 PM, in the progress notes, nursing documented a late entry for the IDT note for R50's fall on 12/14/2022 at 6:50 PM, sixteen days after the fall. The IDT determined the root cause of the fall was due to impaired cognitive function, Parkinson's Disease, anxiety, and forgetfulness. The IDT determined the following intervention to be implemented: a floor mat and sensor was to be placed at bedside. Surveyor noted the floor mat and alarm had been placed in R50's room on 12/13/2022 and put on the High Risk for Falls Care Plan on 12/19/2022. On 1/1/2023, at 7:48 AM, in the progress notes, nursing charted an incident note for a fall on 1/1/2023 at 7:30 AM. R50 was found on the floor. R50 stated R50 had moved their legs around and got onto the floor mat and then onto the floor. R50 the proceeded to scoot across the floor toward the wheelchair. No injuries were sustained. The Post Fall Report for the 1/1/2023 fall at 7:30 AM documented R50 was found sitting on the floor near the wheelchair. R50's vital signs were stable, and no injuries were sustained. R50 stated that R50 tried to move the feet off the bed, got on the floor, and then proceeded to scoot across the floor toward the wheelchair. No CNA statement was documented. The nurse statement was R50's light was going off and found R50 sitting on the floor. R50 had a history of frequent falls due to mental state and R50 continued to try to self-transfer. The following interventions were in place at the time of the fall: call light within reach, low bed, shoes/gripper socks on, floor mat in place, and sensor mat on floor. R50 had last been toileted on night shift. Factors present at the time of the fall that may have contributed to the fall were R50 can become disoriented and confused and often becomes forgetful and restless. The root cause of the fall was R50 was attempting to self-transfer and ended up on the floor. New interventions put in place to help prevent further falls or injury from falls: No new interventions. Resident has impaired cognitive function and has impaired judgement. The section of the form for Nursing Care Plan revision was circled N/A (not applicable) because Resident continues to self-transfer. Multiple precautions in place for safety. The Nurse Manager signed the Post Fall Report on 1/15/2023, fourteen days after the fall, and the DON signed the Post Fall Report on 1/16/2023, fifteen days after the fall. The High Risk for Falls Care Plan was not revised on 1/1/2023 with any interventions to prevent future falls. On 1/10/2023, at 12:22 PM, in the progress notes, nursing documented an IDT note for the fall on 12/15/2022 at 5:25 PM, twenty-six days after the fall. The IDT determined R50 had a UTI which caused increased confusion that lead to multiple falls. No new interventions were documented. On 1/10/2023, at 1:38 PM, in the progress notes, nursing documented an IDT note for the fall on 12/16/2022 at 12:13 AM, twenty-five days after the fall. The IDT determined R50 had a UTI which caused increased confusion and impaired safety awareness due to impaired cognitive functioning. No new interventions were documented. On 1/10/2023, at 2:31, PM in the progress notes, nursing documented an IDT note for the fall on 12/17/2022 at 6:39 AM, twenty-four days after the fall. R50 was placed on 15-minute checks immediately after the incident. The IDT determined R50 should be placed on 15-minute checks due to impaired cognitive function and the inability to remember to use the call light. Surveyor could not find any documentation of 15-minute checks being completed. On 1/10/2023, at 2:55 PM, in the progress notes, nursing documented an IDT note for the fall on 12/22/2022 at 5:00 PM, nineteen days after the fall. The IDT determined R50 fell out of bed due to impaired safety awareness related to impaired cognition. No new interventions were documented. On 1/11/2023, at 8:34 AM, in the progress notes, nursing documented an IDT note for the fall on 12/22/2022 at 5:20 PM, twenty days after the fall. The IDT determined R50 had many safety precautions in place to ensure resident's safety and R50 was in transmission based precautions due to COVID-19 with impaired cognitive function. The IDT determined no new interventions were necessary. On 1/15/2023, at 9:49 AM, in the progress notes, nursing documented an IDT note for the fall on 12/24/2022 at 6:45 PM, twenty-two days after the fall. The IDT determined the fall was due to a neurocognitive impairment with impaired judgement and many safety precautions in place. R50 was in transmission based precautions due to COVID-19. The IDT determined no new interventions were necessary. On 1/15/2023, at 10:25 AM in the progress notes, nursing documented an IDT note for the fall on 1/1/2023 at 7:30 AM, fourteen days after the fall. The IDT determined the fall was due to a neurocognitive impairment with impaired judgement and forgetfulness. The IDT determined R50 had several safety measures in place including a tall floor mat with sensor alarm next to the bed to prevent injury. The IDT determined no new interventions were necessary. 2/2/2023 at 1:55 AM in the progress notes, nursing charted an incident note for a fall on 2/2/2023 at 1:55 AM. R50's vital signs were stable. R50 was found sitting with bedding on the floor mat between the bed and the wall. R50 did not sustain any injuries. Range of motion and neurological checks were within normal limits. R50 was assisted back to bed with a mechanical lift. The Post Fall Report for the 2/2/2023 fall at 1:55 AM documented R50 had no statement of what happened or what R50 was trying to do at the time of the fall. The CNA statement was the CNA was told by another staff member that R50 was sitting on the side of the bed in the room. The nurse statement was the nurse was notified by a staff member R50 was on the floor. The nurse saw R50 with bedding on the floor surrounding R50. R50 had a history of falls with falls on 12/24/2022 where R50 slid

Based on record review, and interview, the facility did not ensure residents received treatment and care in accordance with facility policy and procedure after unwitnessed falls for 2 (R50 and R19) of 6 residents reviewed for falls. R50 and R19 had multiple unwitnessed falls and were not neurologically assessed after the falls. Findings include: The facility policy and procedure entitled Falls dated 6/2/2017 states 9. When a resident fall [sic], the Charge Nurse and RN supervisor or Nurse Care Manager will be called to assess and provide immediate and ongoing direction. The RN supervisor or Nurse Care Manager will determine if the resident requires emergency evaluation at the hospital for assessment of the injury. 11. With head trauma the Charge Nurse will complete: -Evaluation if the resident will require further medical work up and be transported to the Hospital emergency room . -Head Trauma Craniotomy Check Flow Sheet will be initiated. The facility Head Trauma Craniotomy Check Flow Sheet, as referenced in the facility's Fall policy and procedure, has the following time indicators for when a neurological check should be performed: initial, every 15 minutes for the first hour, every hour for the next four hours, every four hours for the next 16 hours, and every eight hours for the next 32 hours. 