Every finding on record at Countryside Center for Rehabilitation and Nursing

Number of residents sampled: Number of residents cited: Based on facility policy review, record review, review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely for 2 Residents (R)23 and R40 of 2 residents reviewed for resident assessment requirements. The findings include: Review of facility policy titled, RAI Assessment-MDS 3.0 Completion, revised March 2025, revealed residents were assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. The policy further revealed Types of OBRA [Omnibus Budget Reconciliation Act] Assessments included, b. admission Assessment- completed within 14 days of admission counting the day of admission as day #1 when, which included, i. The resident had no prior admission. Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0, dated October 2024, included an RAI OBRA-required Assessment Summary that indicated that an admission assessment's completion date (Z0500B) was to be no later than the 14th calendar day of the resident's admission (admission date + 13 calendar days). 1. Review of R23's Face Sheet revealed the facility admitted the resident on 09/16/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of peritoneal abscess. Review of R23's admission MDS, with an Assessment Reference Date (ARD) of 09/21/2025, revealed, A1900. admission Date was entered as 09/16/2025. Per the MDS, the completion date (Z0500B) was dated 09/30/2025, the 15th calendar day of the resident's admission. During an interview on 02/19/2026 at 11:09 AM, the MDS Coordinator stated the resident's admission assessment was completed late, and she expected the MDS to be completed by day 13. She stated that the assessment was signed as completed late due to sections being signed late, but she did not have a specific reason for the late completion. 2. Review of R40's Face Sheet revealed the facility admitted the resident on 09/08/2025. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of atherosclerotic heart disease of the native coronary artery with unstable angina pectoris. Review of R40's admission MDS, with an Assessment Reference Date (ARD) of 09/12/2025, revealed, A1900. admission Date was entered as 09/08/2025. Per the MDS, the completion date (Z0500B) was dated 09/24/2025, the 17th calendar day of the resident's admission. During an interview on 02/19/2026 at 11:09 AM, the MDS Coordinator stated an admission MDS assessment was to be completed by day 13 after admission. The MDS Coordinator reviewed Resident #40's medical record and admission MDS assessment and verified the facility admitted the resident on 09/08/2025 and the admission MDS assessment indicated the assessment was completed on 09/24/2025. She stated that she expected the MDS to be completed by 09/20/2025. The MDS Coordinator stated that she did not know why it was not completed on time. During an interview on 02/19/2026 at 11:45 AM, the Director of Nursing (DON) stated she was not involved in the MDS process or what time requirements were for completion or submission. The DON stated she expected MDS assessments to be completed timely for the facility to receive payment. During an interview on 02/19/2026 at 12:14 PM, the Administrator (ADM) stated she did not have knowledge of the timeliness required for MDS assessments and was not familiar with what guide was used to determine the time requirements. The ADM stated she had a regional MDS consultant as a resource if she had questions related to the MDS process; however, she expected all MDS assessments to be completed timely.

Based on interviews and review of the facility's policy, it was determined the facility failed to ensure the individual assigned the responsibilities of the Infection Preventionist (IP) had received specialized training in infection control and prevention. This had the potential to affect all fifty (50) residents residing in the facility On 01/27/2025 at 7:05 PM, the entrance conference was conducted with the Administrator who revealed that the Staff Development Coordinator (SDC) was the designated Infection Preventionist (IP) for the facility. The findings include: Review of facility policy Infection Preventionist, revised 08/20/2024, revealed, the facility would employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. Continued review revealed, that an infection preventionist was defined as an individual designated by the facility to be responsible for the infection prevention and control program. The facility would ensure the infection preventionist was qualified by education, training, experience or certification. Additionally, the IP must have obtained specialized Infection Prevention and Control (IPC) training beyond initial professional training or education prior to assuming the role and must provide evidence of training through a certificate of completion or equivalent documentation. Review of the facility policy, Infection Prevention and Control Program, revised on 02/21/2024, revealed, the facility would establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Continued review revealed the designated Infection Preventionist (IP) was responsible for oversight of the program and served as a consultant to the staff on infectious diseases, resident room placement, implementing isolation precautions, and staff/resident exposure surveillance. All staff were responsible for following all policies and procedures related to the program. Review of The Centers for Disease Control and Prevention (CDC) certificate, provided by the facility, revealed the Director of Nursing had completed the Nursing Home Infection Preventionist Training Course on 05/11/2023. However, no certificate of completion was received for the SDC/IP. In interview with the Staff Development Coordinator/Infection Preventionist, RN, on 01/30/2025 at 2:43 PM, she stated she had been the designated IP since August 2024. When asked about her training, the IP stated she had not completed the specialized training on infection control. She stated she performed all duties related to infection control such as antibiotic stewardship, infection tracking, staff and resident vaccines and reported her findings to the Quality Assurance Performance Improvement (QAPI) meetings. During an interview with the Director of Nursing (DON) on 01/30/2025 at 3:45 PM, she stated the Infection Preventionist had six months to complete the specialized training on infection control. She stated the IP had until mid February to complete the training. When asked if that was the requirement, the DON stated it was. The Surveyor requested to review the requirement. In a follow up interview with the DON on 01/30/2025 at 4:43 PM, she stated she had thought there was a six month window. She further stated she had completed the training and was the facility back up. She stated the SDC/IP was designated as the IP and performed all duties related to infection control. She stated the SDC was working on the training now. In an interview with the Administrator on 01/30/25 at 5:43 PM, she stated the facility was currently working on changing their enhanced barrier precautions guideline changes. She stated she was under the impression the SDC had six months to complete the specialized training on infection control. She further stated the SDC had been performing the duties of the IP.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure that foods brought in by family and/or visitors were stored in a safe and sanitary manner for four of 13 sampled residents (Resident (R) 5, 6, 37, and R50) with personal in room refrigerators. The findings include: On 01/28/2025 and 01/30/2025, the State Survey Agency (SSA) requested a policy on resident refrigerators. On 01/30/2025 at 4:50 PM, the Director of Nursing (DON) stated the facility did not have a policy on resident personal refrigerators. Review of facility policy, Use and Storage of Foods Brought in by Family or Visitors, revised on 01/06/2025, revealed. it was the right of the residents of the facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident. Family members or other visitors may bring the resident food of their choosing. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The prepared food must be consumed by the resident within three days. If not consumed within three days, food would be thrown away by facility staff. The facility will not be responsible for maintaining any reusable items. Facility staff would assist residents in accessing and consuming food that were brought in by the resident and family if the resident is not able to do so on their own. 1. Observation on 01/28/2025 at 9:46 AM in room [ROOM NUMBER]B of R5's personal refrigerator revealed a temperature check form taped to the outer door, dated January 2025, with the last temperature reading recorded on 01/24/2025. The temperature reading on thermometer located inside the door read fifty-four (54) degrees Fahrenheit (F). The inside of the refrigerator was dirty and there were 2 styrofoam containers, and a paper plate covered with aluminum foil visible inside the refrigerator. The freezer had a large amount of ice build up that was brown in color which looked like a soda may have leaked in the freezer. Certified Nursing Assistant (CNA) 1 and CNA2 were observed in the hall and the surveyor requested they check the resident's refrigerator. CNA1 and CNA2 checked refrigerator and removed the items (styrofoam containers, foil covered plate and molded food items) from the refrigerator. Continued observation with CNA1 and CNA2, of R5's refrigerator revealed a large foam container, not labeled or dated, with left over dessert (cake) that was covered with black specks, a foam container, not labeled or dated, with left over food that appeared to be turkey and dressing, a small piece of ham, and green beans. The ham had a circular area of green and white mold, the green beans were completely covered with a green mold, the turkey had spots of green and white mold. The paper plate contained 3 partially eaten desserts with green mold. 2. Observation with CNA1 and CNA2 on 01/28/2025 at 9:55 AM, in room [ROOM NUMBER]A of R6's personal refrigerator revealed a temperature check form taped to the outer door dated January 2025. Further observation revealed the form has no temperature recordings for January 2025. The temperature reading on the thermometer located inside the refrigerator read fifty (50) degrees F. Observed inside the refrigerator was four chocolate drinks with an expiration date of 12/22/2024, a Ziploc bag not labeled or dated that contains 4 pieces of lunch meat (bologna) that was a light brown in color with black mold present on the edges, and packaged lunch meat (ham) with an expiration date of 12/19/2024. Further observation revealed the CNAs removed the old and molded food from R6's refrigerator. 