1.) R50 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, ulcerative colitis, glaucoma, and cognitive communication deficit. R50's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R50 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 and coded R50 as needing extensive assistance with all activities of daily living. On 12/14/2022 at 7:14 PM in the progress notes, nursing charted a nurse found R50 on the floor. Nursing charted R50 stated R50 had slid out of the recliner chair, was able to move all extremities, and denied hitting their head. Nursing charted R50 had a skin tear to the right lower shin and an abrasion to the left lower back. Nursing charted R50 stated R50 just does not want to be here anymore. On 12/14/2022 at 7:21 PM in the progress notes, nursing charted an incident note for the fall on 12/14/2022 at 6:50 PM. R50's vital signs were stable. R50 was found sitting in front of the recliner, sitting on the buttocks but had rolled onto the left side. R50 sustained a skin tear to the right lower shin and an abrasion to the left mid back. The Post Fall Report for the 12/14/2022 fall at 6:50 PM documented R50 had a 1 cm skin tear to the right lower shin and a red area to the right mid back. (Surveyor noted the progress note charted an abrasion to the left mid/lower back, not the right mid back.) R50's vital signs were stable, and the initial craniotomy check was within normal limits. No additional craniotomy checks were documented following the 12/14/2022 fall. On 12/16/2022 at 3:52 AM in the progress notes, nursing charted an incident note for a fall that occurred on 12/16/2022 at 12:13 AM in R50's room. R50 had an unwitnessed fall from bed onto an alarming sensor floor mat. R50 was observed to be sitting on the mat, leaning back against the bed. Nursing charted R50's vital signs were stable and did not sustain any injuries but had bruising from previous falls to bilateral lower extremities. The Post Fall Report for the 12/16/2022 fall at 12:13 AM documented R50 had an unwitnessed fall out of bed onto an alarming sensor mat. R50's vital signs were stable, and the initial craniotomy check was within normal limits. No additional craniotomy checks were documented following the 12/16/2022 fall. On 12/24/2022 at 7:55 PM in the progress notes, nursing charted an incident note for a fall on 12/24/2022 at 6:45 PM in R50's room. R50 was found sitting on the buttocks on the right side of the recliner. No injuries were sustained, and vital signs were stable. The Post Fall Report for the 12/24/2022 fall at 6:45 PM documented R50 was found sitting on the buttocks on the right side of the recliner. R50's vital signs were stable, and the initial craniotomy check was not completed. No craniotomy checks were documented following the 12/24/2022 fall. On 1/1/2023 at 7:48 AM in the progress notes, nursing charted an incident note for a fall on 1/1/2023 at 7:30 AM. R50 was found on the floor. R50 stated R50 had moved their legs around and got onto the floor mat and then onto the floor. R50 the proceeded to scoot across the floor toward the wheelchair. No injuries were sustained. The Post Fall Report for the 1/1/2023 fall at 7:30 AM documented R50 was found sitting on the floor near the wheelchair. R50's vital signs were stable, and the initial craniotomy checks were within normal limits. No additional craniotomy checks were documented following the 1/1/2023 fall. 2/2/2023 at 1:55 AM in the progress notes, nursing charted an incident note for a fall on 2/2/2023 at 1:55 AM. R50's vital signs were stable. R50 was found sitting with bedding on the floor mat between the bed and the wall. R50 did not sustain any injuries. Range of motion and neurological checks were within normal limits. R50 was assisted back to bed with a mechanical lift. The Post Fall Report for the 2/2/2023 fall at 1:55 AM documented R50 had no statement of what happened or what R50 was trying to do at the time of the fall. R50's vital signs were stable, and the initial craniotomy checks were within normal limits. No additional craniotomy checks were documented following the 2/2/2023 fall. On 2/25/2023 at 6:41 AM in the progress notes, nursing charted an incident note for a fall on 2/25/2023 at 6:10 AM. R50 rolled out of bed onto the floor mat at bed level with the sensor alarm and pulled a lamp into bed with R50. R50 sustained a 4.5 cm skin tear to the right lower shin. The Incident Report for the 2/25/2023 fall at 6:10 AM documented R50 pulled a lamp down after rolling onto a high level mat causing a skin tear. No vital signs or craniotomy checks were documented on the incident report. No additional craniotomy checks were documented following the 2/25/2023 fall. On 3/8/2023 at 7:25 PM in the progress notes, nursing charted an incident note for a fall that occurred on 3/8/2023 at 7:20 PM. R50 was found sitting on the buttocks on the floor in R50's room. It appeared R50 got out of bed and was scooting towards the door. No injuries were noted. No craniotomy checks were documented for the 3/8/2023 fall. In an interview on 3/29/2023 at 8:46 AM, Surveyor asked RN Unit Manager (RNUM)-D what the process was for the facility when a resident has a fall. RNUM-D stated an RN will do the initial assessment of the resident. RNUM-D stated a lot of Licensed Practical Nurses (LPNs) work on the floor, and they will check to see if the resident is okay, but then will get an RN. RNUM-D stated the LPN will get the vital signs and if there is an injury at the time, the LPN will make sure it is treated, but the RN does the overall assessment. Surveyor shared with RNUM-D the concern neurological, or craniotomy checks were not documented after R50 had unwitnessed falls. In an interview on 3/29/2023 at 10:00 AM, Surveyor asked MDS-I if neurological checks are done with each fall. MDS-I stated neurological checks are only done if the resident is incapacitated, but if the resident can answer, then they would not do neurological checks if the resident stated they did not hit their head. MDS-I stated we know if it is not written, it was not done. On 3/29/2023 at 2:10 PM, Surveyor shared with NHA-A and DON-B the concerns with R50's falls and no neurological checks when the fall was unwitnessed. No further information was provided at that time. 2.) R19 was admitted to the facility on [DATE] with diagnoses of posthemorrhagic anemia, gastrointestinal hemorrhage, congestive heart failure, depression, anxiety, and chronic kidney disease. R19's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R19 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and coded R19 as needing extensive assistance with bed mobility and toilet use and total assistance with transferring. On 7/23/2022 at 3:08 PM in the progress notes, nursing charted an incident note for a fall on 7/23/2022 at 11:45 AM. R19 was found sitting at the side of the bed. R19 had slid off the bed that had slippery bamboo sheets on it. Nursing charted R19 did not have any injury and did not hit their head. The Post Fall Report for the 7/23/2022 fall at 11:45 AM documented R19 slid off the bed and reported to nursing staff R19 did not hit head. R19's vital signs were stable, and the initial craniotomy check was within normal limits. No additional craniotomy checks were documented following the 7/23/2022 fall. On 9/28/2022 at 2:10 AM in the progress notes, nursing charted an incident note for a fall on 9/27/2022 at 10:20 PM in R19's room. R19 had an unwitnessed fall out of bed and was observed to be lying on the back on the floor next to the bed with a pillow under the head. R19 denied pain, range of motion was within normal limits and neurological checks were negative. No injuries were noted. The Post Fall Report for the 9/27/2022 fall at 10:20 PM documented R19 was found on their back with a pillow under their head against the bedside table and the floor mat pushed to the side of R19. R19's vital signs were stable, and the initial craniotomy check was within normal limits. No additional craniotomy checks were documented following the 9/27/2022 fall. On 10/30/2022 at 10:57 AM in the progress notes, nursing charted R19 slid off the recliner at 10:15 AM with no injury. R19 stated R19 wanted to walk to the bathroom. Vital signs were stable, and the neurological check was negative. The Post Fall Report for the 10/30/2022 fall at 10:15 AM documented R19 was found sitting on the floor and leaning against the recliner. R19 denied hitting their head and had no complaints of pain. R19's vital signs were stable, and the initial craniotomy check was within normal limits. No additional craniotomy checks were documented following the 10/30/2022 fall. In an interview on 3/29/2023 at 8:46 AM, Surveyor asked RN Unit Manager (RNUM)-D what the process was for the facility when a resident has a fall. RNUM-D stated an RN will do the initial assessment of the resident. RNUM-D stated a lot of Licensed Practical Nurses (LPNs) work on the floor, and they will check to see if the resident is okay, but then will get an RN. RNUM-D stated the LPN will get the vital signs and if there is an injury at the time, the LPN will make sure it is treated, but the RN does the overall assessment. Surveyor shared with RNUM-D the concern neurological, or craniotomy checks were not documented after R19 had unwitnessed falls. In an interview on 3/29/2023 at 10:00 AM, Surveyor asked MDS-I if neurological checks are done with each fall. MDS-I stated neurological checks are only done if the resident is incapacitated, but if the resident can answer, then they would not do neurological checks if the resident stated they did not hit their head. On 3/29/2023 at 2:10 PM, Surveyor shared with NHA-A and DON-B the concerns with R19's falls and no neurological checks when the fall was unwitnessed. No further information was provided at that time.

Based on observation, interview, record review the facility did not ensure that residents received care consistent with professional standards of practice to prevent pressure injuries from developing for 1 (R2) of 2 residents reviewed for pressure injuries. * R2 did not have interventions in place to keep R2's heels offloaded while lying in R2's bed and sitting in R2's recliner chair. Surveyor had observations of R2's heels not being offloaded while lying in bed and sitting in recliner chair on several occasions during the survey. Findings include: The facility policy, entitled PRESSURE ULCER PREVENTION AND TREATMENT INTERVENTIONS GUIDELINES, updated on 6/15/2018, states: PROCEDURE: . B. Decreased Mobility, Activity or Sensory Perception . 3. Position the resident on bed pillows or other support devices. 5. Boney prominences susceptible to pressure will be protected. 7. Elevate heels off bed as indicated (e.g., place pillows under calf to raise heels off the bed or utilize foam heel boots, unless contraindicated due to medical condition.) . C. Protect from Friction or Shear . 6. Protect elbows and heels as needed (sheepskin, heel and elbow protectors will reduce shear and friction and may provide comfort but will not protect against pressure). R2 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus, chronic obstructive pulmonary disease, major depressive disorder, peripheral vascular disease/ chronic venous insufficiency, pain, morbid obesity, gout, lymphedema, localized edema, encephalopathy/other disorders of the brain, and muscle weakness. R2's quarterly minimum data set (MDS) dated [DATE] indicated R2 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10 and coded R1 needing extensive assist with bed mobility, dressing, toileting, and hygiene, and total dependence with transferring and bathing. R1 was non ambulatory and transferred using a Hoyer lift with assistance of 2 people. R1 was frequently incontinent of urine, always incontinent of bowel and wore an adult brief. R2's Potential Impairment to Skin Integrity Care Plan was initiated on 5/30/2017 with the following interventions in place on 3/27/2023: - Alternating air mattress to bed for pressure relief. Check for placement and function every shift - 1/2 side rails to aid resident in self-off loading, repositioning. - May use EZ glide sheet as needed for repositioning. - Check blood sugars as ordered to monitor Type 2 diabetes. - Educate resident/family of risk of increased bruising with Coumadin use. Monitor for signs and symptoms of bleeding. Report concerns to physician. - Educate resident/family/caregivers of causative factors and measures to prevent skin injury. - Encourage good nutrition and hydration to promote healthier skin. Dietary review as indicated. - Float heels when in bed. - Follow facility protocols for treatment of injury. - Follow turning and toileting schedule per Kardex. - Keep skin clean and dry. Use lotion on dry skin. - May leave sling under resident in chair. Ensure it is flat and not bunched. - Monitor for pain and administer medication as ordered. Encourage resident to sit up in chair daily (will often refuse) to off load. - Monitor for side effects of antibiotics, and over the counter medications: gastric distress, rash, and allergic reactions which could exacerbate skin injury. - Pressure reducing cushion in chair. - See urinary and activities of daily living (ADL) care plans. - Treatments as ordered. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Make sure resident has clothing on before putting sling on. - Weekly body check with nurse. - Daily skin inspection with certified nursing assistant (CNA) during cares. R2's visual/ bedside Kardex report that the CNA's use to provide cares for R2 did not have interventions listed to have R2's heels floated when R2 was lying in bed or sitting in recliner chair. On 3/27/2023 during record review, Surveyor saw in ORDERS an order that was dated 4/29/2019 to Float (R2's) heels when in recliner every shift. On 3/27/2023 at 11:05 AM Surveyor observed R2 lying in bed covered. R2's heels were not off loaded and R2's heels were directly on R2's mattress. On 3/28/2023 at 9:39 AM Surveyor observed R2 sitting up in R2's recliner chair. Surveyor R2's footrest was not elevated and R2's legs were hanging down. Surveyor observed R2 had Tubigrips (elasticated tubular bandage that provides continuous support for swelling) and anti-slip socks on right and left feet. Surveyor observed R2's calves were exposed and looked very swollen, shiny, and skin light pink/reddish. On 3/29/2023 at 8:04 AM Surveyor observed R2 sitting up in R2's recliner chair. Surveyor observed R2's footrest was elevated and R2's heels were resting directly on the footrest and heels were not off-loaded. Surveyor observed R2 had Tubigrips on with anti-slip socks on R2's right and left feet. Surveyor observed R2's calves looked very swollen, shiny, and R2's skin appeared light pink/reddish. Surveyor had observations on multiple days for R2 not having heels offloaded while lying in bed or sitting in recliner chair during the survey process. On 3/29/2023 at 8:04 AM Surveyor interviewed CNA-E. Surveyor asked CNA-E if R2 was able to reposition themselves when in bed or the recliner chair. CNA-E replied R2 is unable to reposition themselves without assistance of 2 aides. Surveyor asked CNA-E if there are interventions in place to help with preventing pressure injuries from developing on R2's feet or heels since R2 had very swollen legs and feet. CNA-E replied CNA-E was not aware of any interventions for R2 regarding the swelling in R2's legs or prevention of a pressure injury from developing. On 3/29/2023 at 8:46 AM Surveyor interviewed Registered Nurse Unit Manager (RNUM)-D. Surveyor asked RNUM-D if R2 had any open areas. RNUM-D replied that R2 did not currently have any open areas. Surveyor informed RNUM-D of Surveys observation of R2's swollen right and left legs. Surveyor asked RNUM-D what interventions were currently in place to prevent open areas from developing on R2's heels. RNUM-D replied that the nurse practitioner (NP) saw R2 on 3/24/2023 and ordered and increase for R2's Lasix dose and ordered a consult with the Lymphedema specialist. Surveyor asked if there were any interventions in place at the time for R2's swelling. RNUM stated that R2 had issues with R2's right and left leg swelling intermittently since R2's admission and the CNA's were to put on Aquaphor to R2's right and left feet. On 3/29/2023 at 1:08 PM Surveyor informed the Director of Nursing (DON)-B of Surveyors concern regarding R2's heels not being off-loaded while R2 was lying in bed and sitting in recliner chair. Surveyor also informed DON-B that staff is not aware of R2's interventions for offloading R2's heels and interventions were not listed on the visual/ bedside Kardex report for the CNA's. On 3/29/2023 at 2:10 PM Surveyor informed the Nursing Home Administrator (NHA)-A and DON-B of Surveyors concern regarding R2's heels not being off-loaded while R2 was lying in bed and sitting in recliner chair. Surveyor also informed NHA-A and DON-B that staff is not aware of R2's interventions for offloading R2's heels and was not listed on the visual/ bedside Kardex report for the CNA's. No further information provided at that time.

Based on observations, interviews, and record review the facility failed to ensure that paid feeding assistants feed only residents with no complicated feeding problems, select residents based on an assessment completed by a Registered Nurse (RN), and that paid feeding assistants had completed a State-approved training before feeding residents. This failure had the potential to affect 7 (Residents #3,#4,#7, #8,#9,#11, and #12) out of 13 sampled residents and 12 (Residents #16,#17, #18, #19, #20, #22, #23, #24, #25,# 26, #27, and #28) supplemental residents. The facility's failure to ensure that feeding assistants feed only residents who have no complicated feeding problems, failure to base resident selection off of a Registered Nurse (RN) assessment if a resident is eligible to be fed by a paid feeding assistant, failure to ensure that Residents are not being fed by non-nursing staff or staff who have successfully completed a State-Approved training course, and failure to have a policy in place regarding paid feed assistants created a finding of immediate jeopardy. The immediate jeopardy began on 4/27/16 when: * Resident #9 was observed being assisted by a paid feeding assistant although Resident #9's safe feeding assessment documented that feeding assistants may not feed. *Residents #7, #16, #17, and #18 where observed being assisted by a paid feeding assistant without an RN assessment to determine if safe to be fed by a paid feeding assistant. * Resident #19 was observed being fed by a non-nursing employee who had not completed a State-approved training course for paid-feeding assistants. The Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 5/2/16 at 2:15 p.m. The immediacy was removed on 5/2/16, however, the deficient practice continues at a scope and severity level of E (potential for harm that is not immediate jeopardy/ pattern) while the facility implements its removal plan. Findings Include: 1.) Resident #9 was admitted to the facility on [DATE]. Resident #9's patient history form documents [DIAGNOSES REDACTED]. Resident #9's current Care Plan with a goal date of 5/25/16 includes Potential risk