3. Observation in room [ROOM NUMBER] of R50's personal refrigerator revealed a temperature check sheet form attached to the outside of the door which had no temperatures recorded for January 2025. The current temperature inside the refrigerator was 40 degrees F and there were no items observed in the refrigerator. 4. Observation in room [ROOM NUMBER] of R37's personal refrigerator revealed a temperature check sheet form attached to the outside of the door which had no temperatures recorded since 01/24/2025. The current temperature inside the refrigerator was 38 degrees F. The freezer was observed to have a large amount of ice built up. In interview on 01/28/2025 at 10:10 AM, CNA1 stated she thought maintenance was responsible for checking the temperatures on the resident refrigerators but was not sure. She further stated she thought maybe nursing staff was responsible for cleaning the refrigerators. She stated she had not been told to clean or check the resident refrigerators. CNA1 then stated that housekeeping was supposed to be checking the temperatures. She stated she would find out for sure and let me know. She stated fifty (50) degrees was too warm for a refrigerator and if a resident ate food that was molded or spoiled they could get sick. Interview with CNA2 on 01/28/2025 at 10:10 AM, she stated she did not know who was responsible for checking the refrigerators. In a follow up interview with CNA1 on 01/28/2025 at 2:25 PM, she stated she asked and there was some confusion on who was supposed to be checking the refrigerators. She stated she did not have a definite answer. In an interview on 01/30/2025 at 4:50 PM, the Director of Nursing (DON) stated the facility did not have a policy on resident personal refrigerators. When asked who was responsible for checking, cleaning and obtaining the temperatures, she stated there was some confusion on who was doing what. She stated everybody thought someone else was checking them. She stated they were in the process of fixing it. The DON stated a refrigerator at 50 degrees F was too warm and a resident could get sick if they ate spoiled food. During an interview with the Administrator on 01/30/2025 at 5:43 PM, she stated there was confusion about who was responsible for taking temperature readings and cleaning resident refrigerators. The Administrator stated she believed there was a policy in the admission paperwork, but she would have to review it. She stated fifty (50) degrees Fahrenheit was too warm for a refrigerator. She stated an outcome for residents consuming out-of-date or spoiled foods was that a resident could get food poisoning.

Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled residents (Resident (R) 12) receiving hemodialysis services. R12 began receiving off-site hemodialysis services on 12/26/2024; however, the facility failed to include the hemodialysis services on the resident's Comprehensive Care Plan. The findings include: Review of the facility policy titled, Comprehensive Care Plan with a revision date of 02/2024 revealed the Comprehensive Care Plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review of the facility policy titled, Hemodialysis with a revision date of 02/24/2024, revealed the facility will provide the necessary care and treatment consistent with professional standards of practice, physician orders, and the comprehensive care plan to meet the special medical and nursing needs of residents receiving hemodialysis. Record review revealed the facility admitted R12 on 09/21/2022 with diagnoses which included: schizophrenia disorder, bipolar type; hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease; type 2 diabetes mellitus without complications; and chronic obstructive pulmonary disease. Review R12's of the most recent Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/20/2024 revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15, indicating moderate cognitive impairment. Review of the facility's CMS-802 (Matrix of resident care needs) revealed the matrix indicated zero residents were receiving dialysis in the facility. Review of the nursing progress notes revealed the R12 received the first hemodialysis treatment via perm-a-cath on 12/26/2024. Review of the physician's orders dated 01/29/2025 revealed R12 attends hemodialysis off-site three times per week. The order included the pick up time, location, and phone number of the hemodialysis facility. Review of R12's Comprehensive Care Plan revealed the plan did not address that the resident was receiving hemodialysis services. During an interview on 01/30/2025 at 11:05 AM, the Minimum Data Set Nurse (MDS) nurse stated she would expect R12 to have a care plan related to dialysis. The MDS nurse stated that while she does have a large role in the development of the care plan, all nurses in the facility are capable of making entries in the care plan. During an interview on 01/29/2024 at 10:15 AM, the Director of Nursing (DON) stated R12 had begun hemodialysis in December of last year. She further stated that there were no other residents who were receiving dialysis currently and it had been a while since there was a resident who received dialysis. The DON stated that dialysis was addressed in the nutrition care plan for R12 but that the resident was not specifically care planned for hemodialysis. The DON stated the hemodialysis services for R12 should have been reflected in the resident's care plan.

Based on observation, interview, and review of facility policy, the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained by the facility for one of four medication carts and one (1) of one (1) medication storage room. Observation during a narcotic count of the 100 Hall medication cart on 01/30/2025 at 11:00 AM with Licensed Practical Nurse (LPN) 2 revealed the narcotic count was incorrect for six narcotic medications belonging to four different residents (Resident (R) 4, 5, 10, and R16). The findings include: Review of the facility policy titled, Medication Storage in The Facility - Controlled Substance Storage dated May 2022, revealed that at each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items was conducted by two licensed nurses and was documented. Further review of the policy revealed that any discrepancy in controlled substance counts was reported to the Director of Nursing (DON) immediately. On 01/30/2025 at 11:00 AM, the narcotics in the 100 Hall medication cart were counted with LPN2 and there were discrepancies with six of the narcotic medications. 1. Resident (R) 16's tramadol count was 49; however, according to the narcotic record, the count was 53. 2. R16's liquid Morphine amount on the count sheet was 9.25 milliliters (ml); however, observation of the bottle revealed 8 ml. 3. R16's refrigerated liquid lorazepam count was 28.25 ml; however, observation of the bottle revealed approximately 24 ml. 4. R10's oxycodone/acetaminophen (APAP) count was 39; however, according to the narcotic record, there should have been 40. 5. R5's liquid Morphine on the count sheet was 6.75 ml; however, observation of the bottle revealed four ml in the bottle. 6. R4's liquid Morphine on the count sheet was 14 ml; however, observation of the bottle revealed eight ml in the bottle. In an Interview on 01/30/2025 at 11:30 AM, LPN2 stated she did not count the narcotics when she accepted the medication cart keys when her shift started on 01/30/2025. She stated the cart had been counted this morning by Kentucky Medication Aide (KMA) 5 who was working dayshift and the LPN from night shift. LPN2 stated she trusted that the narcotic count was correct but didn't complete a narcotic count. In an interview on 01/30/2025 at 11:45 AM, KMA5 stated she counted the cart with the night shift nurse, LPN7. She stated it was chaotic this morning due to a resident having behaviors and that she must have missed it due to the distractions in the vicinity. KMA5 stated it was difficult concentrating and that she failed to notice the counts were not correct. KMA5 stated during the narcotic count this morning, she counted the pills and the night nurse had the count sheet which she used to call out the number of pills listed on the sheet. Per KMA5, she checked the pills to see if the number matched the count sheet. She stated if the count was wrong, the staff counting would figure it out. KMA5 stated if she had noticed the discrepancy, she would have told the dayshift LPN or the DON. KMA5 stated that dayshift did not typically count the liquid controlled substances in the refrigerator because night shift was typically the ones who give the liquid narcotics. In an interview on 01/30/2025 at 12:10 PM, the DON stated there was not a history of discrepancies with narcotic medication counts in the facility and if there was a discrepancy, the staff was supposed to notify her. However, staff did not notify her of a narcotic count discrepancy this morning, 01/30/2025. The refrigerator controlled substance container was obtained from the refrigerator and accessed by the DON to confirm the count of the liquid lorazepam for Resident (R)16, the DON advised the bottles of liquid lorazepam leak but did not verbalize a method of accounting for loss due to leakage. In an interview on 01/30/2025 at 6:30 PM, LPN6 stated she has received education regarding narcotic handling. LPN6 reported that two nurses work at night. LPN6 verbalized that if a narcotic was dropped, it was wasted with another nurse as a witness. She stated if the narcotic count was incorrect, she was to notify the DON immediately. LPN6 also stated if she had to leave during her shift, she would complete a narcotic count when she left and when she returned. In an interview on 01/30/2025 at 6:39 PM, LPN7 stated she had been trained upon hire regarding handling of narcotics and verbalized that a narcotic should be signed out at the time the medication was removed from the cart. Per LPN7, she had completed the narcotic count with KMA5 at the end of her shift on the morning of 01/30/2025. LPN7 stated, It was so crazy this morning, we had a rough night with another resident, and I get distracted. I called the numbers on the count sheet. LPN7 stated that if there was a discrepancy she was to call the DON for further instructions. In an interview with the DON and the Regional Resource Nurse on 01/30/2025 at 5:21 PM, the DON stated the Pharmacy representative looks at expiration dates for the medications on the carts but does not complete a narcotic count. The DON and Regional Resource Nurse advised it was their expectation that narcotics were counted, according to facility policy. They also stated that documentation of wasted narcotics should be documented according to facility policy. In an interview on 01/30/2025 at 6:06 PM, the Administrator stated it was important to follow the process for narcotic medication counts. She stated moving forward focused attention would be placed in this area including Quality Assurance and Performance Improvement follow up.

Based on interview, record review, and facility policy review, it was determined the facility failed to facilitate the inclusion of a resident's Representative in care plan meetings and failed to ensure care plan meeting were held quarterly for one (1) of four (4) samples residents (Resident #2). The findings include: Review of the facility policy titled, Care Planning - Interdisciplinary Team, last revised September 2013, revealed the Resident, resident's family, and/or the resident's legal representative/guardian or surrogate, should be encouraged to participate in the development of and revisions to the resident care plan. Every effort should be made to schedule care plan meetings at the best time of the day for the resident and family. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face to face, teleconference, written communication, etc.) was at the discretion of the Care Planning Committee. Record review revealed the facility admitted Resident #2 on 01/04/2019 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 09/30/2020; and, Annual MDS assessment, dated 01/12/2020; revealed the Brief Interview for Mental Status (BIMS) score was coded 99 which indicated the resident was unable to complete the interview. Review of Nursing Progress Notes revealed there was no documented evidence a Care Plan meeting was held for Resident #2 since 06/17/2020. Interview with Resident #2's family member, on 01/13.2021 at 10:12 AM, 11:28 AM and 1:42 PM, revealed care plan meetings were not regular. She stated they were told on admission the care plan meeting would be held: however, the family had to request them. Further interview (Post Survey) with Resident's #2's family member, on 01/21/2021 at 2:11 PM revealed they had never received any letters related to care plan meetings from the facility. Interview with the MDS Nurse, on 01/13/2021 at 3:07 PM revealed she scheduled the care plan meetings. The MDS Nurse stated she invited families to attend the residents' Quarterly care plan meetings by sending out a letter. She revealed quarterly care plan meetings was the standard timeframe and letters were sent out every three (3) months. She stated the care plan meeting summary was documented in the progress notes and included what was discussed and who was in attendance. She revealed the care plan meetings with a list of the attendees would not be documented anywhere other than the progress notes. She further revealed she did not keep a list of letters that were sent out and she used a calendar on her computer to know when to send letters. She stated she was not sure when Resident #2's last care plan meeting was held but she must have failed to document them. Interview with the Director of Nursing (DON) on 01/14/2020 at 2:42 PM revealed, care plan meeting letters were sent out by the MDS Nurse. The DON stated care plan meetings should be held quarterly and when needed. She stated she expected the care plan meeting to be documented in the progress notes as part of the medical record. Interview with the Administrator on 01/14/2021 at 3:58 PM revealed, care plan meetings should be done quarterly. She stated the MDS Nurse sends out letters inviting the families, and some families choose to participate and some do not. She further revealed the facility had to do care plan meetings by phone now due to COVID. She stated care plan meetings should be held quarterly and documented in the progress notes.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the Comprehensive Care Plan for one (1) of twelve (12) sampled residents (Resident #12). Resident #1 was care planned for one staff to provide oral care with dentures; however, observations revealed oral care was not being completed by staff. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review revealed the facility admitted Resident #12 readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/07/19 revealed the facility assessed Resident #13's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. However, interview with the Resident revealed the resident was interviewable and answered all questions appropriately. Further review of the MDS assessment revealed the resident required extensive assist for personal hygiene which included oral hygiene. Review of Resident #12's Activities of Daily Living Comprehensive Care Plan for self care performance deficit related to amputation, dated 01/30/19 revealed the resident had upper and lower denture and required extensive assist of one staff to maximize independence. However, interview with Certified Nurse Aide (CNA) #1 on 12/17/19 at 1:40 PM revealed she had given the resident a shower today and was assigned to the resident today and yesterday. She stated she had not cleaned the resident's dentures today nor yesterday. She further revealed she could not remember the last time she cleaned them. She further revealed she knew she was supposed to follow the Care Plan has written. Interviews with Resident #12's family member at 1:33 PM, and Resident #12 at 1:36 PM revealed the resident's dentures are not cleaned by staff. Interview with Resident #12 on 12/17/19 at 1:36 PM revealed his/her dentures were hardly ever cleaned unless his/her family cleaned them. He/She stated, they are busy around here. Interview on 12/17/19 at 1:55 PM with the Charge Nurse revealed she followed up periodically to make sure staff are following care plans. She stated the resident will also let her know. She revealed the resident's caregiver had complained in the past about care; however, she thought it had been resolved. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed they expected staff to follow the Comprehensive Care Plans/CNA care plans as ordered and expected all care to be carried out including oral care/denture care. The DON and ADON revealed they expected the CNA's to tell the charge nurse and the CNA's on the following shift to get the care done.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide oral/denture care for one (1) of twelve (12 ) sampled residents, per facility policy (Resident #12). The findings include: Review of the facility policy for Oral Care, not dated, revealed staff will provide, remind, or cue oral care for residents. Interventions for care of dentures: remove dentures daily for at lease three (3) hours for gums to rest. Clean dentures with denture paste, denture brush, and soak in cool water. Brush the mouth tissues and tongue with soft bristle brush prior to applying the dentures. The dentures should be thoroughly rinsed. Record review revealed the facility admitted Resident #12 readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/07/19 revealed the facility assessed Resident #13's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. However, interview with the Residnet revealed the resident was interviewable and answered all questions appropriately. Further review of the MDS assessment revealed the resident required extensive assist for personal hygiene which included oral hygiene. Review of the Activities of Daily Living Comprehensive Care Plan for self care performance deficit related to amputation, dated 01/30/19 revealed a goal that stated resident will improve current level of function in (ADL index) through the review date. Interventions included oral care: The resident has upper and lower dentures. Personal Hygiene/oral care. The resident requires extensive assist