for altered nutritional status r/t (related to) hx (history) weight loss prior to admission. Has had a desired wt (weight) gain following admission. Dx ([DIAGNOSES REDACTED]. Approaches for this category on Resident #9's Care Plan include: -Provide diet as ordered: PUREED DIET WITH NECTAR THICK LIQUIDS Supplement: Ensure thickened to nectar consistency BID (twice a day) -Assist at all meals. Encourage to close mouth, chew food and swallow after each bite. Disciplines: NUR (nursing) Start Date 3/12/2014 -During meal if she is not accepting food well, attempt to dip spoon tip of food after entrée or vegetable on spoon-dip spoon into sweet item-improved intakes seen when this approach used at times Start Date 11/18/2015 Resident #9's Current Care plan also includes Self care deficit Related To advanced dementia, impaired mobility As Evidenced By total Dependence upon staff for all cares, resident can be resistive with cares, striking out. Aprroaches for this category on Resident #9's Care Plan include: -Seat in Memory Care Dining room for all meals- staff to feed, needs much encouragement to be awake for meals, takes small bites, if not taking food at meal, attempt dipping tip of spoon in sweet food item. Discipline: NUR (nursing) Start Date:12/12/2013. -SUPERVISION RECOMMENDED WHEN HOT LIQUIDS PLACED IN FRONT OF RESIDENT Disciplines:NUR (nursing) Start Date: 12/12/2013 Resident #9's SAFE FEEDING ASSESSMENT FORM dated 8/13/15 states: Use this form to assess a resident's ability to be fed by a non-nursing staff member that has been through the feeding program. Feeding assistants may only feed residents who have demonstrated safe swallowing and chewing ability. The assessment of these residents will be done on admission, quarterly or there is a change of condition in ther swallowing ability. Are swallowing precautions in place? If yes, feeding assistants may not feed- skip to SAFETY Assessment. If NO, Continue with assessment. (no is marked) 1. Does the resident cough when swallowing food/liquids? (no is marked) 2. Does the resident allow food or fluid to run out of mouth? (no is marked) 3. Does the resident pocket food in their mouth (no is marked) 4. Does the resident clamp their mouth shut so not to receive? (no is marked) If any answer to the above questions 1-4 is YES this would be a resident that should NOT be assisted with feeding by a non-nursing staff member. If a resident CAN be fed by a non-nursing staff member, please add this to the Interdisciplinary Care Plan and forward orange Diet Information sheet to Food Service and a copy to the Activity Department. Resident #9's SAFE FEEDING assessment dated [DATE] states: Are swallowing precautions in place? If yes, feeding assistants may not feed-skip to SAFETY Assessment. If NO, Continue with assessment (yes and no are marked, next to yes handwritten is error) 1. Does the resident cough when swallowing food/liquids? (no is marked) 2. Does the resident allow food or fluid to run out of mouth? (yes is marked) 3. Does the resident pocket food in their mouth? (yes is marked) 4. Does the resident clamp their mouth shut so not to receive (yes is marked, handwritten next to it is @x (at times)) If any answer to the above questions 1=4 is YES, this would be a resident that should NOT be assisted with feeding by a non-nursing staff member. If a resident CAN be fed by a non-nursing staff member, please add this to Interdisciplinary Care Plan/CNA Care Plan and forward orange Diet Information sheet to Food Service and a copy to the Activity Department. This assessment was completed by Licensed Practical Nurse (LPN)-GG. Resident #9's most recent SAFE FEEDING ASSESSMENT completed 2/9/16 states: Use this form to assess resident's ability to be fed by a non-nursing staff member that has been through the feeding program. Feeding assistants may only feed residents who have demonstrated safe swallowing and chewing ability. The assessment of these residents will be done on admission, quarterly or if there is a change of condition in their swallowing ability. Are swallowing precautions in place? If yes, feeding assistants may not feed- skip to SAFETY Assessment. If NO, continue with assessment. (yes is marked) 1. Does the resident cough when swallowing food/liquids? (no is marked) 2. Does the resident allow food or fluid to run of mouth? (yes is marked with @x (at times) hand written next to it) 3. Does the resident pocket food in their mouth (yes is marked with@x (at times) hand written next to it) 4. Does the resident clamp their mouth shut so not receive? (yes is marked with @x (at times) hand written next to it) If any answer to the above questions 1-4 is YES, this would be a resident that should NOT be assisted with feedings by a non-nursing staff member. If a resident CAN be fed by a non-nursing staff member, please add this to Interdisciplinary Care Plan/CNA Care Plan and forward orange Diet Information Sheet to Food Service and a copy to the Activity Department. Surveyor # noted that this Assessment was completed by LPN-GG. Surveyor # noted that an assessment was not completed by a Registered Nurse. Surveyor # noted that Resident #9 was identified by the facility's form to be ineligible to receive assistance by a feeding assistant. Resident #9's CNA CARE PLAN and Care Plan do not indicate if she can or cannot be fed by a non-nursing staff member. Resident #9's CNA CARE PLAN under the section DINING marks that Resident #9 needs to be fed, has a pureed diet with nectar thick liquids. The section Swallow Precautions is blank. Under Special Concerns/Hydration if not eating at meal, attempt dipping tip of spoon into sweet food items to trigger swallowing and taste buds. Resident #9's most recent Care Area Analysis for Nutritional Status with an Assessment Date of 11/17/2015 documents that Resident #9 receives a pureed diet with nectar thick liquids. Swallow guidelines in place per therapy recommendation. She requires total assistance from staff for all meals. Description of Problem states the need for a mechanically altered diet, varied meal intake. Description of causes and contributing factors states advanced dementia, with agitation, depression, need for a mechanically altered diet. On 4/28/16 at 8:50 a.m. Surveyor # observed Resident #9 receive her breakfast. Surveyor # observed Activity Specialist-C, who is a paid feeding assistant, assist Resident #9 eat her breakfast. At 4/28/16 at 9:00 a.m. Surveyor # asked Activity Specialist-C what Resident #9 was having for breakfast. Activity Specialist-C informed Surveyor # that Resident #9 had pureed cereal, sweet bread, and yogurt. Activity Specialist-C informed Surveyor # that Resident #9 gets yogurt for breakfast for a protein rather than eggs because eggs are hard for Resident #9 to swallow. Surveyor # observed Activity Specialist/Paid Feeding Assistant-C give total assistance to Resident #9 for the entire breakfast meal for both food and fluid intake. No other staff members assisted Resident #9. On 4/28/16 at 3:35 p.m. Surveyor # interviewed RN-N who is the staff Development Coordinator, and who DON-B directed Surveyor # to talk to regarding concerns to the paid feeding assistant program. When asked how staff knows who paid feeding assistants can feed, RN-N stated that the information is kept in a binder. RN-N stated that a nurse, either an RN or LPN, completes the assessment for safe feeding, but if speech therapy is ordered then speech therapy would evaluate. When asked if a resident with a mechanical diet could be fed by the facility's paid feeding assistants, RN-N stated she was unsure. When asked what swallowing precautions are, RN-N stated that it depends on what speech therapy recommends and that they are kept in a binder on the unit. At 3:55 p.m., when showed Resident #9's safe feeding assessment from 2/9/16 and asked if Resident #9 should be fed by a paid feeding assistant, RN-N stated that Resident #9 should not be fed by a paid feeding assistant per the safe feeding assessment. At 4 p.m. Surveyor # reviewed the SNF 1 South MCU dining room binder that RN-N was referring to with RN-N and DON-B. DON-B stated that paid feeding assistants cannot feed anyone who has swallowing precautions that are determined by speech therapy and that if a resident has swallowing precautions there would be a star on name plate. Two residents (Resident #12 and Resident #2) 1 have swallowing precautions in place in the binder. When showed Resident #9's Safe Feeding Assessment from 2/9/16 DON-B stated, I have no clue what this is. This is with MDS. DON-B stated to RN-N, There is a disconnect between the Safe Feeding Assessment and speech therapy. DON-B confirmed that Resident #9 never had a speech therapy evaluation completed. DON-B confirmed that paid feeding assistants should not feed residents if the assessment indicates yes to swallowing precautions as Resident #9's 2/9/16 assessment did. DON-B confirmed that that information was not in the binder for Resident #9. When DON-B was asked for the facility's policy regarding paid feeding assistants, DON-B stated that facility has no written policy and procedure and that the current policy is that paid feeding assistants do not feed residents with swallowing guidelines. When asked how residents are currently being assessed to determine if they could be safely fed by a paid feeding assistant, DON-B stated that the current system is to use the Safe Feeding Assessment form. DON-B stated that the facility would do an audit that night. At 4:35 p.m. Nurse Manager-E was asked if she reviews the Safe Feeding Assessments. Nurse Manager-E stated that she does not review the Safe Feeding Assessments. On 5/2/16 Surveyor # interviewed Speech Language Pathologist (SLP)-QQ. SLP-QQ informed Surveyor # that nursing decides if a resident is able to be fed by a certified nursing assistant or a paid feeding assistant and that she does not make that decision. On 4/28/16 during the daily exit meeting with facility NHA-A, DON-B, RN-N and Nurse Manager-E were informed of the observations of Resident #9 being fed by a paid feeding assistant. 