of one (1) staff to maximize independence. Interview with Resident #12's family member on 12/17/19 at 1:33 PM revealed most days the resident's face and hands are dirty and dentures are not clean. She stated she cleans them most days when she visits. Interview with Resident #12 on 12/17/19 at 1:36 PM revealed his/her dentures were hardly ever cleaned unless his/her family cleaned them. He/She stated, they are busy around here. Interview on 12/17/19 at 1:40 PM with Certified Nurse Aide (CNA) #1 revealed she had given the resident a shower today and was assigned to the resident today and yesterday. She stated she had not cleaned the resident's dentures today nor yesterday. She further revealed she could not remember the last time she cleaned them; however, she she had cleaned them in the past. She stated the resident dentures should be cleaned daily but she did not have the time. She further revealed she did not make the Charge Nurse aware she had not provided oral/denture care for the resident. She stated she knew she should follow the care plan but did not know if the facility had an oral care policy or not. Interview on 12/17/19 at 1:55 PM with the Charge Nurse revealed CNA #1 did not inform her that she did not provide oral care for Resident #12. She stated, If she had told me I would have gotten it done. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 12/18/19 at 10:12 AM, revealed they expected the staff to follow the Oral Care facility policy and Comprehensive/CNA Care Plans. The DON and ADON stated they also expected all care to be carried out including oral care/denture care. The DON revealed if the staff cannot get it done, she expected the CNA's to tell the charge nurse so that someone can go do the care.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure the nurse staffing data was posted in a prominent place readily accessible to residents and visitors. Observations throughout the survey revealed the only staffing posted was dated 12/09/19, and included the staffing information for 12/09/19. The findings include: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, last revised (MONTH) (YEAR), revealed within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RN's, LPN's, and LVN's) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care would be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Observations on 12/16/19 through 12/18/19, revealed staffing was posted, however the day of staffing showing was dated 12/09/19 on all three (3) days. Interview with the Medical Records Clerk, on 12/18/19 at 10:00 AM, revealed she was responsible for posting the staffing and was not aware she needed to pull it forward daily and update it. Interview with the Director of Nursing (DON), on 12/18/19 at 10:15 AM, revealed staffing should be posted and updated daily. She stated it was the Medical Records Clerks responsibility to update the staffing daily. Interview with the Administrator, on 12/18/19 at 10:25 AM, revealed the staffing should have been updated daily.

Based on interview, record review, and review of facility job description for Certified Nursing Assistants (CNA's) it was determined the facility failed to ensure medications and accu-checks (blood sugar monitoring) were administered by a licensed nurse, not a Certified Nursing Assistant (CNA) to one (1) of three sampled residents (Resident #1). The findings include: Review of the Facility Job Description for Certified Nursing Assistants (CNA's), dated 11/08/12, revealed the following: CNA's can apply simple clean dressings, slings, stockings, and support bandages, under the direction of the licensed nurse, as permitted by state regulations. Job Skills involve knowledge of procedures and techniques in administering simple treatments and providing related bedside patient care services, as permitted by state regulation. In this job description, there is no mention of a CNA being allowed to do accu-checks or administer medications. Review of the faciity policy titled, Daily Work Assignments, last revised (MONTH) 2006, revealed all licensed nursing personnel and other support staff must perform all assigned duties in accordance with their respective job description and facility policy. Record review revealed the facility admitted Resident #1 on 01/29/19 with [DIAGNOSES REDACTED]. Review of Admission Minimum Data Set ((MDS) dated [DATE] revealed facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status score of six (6), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident received seven (7) days of insulin. Review of a (MONTH) 2019 Physician order [REDACTED]. Interview with CNA #2 on 05/16/19 at 11:20 AM revealed she did an accu-check on Resident #1 about a month ago when Registered Nurse (RN) #1 asked her to and also administered the crushed medications from a cup for the RN as the resident would not allow the RN to give the medications nor do the finger stick for the blood sugar. CNA #2 stated she did not think much about doing it as she was allowed to do accu-checks (finger sticks for blood sugar) at the hospital and the medications were already drawn up by RN #1, she just gave them to the resident. CNA #2 stated she realized it was not in her scope of practice at this facility to do accu-checks and not in her scope of practice to give medications. Interview with RN #1 on 05/16/19 at 1:20 PM revealed she asked CNA #2 to do an accu-check and give medications from a cup for her some weeks ago, as Resident #1 would not let her give them. RN #1 stated she did not think anything about doing this as when she worked at a hospital the CNA's were allowed to do accu-checks and the medications had already been drawn up and crushed and all the CNA did was give them to the resident from a cup. Interview with the Compliance Officer on 05/16/19 at 12:00 noon revealed she was made aware a CNA had given medications and completed an accu-check for a nurse, and she reported this to the Director of Nursing (DON) and Administrator. The Compliance Officer stated she did not believe it was in the scope of practice for a CNA to do accu-checks and it was absolutely not in the CNA scope of practice for a CNA to give medications unless they were a Certified Medication Aide (CMA). Interview with the DON on 05/16/19 at 3:15 PM revealed RN #1 was new to Long Term Care (LTC) as she had worked at a hospital. The DON stated it was reported to her by the Compliance Officer that RN #1 had CNA #2 give medications for her and do an accu-check but, she felt it was an isolated event and therefore did not do any written disciplinary action or put anything in their personnel files. She further revealed she did a verbal warning and re-education but, stated she had no documentation of the re-education. The DON stated it was not in the CNA's scope of practice to give medications, and though the CNA may have done accu-checks at the hospital, it was not included in the LTC arena to do so. Interview with the Administrator on 05/16/19 at 5:10 PM revealed the facility had no policy addressing medication administration or accu-checks but, it was her understanding that CNA's were not allowed to give medications or do accu-checks. The Administrator stated the DON followed up with RN #1 and CNA #2 as she was a nurse and the DON did not do an investigation, just gave verbal education to say CNA's do not do accu-checks or give medications here.

Based on observation, interview, facility fall investigations, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan for two (2) of three (3) residents was revised. Record review revealed Resident #1 and #2 were assessed as a high risk for falls and sustained falls; however, the residents' care plans were not revised to address the residents' risk for falls and revised with interventions to prevent further falls after a fall. In addition, Resident #1 was receiving Aspirin (non-steroidal; anti-flammatory) and [MEDICATION NAME] (inhibits platelet aggregation) for [MEDICAL CONDITION] which placed the resident at risk for bleeding; however, the facility failed to revise the care plan to address the resident's high risk for bleeding. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as a part of the comprehensive assessment. Areas of concern that are identified during the resident assessment will be evaluated before intervention's are added to the care plan. Care plan intervention's are chosen only after careful data gathering, proper sequencing of event's, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of resident's are ongoing and care plans are revised as information about the residents and the residents' condition changes. Record review revealed the facility admitted Resident #1 on 03/30/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/19/18, revealed the facility assessed Resident #1's cognition as severely impaired with a score of three (3) for Cognitive Skills for Daily Decision Making. Review of Physician Orders dated 01/09/19, revealed Resident #1 was ordered Aspirin tablet eighty-one (81) mg give one (1) by mouth one time a day for circulation ordered on [DATE] and [MEDICATION NAME] tablet seventy-five milligrams (75) mg give one (1) tablet for [MEDICAL CONDITION], ordered on [DATE]. However, review of the Comprehensive Care Plan dated 01/01/19 revealed there was no revision to the care plan to address the resident's increased risk for bleeding due to taking the [MEDICATION NAME] and Aspirin everyday. Review of Resident #1's Morse fall Scale dated, 09/30/18, revealed the facility had assessed the resident for high risk of fall's with a score of sixty-five (65). {note under the scoring category high risk is forty-five (45) or higher}. In addition, review of facility incident investigations dated, 01/05/19 at 15:50 and 01/06/19 at 23:39, revealed Resident #1 was sitting in his/her wheelchair on both dates and had a fall due to the resident standing without assistance. However, review of the Comprehensive Care Plan revealed there was no care plan revision to address Resident #1's high risk for falls or actual falls until 01/07/19. Review of Hospital Records dated 01/05/19 and 01/06/19, revealed Resident #1 sustained a laceration to left eyebrow requiring stitches, a large skin tear on left elbow, large skin tear found on left shin, a pinpoint skin tear to right shin, and a right frontal cerebral contusion or hemorrhage on 01/05/19; and an open wound on forehead on 01/06/19. Review of CT Scan results dated 01/06/19 at 8:13 PM revealed there was increased density in the adjacent cortex suggesting that there may be some petechial cortical hemorrhage as well. Interview (Post Survey) with the emergency room (ER) Physician on 02/08/19 at 8:07 AM, revealed surgery was not recommend for the bleed because there was no pressure on the brain that would have required surgery. Interview with Neurosurgeon on 1/17/19 at 10:22 AM, revealed if the facility themselves had identified the patient as a high fall risk prior to the first fall on 01/05/19, he would think they should have had interventions in place to possibly keep the patient from falling the first time. If they were aware the patient was a fall risk, they would be obligated to at least try to prevent a fall. Interviews with Registered Nurse (RN) #2 on 01/24/19 at 2:43 PM, and RN #1 on 01/23/19 at 2:40 PM revealed neither of them developed a care plan after the falls on 01/05/19 and 01/06/19 respectively. RN #2 stated it was not her responsibility and she had never been educated to update the care plans; and RN #1 stated he had thought he had twenty-four hours to update the care plan. Interview with the Director of Nursing (DON) on 01/16/19 at 11:45 AM, revealed he did not realize Resident #1 did not have a fall care plan in place until 01/07/19 when he and the interdisciplinary team (IDT) met on 01/07/19 to review Resident #1's two (2) falls that had taken place over the weekend. Further interview on 01/17/19 at 4:16 PM, revealed he was not aware until today, that Resident #1 did not have a care plan in place for the potential/risk for bleeding. He stated he reviewed all the care plans for Resident #1 and could not find that a care plan had been developed. He further, stated, Resident #1 had been on [MEDICATION NAME] and Aspirin way back to the days he had worked as a floor nurse. He revealed the care plan may have been dropped off when we were bought out by the new company back in (MONTH) (YEAR). He stated the resident should have a care plan in place for the potential risk for bleeding. Interview with Corporate Nurse on 01/24/19 at 3:23 PM, revealed she would have expected Resident #1 to have had a fall care plan in place prior to the fall on 01/05/19, as the facility had already assessed the resident as a high fall risk, prior to the fall. She stated Resident #1 should also have had a care plan in place for the potential/risk for bleeding, because the resident was on [MEDICATION NAME] and Aspirin and both of those medication's put the resident at risk for the potential of bleeding. 2. Record review revealed the facility admitted Resident #2 on 01/09/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 01/03/19, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Review of Morse Fall scale dated 09/06/18, revealed Resident #2 was assessed at high risk for falls with a score of sixty-five (65). However, review of Resident #2's Comprehensive Care Plans dated 01/22/19, revealed the care plan was not revised to address Resident #2's high risk for falls. Review of fall investigations revealed Resident #2 sustained falls on 11/02/18 at 3:34 PM, on 11/11/18 at 3:34 AM, on 12/12/18 at 2:30 AM, and on 01/02/19 at 11:00 PM. However, review of the Resident #2's Comprehensive Care Plan dated 11/11/19 revealed the care plan was not revised after each fall with an intervention to address the fall and try to prevent further falls. Interview with the DON regarding Resident #2, on 01/24/19 at 10:04 AM, revealed he would have expected a new intervention to have been added to Resident #2's care plan the actual day of the fall, that was relevant to the root cause of the fall. He stated all licensed staff were educated back in (MONTH) (YEAR) after their last recertification and relicensure survey, regarding adding new interventions the actual day of the fall. Interview with Corporate Nurse on 01/24/19 at 3:23 PM, revealed she would have expected Resident #1 to have had a fall care plan in place prior to the fall on 01/05/19, as the facility had already assessed the resident as a high fall risk, prior to the fall. Further interview revealed, she would have expected the licensed staff on duty the day of the falls to have added a new intervention based on the root cause of the fall, in order to try to help prevent another fall.

Based on observation, interview, record review and review of the Administrator's Job Description, it was determined the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of three (3) of three (3) sampled residents. Four (4) tags were cited at a scope/severity of a E related to the failure to provide care and services related to Care Plan Revision when residents identified at high risk for falls and after falls, Supervision and Assistive Devices to prevent Accidents related to the failure to follow the facility's fall policy, and Quality Assurance Performance Improvement related to monitoring/auditing falls according to the facilities Plan of Correction (PoC) with a completion date of 11/05/18. The findings include: Review of the Administrator's job description, dated (MONTH) (YEAR), revealed the administrator was responsible to lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Monitor each department's activities, communicate policies, evaluate performance, provide feedback, and assist, observe, coach and discipline as needed, oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed, Utilize survey information, in addition to other source documents, to address areas of importance as defined by our customers, responsible for the Quality Assurance (QA) program, maintain a working knowledge of and confirm compliance with all governmental regulations, consult with department manager's concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services, and provide guidance and leadership throughout the survey process to ensure state and federal regulations are met and adhered to. Interview with the Administrator on 01/23/19 at 3:57 PM and 01/24/19 at 3:00 PM, revealed she was aware there was a concern with developing and updating care plan's with appropriate interventions to help prevent further falls, and the facility was cited F-657; and F-689 on their last recertification and relicensure survey back in (MONTH) (YEAR). She stated the PoC stated all licensed staff were to be trained and educated regarding identifying the root cause of fall's and putting interventions in place at the time of the fall, and to her knowledge the education was completed on 10/31/18. She revealed it came to her attention during this survey, some staff were still not adding new interventions at the time of the fall. Further interview revealed, she reviewed the fall incident reports by going into the the Risk Management System (RMS) in Point Click Care (PCC) on a daily basis {Monday through Friday} for the root cause and the intervention that was going to be added to the care plan. However; she was not reviewing the actual care plan to ensure the care plan had been updated on the date of the actual incident. She stated this was brought to her attention just this week, when the corporate nurse was giving her guidance on the RMS in PCC.