2.) Resident #11 has [DIAGNOSES REDACTED]. Resident #11's prescribed diet is for pureed foods that may be thinned to drinkable consistency. Resident #11's most recent Safe Feeding Assessment completed by an RN dated 3/11/16 documents under question #2 Does the resident allow food or fluid to run out of mouth? Option yes is marked with occ (occasionally) written next to it. The form continues to say If any answer to the above questions 1-4 is YES, this would be a resident that should NOT be assisted with feeding by a non-nursing staff member. At 4 p.m. on 4-28-16 Surveyor # reviewed the SNF 1 South MCU dining room binder that identifies who cannot be fed by a paid feeding assistant. Resident #11 was not in the binder even though her Safe Feeding Assessment indicated she should not be fed by a paid feeding assistant. 3.) Resident #22 has [DIAGNOSES REDACTED]. On 3-30-16 the facility completed a Safe Feeding Assessment for Resident #22 that indicated he could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - GG. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 4.) Resident #23 has [DIAGNOSES REDACTED]. On 3-30-16 the facility completed a Safe Feeding Assessment for Resident #23 that indicated he could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - GG. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 5.) Resident #24 has [DIAGNOSES REDACTED]. On 4/23/16 the facility completed a Safe Feeding Assessment for Resident #24 that indicated he could be fed by a non-nursing staff member. However, the assessment was completed by a Licensed Practical Nurse. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 6.) Resident #20 has [DIAGNOSES REDACTED]. Resident #20's speech therapy discharge report date 11/17/15 documents that Nursing and dietary were educated on discharge status. Discharge diet is general, thin liquids, small single sips by cup or straw, slow rate, alternate liquids and solids. On 3/13/16 the facility completed a Safe Feeding Assessment for Resident #20 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by a Licensed Practical Nurse. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 7.) Resident #25 has [DIAGNOSES REDACTED]. On 3/13/16 the facility completed a Safe Feeding Assessment for Resident #20 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by a Licensed Practical Nurse-RR. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 8.) Resident #26 has [DIAGNOSES REDACTED]. On 3/9/16 the facility completed a Safe Feeding Assessment for Resident #26 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by a Licensed Practical Nurse-RR. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 9.) Resident #27 has [DIAGNOSES REDACTED]. On 2/7/16 the facility completed a Safe Feeding Assessment for Resident #27 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by a Licensed Practical Nurse-RR. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 10.) Resident #28 has [DIAGNOSES REDACTED]. On 3/8/16 the facility completed a Safe Feeding Assessment for Resident #28 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by a Licensed Practical Nurse-RR. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # and Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 11.) Surveyor # reviewed Resident #12's medical record on 5/2/16 & 5/3/16. The quarterly MDS (minimum data set) signed as complete on 2/8/16 for Resident #12 documents a BIMS (brief interview mental status) total score of 2 which indicates severely impaired and requires extensive assistance with one person physical assist for eating. Resident #12 is on a pureed diet with nectar thick liquids. The safe feeding assessment dated [DATE] documents Use this form to assess a resident's ability to be fed by a non-nursing staff member that has been through the feeding program. Feeding assistants may only feed resident who have demonstrated safe swallowing and chewing ability. The assessment of these residents will be done on admission, quarterly or if there is a change of condition in their swallowing ability. Are swallowing precautions in place if yes, feeding assistants may not feed - skip to SAFETY Assessment. If NO, continue with assessment. Surveyor # noted Yes is checked. This assessment was completed by LPN (Licensed Practical Nurse)-S and not reviewed by a RN (Registered Nurse). On 5/3/16 at 2:50 p.m. Surveyor # showed RN Manager-E Resident #12's safe feeding assessment dated [DATE] and asked whose signature was on the assessment. RN Manager-E replied LPN-S. Surveyor # informed RN Manager-E that LPN's by virtue of their license can gather data but cannot assess and that Surveyor # did not note where the safe feeding assessment was reviewed by a Registered Nurse. On 5/3/16 at 4:18 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. 12.) Surveyor # reviewed Resident #3's medical record from 4/27/16 to 5/2/16. Resident #3 was admitted to facility on 8/8/15 with a [DIAGNOSES REDACTED]. Section G of the Quarterly MDS (Minimum Data Set) dated 2/22/16 documents under eating that resident requires supervision during eating. The Speech Therapy Evaluation dated 4/18/16 documents under the Precautions section Alternate liquids and solids. Check mouth for pocketing of food on right/left side during/following meal The document titled, Safe Feeding Assessment and dated 4/15/16 documents under the Safety section, 1. Does the resident require total assist with feeding? The checkbox labeled as yes is checked with the words at times written above the box. The document is signed by LPN (Licensed Practical Nurse)-U. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. Surveyor # could not located an assessment completed by an RN (Registered Nurse) in Resident #3's medical record indicating whether Resident #3 could or could not be assisted by a paid feeding assistant while eating. 13.) Surveyor # reviewed Resident #4's medical record from 4/27/16 to 5/2/16. Resident #4 was admitted to facility on 9/15/14 with a [DIAGNOSES REDACTED]. Section G of the Quarterly MDS (Minimum Data Set) dated 2/8/16 documents under eating that resident requires a one person physical assist while eating. The document titled, Safe Feeding Assessment and dated 4/30/16 documents under the Safety section, 2. Is the resident at increased risk of spilling hot liquids due to decreased dexterity, upper extremity strength or upper extremity tremors? The checkbox labeled as Yes is checked. The document is signed by LPN-V.N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. Surveyor # could not located an assessment completed by an RN (Registered Nurse) in Resident #4's medical record indicating whether Resident #4 could or could not be assisted by a paid feeding assistant while eating. 14.) On 4-27-16 at 9 am, Surveyor # observed Social Services - O (Staff - O) assisting Resident #7 to eat her breakfast. On 4-27-16 at 12:40 PM, Surveyor # observed Activity Therapist - C (Staff - C) assisting Resident #7 to eat her lunch. On 4-27-16, Surveyor # reviewed Resident #7's medical record. Resident #7 has a [DIAGNOSES REDACTED]. On 2-16-16 the facility had completed a Safe Feeding Assessment for Resident #7 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - S. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 15.) On 4-27-16 at 12:40 PM, Surveyor # observed Activity Therapist - P assisting Resident #16 to eat her lunch. On 4-28-16 at 8:35 am, Surveyor # observed Social Services - Q assisting Resident #16 to eat her breakfast. On 5-3-16, Surveyor # reviewed Resident #16's medical record. Resident #16 has a [DIAGNOSES REDACTED].#16 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - GG. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 16.) On 4-27-16 at 9 am, Surveyor # observed Social Services - O assisting Resident #17 to eat her breakfast. On 4-27-16 at 12:40 PM, Surveyor # observed Activity Therapist - C assisting Resident #17 to eat her lunch. On 4-28-16 at 8:55 am, Surveyor # 9 observed Activity Therapist - C assisting Resident #17 to eat her breakfast. On 5-3-16, Surveyor # reviewed Resident #17's medical record. Resident #17 has a [DIAGNOSES REDACTED].#17 that indicated she could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - S. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 17.) On 4-27-16 at 12:40 PM, Surveyor # observed Activity Therapist - P assisting Resident #18 to eat her lunch. On 4-28-16 at 8:55 am, Surveyor # 9 observed Social Services - Q assisting Resident #18 to eat her breakfast. On 5-3-16, Surveyor # reviewed Resident #18's medical record. Resident #18 had a [DIAGNOSES REDACTED]. On 4-23-16 the facility had completed a Safe Feeding Assessment for Resident #18. However, the assessment was completed by Licensed Practical Nurse (LPN) - HH. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. Additionally, the assessment was not complete. It indicated that Resident #18 had no swallowing precautions. However, LPN - HH had not completed the questions related to: coughing, food running out of the mouth, pocketing food, and clamping the mouth shut when fed. If LPN - HH had answered yes, to any of these questions; Resident #18 could not be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 18.) On 4-27-16 at 12:40 PM, Surveyor # observed Social Services - Q assisting Resident #19 to eat his lunch. On 4-28-16 at 9:05 am, Surveyor # 9 observed Unit Secretary - R assisting Resident #19 to eat his breakfast. Unit Secretary - R is non-nursing staff. On 5-2-16, Surveyor # reviewed Unit Secretary R's credentials. Unit Secretary - R did not pass a State Approved Training Program and therefore she was not eligible to be a paid feeding assistant and feed Resident #19. DON - B confirmed this information on 5-2-16 at 11:05 PM. On 5-3-16, Surveyor # reviewed Resident #19's medical record. Resident #19 had a [DIAGNOSES REDACTED]. On 4-23-16 the facility had completed a Safe Feeding Assessment for Resident #19 that indicated he could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - GG. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. 19.) Resident #8's medical record was reviewed by Surveyor # from 4/27 - 5/4/16. Resident #8 has a [DIAGNOSES REDACTED]. His 4-18-16 Minimum Data Set indicates that he requires the assistance of 1 staff person to eat his meals. On 4-13-16 the facility completed a Safe Feeding Assessment for Resident #8 that indicated he could be fed by a non-nursing staff member. However, the assessment was completed by Licensed Practical Nurse (LPN) - GG. N6 Wisconsin Administrative Code requires that a Registered Nurse (RN) complete assessments; an LPN is not authhorized to determine if a resident has no complicated eating or drinking problems and can be fed by a paid feeding assistant. On 4-28-16 at 4:35 PM, Surveyor # interviewed RN Manager - E. RN Manager - E stated that she had not reviewed any of the facility's Safe Feeding Assessments for residents that had been completed by an LPN. PAID FEEDING ASSISTANTS QUALIFICATIONS On 5-2-16 Surveyor # reviewed the qualifications for the facility's 15 paid feeding assistants. All but one, Unit Secretary - R, had successfully completed the State Approved Training Course. Unit Secretary - R had a certificate that indicated she had completed a Caregiver Training Program that was developed for the use of individuals providing Supportive Home Care Homemaking and Attended Care. ON 5-2-16 at 11:05 am, Surveyor # shared the preceding information with DON - B. DON - B confirmed that Unit Secretary - R was not eligible to be a paid feeding assistant. DON - B said that she would have to pull Unit Secretary - R from feeding residents. Allowing residents with complicated feeding problems or who had not been properly assessed to determine if they had a complicated feeding problem to be fed by paid feeding assistants created a potential for choking or aspiration. Accordin

Based on record review and interview, facility staff did not provide adequate assistance and supervision for 2 of 4 residents (Resident #1 and #2) who sustained falls. * On 1/14/16, Resident #1 was assisted to stand by two NA (nursing assistant) students who did not use a gait belt. The students were supposed to summon their instructor before transferring the Resident out of bed, but they did not. Resident #1 had to be lowered to the floor. Resident #1 was then transferred back into bed by the nursing students. Resident #1 suffered an ankle fracture that required surgery. * On 2/22/16, Resident #2 sustained a fall from bed while one CNA was assisting with morning cares. The MDS (Minimum Data Set) indicates Resident #2 requires 2 people to assist with bed mobility. Resident #2 suffered rib and clavicle fractures. Findings include: 1. Surveyor # reviewed Resident #1's medical record on 3/10/16-3/11/16 to investigate a complaint regarding a fall with fracture that Resident #1 had sustained on 1/14/16. Resident #1 was admitted to the facility 10/1/15. Resident #1's Cumulative [DIAGNOSES REDACTED]. movements), lumbago, coronary artery disease, interstitial lung disease and chronic kidney disease. Resident #1's Historical [DIAGNOSES REDACTED]. continued back and right lower extremity pain/ weakness November, 2012; TIA's (transient ischemic attacks- mini-strokes); status [REDACTED]. On 1/19/16 (readmission to facility) staff added the [DIAGNOSES REDACTED]. Resident #1's Preadmission assessment dated [DATE] states her Primary [DIAGNOSES REDACTED]. Medical /Surgical History states, Recent fall. Poor vision, unable to read, some vision left eye. ADLS (Activities of Daily Living): Not steady on her feet .devices used: walker and wheelchair. Fall Risk: Yes . Patient has medical condition that affects mobility. Surveyor # reviewed Resident #1's Admission MDS (Minimum Data Set) dated 10/7/15 which indicates Resident #1 is cognitively intact; requires extensive assistance of two+ persons for bed mobility and transfers, ambulation did not occur during the assessment reference period; Resident #1 had limited functional range of motion (ROM) on one side for upper extremities, no limited ROM on lower extremities; vision highly impaired; balance from sitting to standing not steady, only able to stabilize with human assistance. Resident #1 had no falls or fractures in the 6 months prior to admission, and no falls since admission as of 10/7/15. Resident #1 is noted to be 61 inches tall (5 feet, 1 inch) and weighs 203 pounds. Resident #1's Quarterly MDS with an Assessment Reference date of 1/5/16 reflects the same status except ROM of lower extremities is noted as limitations on both sides, and weight is 210 pounds. Resident #1' CAA (Care Area Assessment) for Falls dated 10/7/15 states: Care Plan Reasons: Decline in physical and mental functioning. Had multiple falls while at Assisted Living facility, is non-ambulatory at this time. Needs two assist and a wheeled walker to stand and/or transfer. Aware of need for assist. Uses call light and waits for staff to arrive. Potential for falls/ injury. Need for assist with all mobility. See Falls Care Plan. Description of Problem: Decreased mobility, decreased strength, impaired balance, decreased safety awareness, limited endurance. Non-ambulatory. Need for assist with ADLs (Activities of Daily Living)/ mobility. Chronic pain especially to bilateral knees. No sight right eye, blurred left eye, cannot see to read or watch TV. Rare incontinence, decreased cognitive functioning. Causes and Contributing Factors: Resident (#1) had multiple falls while at Assisted Living apartment related to weakness in legs, known osteoarthritis, severe, to knees, degenerative changes to right shoulder, DJD to multiple joints, rotator cuff syndrome to left, spondylosis with [DIAGNOSES REDACTED] (degenerative changes to the lower spine- such as bone spurs and/or degenerating intervertebral discs with weakness, tingling, gait/balance problems) of lumbar region; hypertension medication, Mirapex for restless leg syndrome. Laxative use. Has very limited sight. Risk Factors related to Care Area: Potential for falls/ injury; skin breakdown; changes to mood with decreased functional ability. Resident #1's Fall Risk Data Collection Tool dated 10/1/15 scores Resident #1 at 15. Zero to 10 is low risk; 11-15 is moderate risk; 16 and above is high risk. Resident #1 is noted to be at risk due to being non-ambulatory; makes multiple attempts but successful for transfers; poor vision (scores as 2 points though legally blind would score 4 points. Resident #1's Cumulative [DIAGNOSES REDACTED]. A score of 17 would be in the high risk category.); medications- for hypertension, laxatives, anti-emetics; and arthritis. Resident #1's Care Plan dated 10/7/15 for Self-care deficit states: Related to history of falls; right leg weakness; obesity; arthritis; pain; restless leg syndrome; admitted from Assisted Living situation with increase in care needs. As evidenced by: decreased mobility; decreased strength; limited endurance; need for assist with ADLs; pain to right shoulder and knees; decline if cognitive functioning; blind right eye, limited blurry vision left eye. Strength: able to participate in cares; makes needs known; uses call light. An Approach dated 10/7/15 states Use gait belt for all transfers. Another Approach was added 1/7/16 stating, Transfer with one assist with WW (wheeled walker). Resident #1's Care Plan dated 10/7/15 for Falls states: Potential for Injury related to decreased strength, decreased ROM, limited endurance, impaired balance, unsteady gait, decreased safety awareness, increased need for assist with mobility, history of falls, right leg weakness, pain, blind right eye, blurred vision left eye, cannot see to read or watch TV, DJD multiple joints, severe osteoarthritis knees, knees give out at times, spondylosis lumbar region, anxiety per history, restless leg syndrome, cardiovascular medication use, need for walker, w/c (wheel chair) used for distance, asthma, history of ataxia. Strength: alert and aware of need to seek assist with mobility. Uses call light. Approaches include: Transfers per therapy direction, see therapy recommendations kept with nurses' notes or see CNA Care plan (10/7/15). On 12/10/15 staff added the approach of Make sure Resident extends knees to prevent knees from buckling. The 12/10/15 Approach was added after Resident #1 fell on [DATE] when she sat down before fully reaching her recliner while staff was assisting her. On 1/7/16 staff added the Approach of Cue Resident when transferring -make sure chair/bed is behind before sitting down. Surveyor # reviewed Resident #1's CNA Care Plan dated 10/1/15 that was in effect on 1/14/16 per RN-A. The Mobility section states: Transfer: 1 Assist. Ext. (extensive) 50% assist with WW (wheeled walker) to/from bed, wc (wheelchair), and recliner. Non-ambulatory. Devices- yes, walker, gait belt for transfers, wheelchair. Special needs: Patient can transfer with 1 assist (50% ext) with wheeled walker- make sure patient extends knees to prevent knees buckling. Surveyor # reviewed Resident #1's Nurses' Notes. A Note dated 1/12/16 states Resident #1's pramipexole (medication for restless leg syndrome) was increased on 1/12/16 from 0.125 mg. (milligrams) once a day to twice a day - give every bedtime and 2nd dose every late afternoon or supper. (Surveyor note: Side effects of this medication include dizziness, and drowsiness.) A nurses notes dated 1/14/16 at 9:20 a.m. by RN (Registered Nurse)-B states: Called to Resident's room at 8:43 a.m. Assigned RN (Registered Nurse) reports Resident fell with legs buckling up. Lowered to floor by assigned NA (nursing assistant) students. When writer arrived, the resident was laying on her bed. Right ankle appears fractured. Writer ensured staff is with resident until ambulance arrived at approximately 9:10 a.m.MD (doctor) and family notified . Report given to ER RN .Ambulance left at 9:20 a.m. Another Nurses' Note dated 1/14/16 at 1330 (1:30 p.m.) states: At 8:40 a.m. writer notified of Resident fall. Upon entering room, writer observed resident lying supine in bed with legs elevated on pillow. Resident denies hitting head. Right ankle deformed. Resident reports pain on 8/10 (Note: 8 on scale of 0-10, with 0 being no pain and 10 being worst pain imaginable) to right ankle .Pedal pulse +2 right foot. Scheduled Tylenol 1000 mg. given . Another Nurses' Note dated 1/14/16 at 1350 (1:50 p.m.) by RN Supervisor -A states, Writer notified of fall at 8:45 a.m. WCTC (Waukesha County Technical College) CNA (Certified Nursing Assistant) students #1 and #2 were assigned to Resident. While Resident standing with WW (wheeled walker) at bedside, resident reported her legs felt weak. Students #1 and #2 attempted to sit Resident on bed, but her knees flexed forward and was eased to the floor with right leg under her body. Students were not using gait belt. Students #1 and #2 helped Resident straighten out legs. Students reported Resident denied pain and asked to get up. Student #2 went out to get student #3. All 3 students lifted resident back to bed. After getting resident into bed, nursing instructor was called to room. RN-A also noted on 1/14/16 at 1415 (2:15 p.m.) that Resident #1 was being admitted to the hospital with [REDACTED]. Surveyor # reviewed a Discharge Summary from the hospital for Resident #1 dated 1/19/16. It states: [DIAGNOSES REDACTED]. 1. S/P ORIF (status [REDACTED]. Workup has been performed that showed right distal tibia and fibular fracture .Patient underwent open reduction and internal fixation . Patient provided Physical and Occupational Therapy .Continue non-weight bearing . The NHA (Nursing Home Administrator) and the DON (Director of Nursing) were both unavailable during this survey. Director of Social Services-C provided Surveyor # with a copy of the Resident Fall Report Data Collection SNF (Skilled Nursing Facility) document dated 1/14/16 regarding Resident #1's fall. The report states Resident #1 had a fall witnessed by CNA students on 1/14/16 at approximately 8:45 a.m. that resulted in a right foot fracture. The Form states, Describe exactly what happened. RN-A wrote what was documented in the Nurses' Notes described above. Under Analysis of Fall, RN-B wrote Resident #1's legs buckled and she was lowered to the floor while they were attempting to do peri-care. Care plan updated to ensure peri-care is done while laying in bed or sitting up. Resident sent to ER for evaluation. For Supervisor Follow Up, RN-A wrote, Follow up with nursing instructor regarding fall. Statement received from 1 student and instructor. Students were dismissed from clinicals at facility. Nursing instructor advised we would need statements from all students involved. Instructor will get statements and forward to facility. Plan of Care new interventions added: Peri-care done while in bed or sitting up on toilet. Gait belt to be used with all transfers. Surveyor noted, Gait belt to be used with transfers was already on the Care Plan as of 10/7/15. Factors that may have influenced fall: Legs felt weak, knees buckled. A statement from NAS (Nursing Assistant student)-D dated 1/13/16 (date error- fall occurred on 1/14/16) at 9:40 a.m. stated NAS-E was the student assigned to Resident #1; NAS-D was assisting NAS-E and was going to provide peri-care for Resident #1 who was in bed at the time. Resident #1 told us alertly that she never uses a gait belt and (NAS-E) didn't really say much because she had originally gotten the care plan. She said she uses a walker to get up and wipe. As we were pulling her briefs up, her legs gave out and we helped her lie down on the floor. I said I was going to get (NA Instructor-G) and NAS-E said no, I'm going to get (NAS-F) to pull her up. So (NAS-F) got the gait belt on to lift her on to the bed which I knew was not a good idea but the Resident said she wanted to get back on the bed so we all helped her get straightened out and up so her leg was out of the way. I never knew (Resident #1) was light-headed or I didn't know that she really did use a gait belt because I wasn't in the room when they gave the plan. The statement from NA-Instructor (Nursing Assistant Instructor)-G is dated 1/14/16 at 9:40 a.m. indicates NA (nursing assistant) students (D, E, and F) cared for Resident #1. After interviewing the students involved in this incident, this is a composite of their recollections of the events. Students (NAS-E and D) were in the resident's room giving her a partial bed bath. Students indicated that they were aware of the need to come and get writer (instructor) prior to getting the resident up. After completing most of the partial bed bath, resident told students to stand her up at the side of the bed and complete her peri-care with her standing and holding on to the walker as that is how they do it. Students said resident had her shoes on and her pants half way up. Students said they completed peri-care and pulled up the resident's pants. Student reported that the resident stated her legs felt weak and they attempted to sit the resident down on the bed but her knees flexed forward and students (NAS-E and D) eased the Resident to the floor and one of her legs (right) was under her body. Students (NAS-E and D) then moved the resident to her buttocks and helped the resident straighten out her legs. Students report that the resident denied pain and requested to be gotten up. Student (NAS-D) went out of the room and brought back (NAS-F). Students (NAS-D, E, and F) lifted resident back into bed. Student (NAS-F) came and brought writer back to resident's room. Writer noticed (Resident #1)'s right ankle deformity, palpated the ankle/foot and found a dorsalis pedis pulse. Writer instructed students to bring the nurse back to the room. Resident denied discomfort. Resident's right ankle was placed on a pillow in the bed. Facility staff never received individual statements from NAS-E or NAS-F. On 3/11/16 at 9:10 a.m., Surveyor # interviewed RN Supervisor-A regarding Resident #1's fall and fractured ankle. RN-A summarized what was in her Nurses' Notes (above). RN-A provided Surveyor # with a copy of the facility's Policy and Procedure (P&P) titled, Moving a Resident, Bed to Chair/Chair to Bed, dated 12/11/2002. Excerpts of the P&P state: Purpose: The purposes of this procedure are to allow the residents to be out of his or her bed as much as possible and to provide for safe transferring of the Resident. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. Equipment and Supplies: 1. Gait belt. Steps in the Procedure: Note: This procedure may require two persons. 1. Wash hands . 2. Lower height of the bed to the lowest position. 3. If moving a resident from a bed to chair . D. Assist the resident to a sitting position and apply gait belt . H. If the Resident cannot stand alone, two persons, (one on each side) should hold the gait belt, gently stand and turn the resident and sit him or her in the chair . RN-A stated they do not have a policy specifically for assisting a Resident to stand up, but the beginning of the Bed to Chair scenario describes how a Resident would be assisted to a standing position from bed, and it does require use of a gait belt, which the students did not use. On 3/11/16 at 9:40 a.m., Surveyor # interviewed In-service/ Education RN-B, who stated the nursing assistant students were on day 4 of a 6 day clinical experience when Resident #1 fell and fractured her ankle. The school instructors assess the students to ensure they are competent in the skills lab before they come to their clinical site. The students must pass a skills test prior to advancing to the clinical portion of their training. RN-B stated the instructor makes the assignments. Facility staff provides input regarding what Residents would be appropriate for nursing assistant students and which Residents and families have expressed willingness and agree to work with the students. The Instructor and students again each day ask the resident if they want to work with the student. On 3/11/16 at 12:01 p.m. RN-B provided Surveyor # with information from Waukesha County Technical College (WCTC). The first document was a Memorandum of Agreement between WCTC and Congregational Home, signed 7/1/11, became effective 9/1/2011, and continuous unless either party terminates with notice . The Memorandum states B. The Clinical site, Congregational Home, . 