Based on observation, interview and record review, it was determined the facility failed to have an effective system in place to identify quality issues and/or develop and implement an effective plan to correct identified quality deficiencies in a timely manner related to reviewing and revising care plans related to falls and trying to preventing falls. The findings include: Review of the facilities policy, titled Quality Assurance and Performance Improvement (QAPI) Committee, dated (MONTH) (YEAR), revealed the facility shall establish and maintain a Quality Assurance and Performance Improvement committee that oversees the implementation of the QAPI Program. The primary goals of the QAPI Committee are to establish, maintain, and oversee facility systems and processes to support the delivery of quality of care and services, help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; coordinate the development, implementation, monitoring, and evaluations of performance improvement projects to achieve specific goals, and the committee shall track the progress of any active plans of corrections. The committee will meet monthly at an appointed time, and special meetings may be called by the coordinator as needed to address issues that cannot be held until the next regularly scheduled meeting. Review of the facilities Plan of Correction (PoC) signed by the Administrator on 10/24/18 revealed, the facility was cited F-656, F-657 and F-689, with a completion date of 11/05/18. Review of the PoC, revealed Licensed nurses will be trained by the Director of Nursing (DON) with completion date of 10/31/18, regarding facility policy on falls to include identifying root cause and putting intervention in place. Unit Manager and Director of Clinical Reimbursement will ensure root cause has been identified and new interventions have been put into place during daily clinical meeting five (5) days per week. The Nursing Home Administrator or Director of Nursing will audit all falls times thirty (30) days, five (5) falls per month times sixty (60) days and two (2) falls per month time ninety (90) days, to ensure root cause has been identified and new intervention had been put into place. Finding's will be reported by the DON to the QAPI meeting monthly for six (6) months for any additional follow up or inservicing until the issue is resolved, then ongoing thereafter as determined by the QAPI committee. However, review of Resident #1's and Resident #2's Fall Risk Assessments and Comprehensive Care Plans revealed staff failed to revise the Care Plan after the residents were either assessed at high risk for falls (dated 09/30/18 and 09/06/18 respectively) and after actual falls (01/05/19 and 01/06/19 for Resident #1 and 11/02/18, 11/11/18, 12/12/18 and 01/02/19 for Resident #2) to include interventions to prevent future falls. In addition, fall risk assessments were not completed after Resident #1, #2 and #3 falls (11/14/18, 11/27/18 and 01/17/19 for Resident #3) per facility fall policy. Interview with the Unit Manager on 01/18/19 at 2:02 PM revealed her and the DON were reviewing falls everyday Monday through Friday to ensure the residents' care plan was revised with an updated intervention to prevent future falls. She stated a few were identified as not having intervention for the fall. She stated Resident #1's care plan was not reviewed until Monday on 01/07/19 and the falls happened over the weekend. Interview with the Director of Nursing (DON) on 01/18/19 at 3:10 PM, revealed according to our PoC all staff were educated as of 10/30/18. He stated he typed up a paragraph related to each tag they were cited on, with a brief description of the actual problem that was cited on, regarding F-657 & F-689, and instructed each nurse they were to add an appropriate intervention for the situation related to the actual incident, and that they could not use the same intervention, and the intervention had to be added to the care plan at the time of the actual time/day of the fall. He printed a copy, attached it to the sign inservice sheet, for his records. However, he stated he did not recall going over the actual fall policy with the licensed staff, it was mainly to ensure they knew to add a new interventions at the time of the fall. He further stated the actual care plans should have been reviewed to ensure the care plan had been updated with an intervention to address the fall on the day of the fall. He revealed he did not have a good system in place nor a good grasp to ensure every fall care plan had been reviewed. He stated if he had reviewed the fall policy according to the PoC, he would have noticed a fall risk assessment was required after every fall. However; he did not realize a fall risk assessment was required until the surveyor brought it to his attention. He stated he has since spoken with their new Corporate nurse, and came to the realization he was personally trying to handle everything himself, and needed to learn to delegate more responsibilities to other staff. He further stated, he wished he had a better answer on how the care plans were not reviewed as they should have been. Interview with the Medical Director on 01/23/19 at 12:51 PM, revealed the last QAPI meeting he attended was in (MONTH) (YEAR), as there was no QAPI meeting in (MONTH) (YEAR), because of the holiday. He stated all Quality Assurance (QA) meetings are held the last Thursday of the month, and that Thursday fell during the holidays and the next meeting will be the last Thursday of this month. He revealed at the last QA meeting in November, the QA Committee discussed falls. He stated if the facility had identified any concerns with care plans that were not correct related to falls they never mentioned it at the meeting. He further stated, I do know they were monitoring falls because of a bad survey they had back several months ago. Further interview revealed, he had not been made aware there were any recent concerns with care plans not being updated, but they may be going to tell him at the next QA meeting at the end of this month. Interview with the Administrator on 01/23/19 at 3:57 PM and 01/24/19 at 3:15 PM, revealed the members of the QA committee were herself, the Medical director, Director of Nursing, Unit Manager, Business office Manager, Social Services, Dietary Services, and Minimum Data Set (MDS) Assessment Coordinator. She stated according to their PoC, they were to have a monthly QA meeting to discuss falls and the monitoring of falls, and the meetings were always held the last Thursday of the month. She revealed there was no QA meeting in (MONTH) because of the holiday, and as the Administrator, she should have ensured they met in December, according to their PoC. Further interview revealed, she was reviewing the fall incident forms located in the Risk Management System (RMS) for the root cause and the immediate action; however, she was not looking at the actual care plan to ensure a new intervention had been added. She stated this was brought to her attention, just this week by their Corporate nurse, when they were discussing falls, and the auditing of falls. She further revealed, she thought she was auditing falls according to their PoC; however, she was not verifying the intervention were added to the actual care plan. Therefore, she would have to say she was not following their PoC.

Based on observation, interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure three (3) of three (3) sampled residents were provided with adequate supervision and assistive devices to prevent accidents (Residents #1, #2 and #3). The facility assessed Resident #1 and Resident #2 at a high risk for falls; however, the facility failed to ensure a care plan was in place to address each resident's risk for falls and the care to provide to try to prevent falls. The facility also failed to put appropriate interventions in place after each of Resident #1's and #2's falls to ensure staff were aware of the care to provide to prevent further falls and/or to address the root cause of the fall; per facility policy. In addition, the facility failed to ensure Falls Risk Assessments were completed after each fall for Resident #1, #2 and #3 falls, per facility policy. The findings include: Review of facility policy titled, Assessing Falls and Their Causes, last revised (MONTH) 2010, revealed the purpose of the procedure was to provide guidelines for assessing a resident after a fall and to assist in identifying causes of the fall. Review the resident's care plan to assess any special needs of the resident, and when a resident falls, the following information should be recorded in the resident's medical record: The condition in which the resident was found, assessment data, including vital signs and any obvious injuries, interventions, first aid, or treatment administered, completion of a falls risk assessment, appropriate interventions taken to prevent future fall, and the signature and title of the person recording the data. Record review revealed the facility admitted Resident #1 on 03/30/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired with a code of 3 for Cognitive Skills for Daily Decision Making. Further review revealed the facility assessed Resident #1 required extensive assistance of two (2) staff for bed mobility, was totally dependent on two (2) staff for transfers, and required extensive assistance of one (1) staff with locomotion on the unit. Review of Resident #1's Morse Fall Scale, dated 09/30/18, revealed the facility assessed the resident at high risk for falls with a score of sixty-five (65). The conditions that led to him/her as high risk for falls were he/she had a history of [REDACTED]. Note on form revealed High Risk for falls is forty-five (45) or higher. Review of Resident #1's Comprehensive Care Plans dated 01/01/19, revealed there were no care plan and interventions developed to ensure Resident #1 had adequate supervision and assistive devices to try to prevent falls after being assessed at high risk for falls. Review of facility incident investigation, dated 01/05/19 at 3:50 PM, revealed Resident #1 was in wheelchair in doorway of Television (TV) Room, near nursing station, when three or four (3 or 4) staff at nursing station heard the resident hit the floor. Resident #1 was observed lying on his/her left side with no loss of consciousness (L[NAME]), awake and alert. Laceration was noted to left eyebrow that required stitches, and a large skin tear seen on left elbow. Upon Emergency Medical System (EMS) arrival, an additional large skin tear was found on left shin, and a pinpoint skin tear was identified to right shin. The wounds were cleansed and dressings applied. The daughter, Medical doctor, and nursing administration were notified. Resident #1 was sent to emergency room (ER) for evaluation. Further review of the investigation revealed the facility determined the root cause of the fall, appeared to be the resident may have been trying to pick a small purse up off the floor, and added an intervention for staff to carry resident's bag for the resident upon return back to the facility to prevent the resident from dropping it again. Review of hospital #1 medical records dated 01/05/19, revealed patient was found to have a right frontal cerebral contusion, laceration of the eyebrow, multiple skin tears, and a left flank hematoma. The eyebrow laceration was repaired. Further review of the hospital medical records revealed Due to Cerebral contusion/hemorrhage read by radiology, patient will need admission to neurosurgery. Unfortunately, this weekend we do not have a neurosurgery on call and patient will need to be transported to another hospital . Review of hospital #2 medical records, date 01/05/19, revealed patient will be admitted for overnight serial neurologic exams and repeat CT scan. Repeat CT Scan dated 01/06/19 at 8:32 AM, revealed it does not show significant progression from the outside CT of a day earlier. No additional hemorrhage present. There is left periorbital soft tissue swelling. Resident #1 returned back to the facility on [DATE] at 2:41 PM. Review of facility incident investigation date 01/06/19 at 11:39 PM, approximately nine (9) hours after returning from the hospital) revealed Resident #1 was sitting in wheelchair at the end of 300 hall near nurses station following dinner and staff were attempting to get residents ready for bed and organized for the night shift. Further review revealed the resident apparently used the handrail on the wall to pull him/herself from the chair and was unable to stand, and fell face first to the floor. A temporary dressing was placed on open wound on forehead, ambulance called, vitals taken, and resident sent to emergency room . The facility determined the root cause of the fall for Resident #1 was he/she may have been attempting to pull self to a standing position, as he/she was unable to verbalize the reason for the action, and added an intervention to utilize a Broda chair for comfort and positioning upon return from the hospital. Review of hospital #2 medical records, dated 01/06/19 at 7:30 PM, revealed patient had a six (6) cm burst type laceration of forehead center with no bony deformity. Sutures already present and holding in left eyebrow with old bruising left side of face. Laceration of nasal bridge that is superficial. No active bleeding. Review of CT Scan results dated 01/06/19 at 8:13 PM revealed, there was now increased density in the adjacent cortex suggesting that there may be some petechial cortical hemorrhage as well. Family informed of a possibly slightly worsened bleed in brain, but still no mass effect and nothing to do, and family does not want anything done. Also, discussed with neurosurgeon, who also understood family did not want treatment, with family in agreement, wound on forehead was steri-stripped by nursing staff. Interview (Post Survy) with the emergency room (ER) Physician on 02/08/19 at 8:07 AM, revealed he saw Resident #1 in theER on evening 01/06/19. The resident was seen in the ER related to a fall he/she had sustained at the long-term care facility. He stated when comparing the CT scan the evening of 01/06/19 to the previous CT Scan earlier on the 01/06/19, there was only a small about of change noted. He revealed he discussed the change of the CT Scan with the Neurosurgeon, and surgery was not recommend at that time as there was no pressure on the brain that would have required surgery. He stated he also discussed with the family the possibility of keeping the patient over night for further observation; however, the family declined keeping the patient overnight for further observation, because even if surgery was recommended at a later date, they would decline the surgery because of the patient's age, advanced Dementia and already declining health. Further review of Resident #1's record revealed there was no documented evidence a fall risk assessment was completed after the fall on 01/05/19 and the fall on 01/06/19, per facility policy. In addition, further review of the Comprehensive Care Plan dated 01/01/19, revealed there was no documented evidence a Care Plan was put in place to ensure staff were aware of the interventions developed to address the root cause of each fall at the time of the falls investigations; to try to prevent future falls until 01/07/19. Interview with Registered Nurse (RN) #2 on 01/24/19 at 2:43 PM, revealed after Resident #1's fall on 01/05/19, she did not update the care plan with new interventions to help prevent a second fall. RN #2 stated creating and updating care plans were not her responsibility, that was the responsibility of the nursing administration staff. She revealed no one had ever educated her on creating or updating a care plan. She further, stated I do not even know how to locate the resident care plans' in the computer system, much less update them. She revealed as far as she could recall, she had not received any recent training on creating or updating care plans. She further stated, If it is my reasonability to update care plans with new interventions then I should be educated on the facility's care plan policy and practice. Interview with RN #1 on 01/23/19 at 2:40 PM, revealed he had been educated on updating the care plan after a fall several months back by the Director of Nursing (DON). However; it was his understanding he had twenty-four (24) hours to update the care plan so he did not update Resident #1's care plan after the second fall on 01/06/19. Interview with the Neurosurgeon on 01/17/19 at 10:22 AM, revealed, if the facility identified Resident #1 as a high fall risk prior to the first fall on 01/05/19, he would think they should have had interventions in place to possibly keep the patient from falling the first time. He stated if they were aware the patient was a fall risk, they would be obligated to at least try to prevent a fall. Further interview revealed, there were several things they could have tried, placing Dycem (plastic non-skid device) in the seat of the wheelchair, placing a foam cushion device in front of the patient while up in the wheel chair to keep the patient from leaning forward, a self-releasing seat belt, switched the chair to something different, and putting the patient back to bed when he/she was looking tired. He stated they should have tried something to help prevent the second fall. He revealed the resident had two (2) injuries within a day a part that possibly could have been avoided had they put appropriate interventions in place, especially after the first fall on 01/05/19. Interview with the Director of Nursing (DON) on 01/16/19 at 11:45 AM, and on 01/24/18 at 10:04 AM, revealed he did not realize Resident #1 did not have a fall care plan in place until 01/07/19 when he and the interdisciplinary team (IDT) met on 01/07/19 to review Resident #1's two (2) falls that had taken place over the weekend. The DON stated even though Resident #1 had a Morse fall assessment score of sixty-five (65), he did not consider Resident #1 to be a high fall risk, because the resident's last fall was back in (MONTH) (YEAR). The DON further revealed he would have expected the staff to have completed a Morse fall assessment after each fall; however; he did not know a fall risk assessment was required after each fall, until the surveyor brought it to his attention when reviewing the facility's falls policy. He further stated he was on call the weekend of the falls, and as part of the IDT team, it was his responsibility to have ensured Resident #1's care plan had been updated. He also stated he was called regarding both falls; however, he did not ensure the care plan was updated with new interventions. He stated he did not review Resident #1's falls until the following Monday on 01/07/19, two (2) days after the first fall on 01/05/19. 