3. Shall retain responsibility and accountability for the planning and continuity of health care even though one or more aspects of care may be delegated to the nursing student. RN-B also provided Nursing Assistant Performance Checklists from WCTC for the three nursing assistant students, (NAS-D, NAS-E and NAS-F), indicating that all three had satisfactory performance according to established criteria in autotutorial lab for Transfer bed to chair and Use transfer/gait belt. The specific names on the Performance Checklists were redacted. RN-B stated the school staff told her they cannot divulge records identifying the individual students. Surveyor # met with RN-A, SW-C, and CFO (Chief Financial Officer)-H for the exit conference on 3/11/16 and shared concerns that the nursing assistant students did not follow Resident #1's plan of care which stated a gait belt is to be used for transfers, when they stood Resident #1 up at the side of her bed. Without the gait belt, the students could not safely lower Resident #1 to her bed or floor and Resident #1 sustained a fractured ankle, requiring surgery. No further information was provided. 2. Surveyor # reviewed Resident #2's medical record on 3/10/16 and 3/11/16. Resident #2 was admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. On the facility Roster matrix, Resident #2 was marked as having a fall with fracture. Surveyor # reviewed a Resident Fall Report Data Collection SNF (Skilled Nursing Facility) dated 2/22/16 at 6:50 a.m. The report states: Writer called to Resident's room. Resident rolled off bed during cares. CNA (Certified Nursing Assistant) was with Resident and had resident on her side (right). CNA was supporting resident with one hand and getting washcloth with other hand. Resident slipped off of bed. CNA unable to stop her. The report documents Resident #2 stated, I couldn't hold on any longer and I fell . X-rays revealed fracture to left clavicle, and left 3rd, 4th, 5th and 6th rib fractures. Analysis of fall to include potential/ causal contributing factors: CNA did not recognize Resident was too close to side of bed. Follow-up: Resident should have 2 caregivers when rolled onto side for cares or repositioning. The statement from the CNA who was providing cares states: While doing cares on (Resident #2), I was doing pericare and rolled her to do her backside. Normally (Resident #2) holds onto the bed, but she let go as I was putting the towel in the basin. I had one hand on her hip holding her and she just rolled off the bed. Rolled her to right side to clean her backside and she rolled out of bed onto her right side. Inservice/ Education RN-B provided re-education to the CNA and had her perform skills to be evaluated on the Skills Checklist again regarding bed mobility, transfers, peri-care, safe resident handling, range of motion, body mechanics, personal cares, elimination and repositioning. Resident #2's Admission MDS (Minimum Data Set) with an Assessment Reference date of 2/5/16 indicates Resident #2's BIMS (Brief Interview for Mental Status) shows moderate cognitive impairment, score of 10. Scores of 13-15 indicate cognitively intact; 8-12 moderate impairment; 0-7 severe impairment. Resident #2's Admission MDS indicates Resident #2 requires extensive assistance of two+ persons physical assist for bed mobility, and total dependence of two+ persons for transfers. Resident #2 is noted to have impairment on one side of upper extremities (shoulder, elbow, wrist, hand), and impairment on both sides of lower extremity (hip, knee, ankle, foot). The MDS reflects Resident #2 had no falls or fractures within the past six months before admission to the facility. Resident #2 had no falls since she was admitted to the facility (1/30/16) to the Assessment Reference Date (2/5/16). Resident #2's CAA (Care Area Assessment) dated 2/5/16 for Falls states: Care Plan Reasons: Resident admitted with [DIAGNOSES REDACTED]. Has been living at home with husband caring for her until husband had health decline. Score of 16 on Fall Risk Data Assessment which places resident at high risk for falls. No recent falls. Transfers with EZ lift and 2 assist. Non-ambulatory. Will address under potential for injury. Description of Problem: Weakness to both legs, balance problems, dependent on staff for mobility, non-ambulatory. Causes and Contributing Factors: [DIAGNOSES REDACTED]. Risk Factors Related to Care Area: Potential for injury. Surveyor # reviewed Resident #2's Fall Risk Data Collection dated 1/30/16, which indicates Resident #2 is at high risk for falls (scored 16- score of 16 or higher are high risk). Resident #2 is noted to have modified independence in cognitive skills for decision making- some difficulty in new situations only; Ambulation- total dependence, non-ambulatory; Transfer- unable to rise without assistance; Continence- partially continent of bowel and bladder (has supra-pubic catheter); Medications- laxatives; Pre-disposing diseases/ conditions- significant pain, MS. Surveyor noted Resident #2 also receives baclofen, a muscle relaxant, to treat muscle spasms. Resident #2's Care Plan for Falls with start date of 2/8/16 states: Potential for injury related to [DIAGNOSES REDACTED]. Strength: no falls since admission. Goal: (Resident #2) will remain free of bodily injury/ accident through 5/8/16. Approaches include: Transfer with assist of 2 and EZ stand; Monitor for safety and assist to maintain. Resident #2's Care Plan dated 2/8/16 for Self-care deficits related to multiple sclerosis, neurogenic bladder, right knee/ankle pain, as evidence by weakness of both legs, balance problems, right hand contracture/ weakness. Strength: Resident wants to be as independent as possible. Approaches include: Assist with ADL's as necessary: 25% assist for UE (upper extremities) bathing and dressing, 75% assist to LE (lower extremity) dressing, 2 assist for toileting. Surveyor # reviewed Resident #2's current CNA (Certified Nursing Assistant) Care Plan dated 3/2/16 which states: Safety: 2 caregivers when rolled onto side for cares .Bed Mobility: Total, 2 assist. Surveyor # requested the CNA Care Plan in place when Resident #2 rolled off her bed and sustained a left clavicle fracture, and left 3rd, 4th, 5th and 6th rib fractures on 2/22/16. Resident #2 returned to the facility 2/25/16, and staff, Resident and family noted Resident #2's right leg did not appear right, it was rotated externally. Family said Resident #2's leg was of concern in the hospital and they asked for hospital staff to assess it but they never did. Facility staff sent Resident #2 back to the hospital for evaluation of her right leg and they diagnosed a right subtrochanteric femur fracture. RN-I provided Surveyor # with an older CNA Care Plan for Resident #2. The CNA Care Plan was initiated on admission 1/30/16, and updated 2/3/16, 2/9/16, 3/2/16 and 3/3/16. The CNA Care Plan was then re-written for clarity on 3/2/16. This CNA Care Plan states Special Concerns: .Encourage Resident to turn side-to-side and use pillows to support in place. 2 persons assist with positioning .Safety: 2 caregivers when rolled onto side for cares or positioning Bed Mobility: Total-2 assist . Surveyor # pointed to the statements to use 2 person assist with positioning, and noted when Resident #2 fell off her bed, the CNA was providing cares by herself. RN-I informed Surveyor # that they use pencil when completing the C N A Care Plans so they can make changes when needed. RN-I stated she believed the 2 assist with positioning was added after Resident #2 fell out of bed. The interventions are not dated so it is not clear when the interventions were added. Surveyor # noted Resident #2's Admission MDS, dated [DATE], indicates Resident #2 required extensive assist of 2+ persons for bed mobility. On 3/11/16 at 2:12 p.m., Surveyor # interviewed CNA (Certified Nursing Assistant)-J, asking how many staff should have been assisting Resident #2 with cares in bed prior to her fall out of bed on 2/22/16. CNA-J stated she has not provided cares in bed for Resident #2- she stated two staff transfer Resident #2 to her chair and she is taken to the shower. Resident #2 has a Foley catheter and can be transferred to the toilet for bowel movements. Surveyor # noted the CNA Care Plan states bed pan for BM's PRN (as needed). CNA-J stated they have two staff provided cares for Resident #2 when in bed now, but she does not know when that began. At the exit meeting on 3/11/16, Surveyor # informed RN-A, Social Worker -C, and CFO (Chief Financial Officer)-H that Resident #2's Admission MDS notes two CNAs are needed for bed mobility. The CNA was working alone and had Resident #2 too close to the edge of the bed, contributing to the fall. No further information was provided.