2. Record review revealed the facility admitted Resident #2 on 01/09/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 01/03/19, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Review of section J1900, revealed the resident had two (2) falls with no evidence of injury. Review of Morse Fall scale dated 09/06/18, revealed Resident #2 was assessed at high risk for falls with a score of sixty-five (65). The conditions that led to him/her as high risk for falls were he/she had a history of [REDACTED]. Review of Resident #2's Comprehensive Care Plans dated 01/22/19, revealed there were no care plan and interventions developed to ensure Resident #2 had adequate supervision and assistive devices to try to prevent falls after being assessed at high risk for falls. Review of fall investigation dated 11/02/18 at 3:34 PM revealed Resident #2 was ambulating in room, and lost his/her balance while using rolater walker. The resident was laying down and stood straight up to grab the walker without pausing, and stated my walker got away from me. Immediate action, the resident was educated on pausing during change of position for blood pressure regulation. Review of the Resident #2's Comprehensive Care Plan revealed a care plan for falls was developed on 11/02/18 after the 11/02/18 fall with interventions to 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, provide prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as walking with /assist; ensure the resident is wearing appropriate footwear (shoes/non-skid socks) when ambulating or mobilizing in wheelchair, follow facility fall protocol, determine and address causative factors of the fall, Physical Therapy consult for strength and mobility, Physical Therapy to evaluate and treat as ordered or as needed, review information on past falls and attempt to determine cause of falls, record possible root causes, after remove any potential causes if possible, educate resident/family/caregivers/IDT as to causes. However, further review of the comprehensive care plan revealed the care plan did not address educating the resident on pausing during change of positioning for blood pressure regulation so staff would know to remind the resident to this. Review of fall investigation dated 11/11/18 at 3:34 AM, revealed Resident #2 was found sitting on floor beside bed at 3:00 AM on 11/11/18. After assessing resident and determining no apparent injuries, he/she was moved back into bed. The resident was wearing no shoes, and wearing regular socks. Resident stated, he/she was attempting to get in wheelchair when he/she slid off the side of the bed. Intervention added to the care plan on 11/11/18 was resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, and personal item's within reach. However, the intervention did not address the resident possibly sliding off the bed or the fact the resident was wearing regular socks instead of non-skid socks per care plan per facility policy. Review of a fall investigation dated 12/12/18 at 2:30 AM revealed Resident #2's call light was on, and when staff entered room the resident was found sitting on floor next to bed on buttocks. The resident stated he/she she was trying to get up and go to the bathroom, and slid. An assessment revealed no injuries. The resident was assisted to feet, given wheeled walker, and was ambulated to bathroom without difficulty. Physician notified, and family to be notified. However, further review of the facility investigation and Comprehensive Care Plan dated 11/11/18, revealed the failed to identify the root cause of the fall, and put appropriate interventions in place to prevent future fall per facility policy. Review of fall investigation dated 01/02/19 at 11:00 PM, revealed Resident #2's call light was on when CNA entered room, resident found sitting in the floor next to bed on buttocks with feet in front of him/her. When asked what happened stated He/she slid to floor. Resident noted to be in socked feet, instructed resident not to ambulate in room with socks related to poor traction. Assessment done, no injuries observed. The resident further stated he/she slid on my way back from the bathroom. However, further review of the facility investigation and Comprehensive Care Plan dated 11/11/18, revealed the facility failed to identify the root cause of the fall, and put appropriate interventions in place to prevent future fall per facility policy. In addition, further review of Resident #2's record revealed there was no documented evidence a fall risk assessment was completed after the falls on 11/11/18, 12/12/19, and 01/02/19, per facility policy. Interview with the Director on Nursing (DON) on 01/24/19 at 10:00 AM revealed, Resident #2 was assessed as a high risk for fall's on 09/06/18. Therefore he/she should have already had a care plan in place for the potential of falls prior to the fall on 11/02/18. The care plan was not developed until after the first fall. 3. Record review revealed the facility admitted Resident #3 on 12/05/11 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 10/29/18, revealed the facility assessed Resident #3's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of Section J1900, revealed the resident had two (2) falls with no evidence of injury. Observation and interview of Resident #3 on 01/22/19 at 5:00 PM, revealed the resident was seated up in bed, fully clothed, well groomed, wearing non-skid socks, call light within reach, personal items within reach, and three (3) blank non-skid strips on the floor beside the bed. Resident #3 stated he/she had lived in the facility for about seven (7) years, and has slid out of the bed on a few occasions without injury. He/she stated the facility keeps telling him/her when he/she slides out of the bed onto the floor, they have to consider it a fall, because they did not see the fall happen. Resident #3 stated he/she has never had an injury related to sliding out of the bed. He/she revealed the facility has added these black strips on the floor next to the bed, and staff try to make sure he/she is wearing non-skid socks. Review of Fall Morse Assessment completed on 12/15/18, revealed a score of seventy-five (75), which indicated a high risk for falls; review of Fall Morse Assessment completed on 12/12/18, revealed a score of ninety-five (95), which indicated a high risk for falls. The conditions that led to him/her as high risk for falls were he/she had a history of [REDACTED]. Review of facility fall investigation's dated 11/14/18, 11/27/18, and 01/17/19 and Comprehensive Care Plan dated 01/22/19, revealed Resident #3 fell on [DATE], 11/27/18, and 01/17/19 and the facility identified the root cause of each fall and put an intervention in place to address the falls. However, further review of the record revealed there was no documented evidence a fall risk assessment was completed after each fall per facility policy. Interview with RN #1 on 01/17/19 at 12:52 PM, revealed he had received education back in (MONTH) regarding implementing a new intervention the day of the actual fall. He stated he gets busy with providing patient care and may sometimes forget. He revealed he had not received any education regarding completing a fall risk assessment after every single fall. He stated when he goes in to fill out the incident report, sometimes a fall risk assessment will be prompted to be filled out, but not always and if it does not prompt him to complete he does not complete a fall risk assessment. He further stated the fall risk assessment was not part of the inservice back in October. Interview with RN #3 on 01/16/19 at 9:03 PM, revealed, she does not recall any education/training that instructed her to update the care plan after a fall, but as an old nurse, it is just something she knew to do, there always has to be a new intervention at least tried. She stated she was not aware a fall risk assessment had to be completed after every fall. She further stated she was under the impression the fall risk assessments were created by the Interdisciplinary Team (IDT) team, after a fall and at least quarterly, and annually. Interview with RN #4 on 01/23/19 at 12:08 PM, revealed she was not aware a fall risk assessment was to be completed after every fall, she thought they were to be completed annually, and quarterly. She stated she did receive education on updating the care plan several months back but nothing was mentioned regarding completing a fall risk assessment after every fall. She further stated she was unaware it was the facility policy, to complete a fall assessment after every fall. Interview with Licensed Practical Nurse (LPN) #1 on 01/19/19 at 3:55 PM, revealed she did recall receiving education regarding adding new interventions to the care plan after a fall, it was back in (MONTH) sometime, several months ago. She stated it was mainly about adding a new intervention the day of the fall. She revealed she did not recall any education about completing a fall risk assessment after every fall. Further interview revealed, sometimes it is just too hectic and she might forget to update a care plan. She stated by the time you assess the resident, call the physician, call the family and call the person who is on call; sometimes updating the care plan gets lost in the shuffle but she tries very diligently to ensure it gets updated. Interview with LPN #2 on 01/20/19 at 3:19 PM, revealed she does recall an inservice back in the latter part of October, where the DON, discussed updating the fall care plan after each fall. She stated she does not recall any education regarding completing a fall risk assessment after each fall, and she was not aware this was required. Interview with Corporate Nurse on 01/24/19 at 3:23 PM, revealed she would have expected Resident #1 to have had a fall care plan in place prior to the fall on 01/05/19, as the facility had already assessed the resident as a high fall risk, prior to the fall. She stated based on all the prior Morse falls scale scores the facility should have developed a falls care plan. She revealed Resident #1 should have already had a care plan in place for the potential/risk for bleeding. She stated she would have expected the facility to follow their falls policy , which required the facility to complete a fall risk assessment after each fall. She stated, according to the DON, the staff were educated on 10/24/18, 10/25/18, 10/29/18 and 10/30/18 regarding adding new interventions to the care plan the day of the fall. She further revealed this education was in follow-up related to their Plan of Correction (PoC) from their last recertification survey back in (MONTH) (YEAR). She further stated, from what she reviewed since taking over this building on 01/07/19, the staff have not added new interventions on the day of resident fall, which was a requirement in their PoC. If the staff were educated on updating the care plan the day of the fall, they should have been aware to update the care plan.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observations on [DATE] revealed a visibly dirty manual can opener and expired foods being stored in the refrigerators. Review of the Census and Condition, dated [DATE], revealed forty-five (45) of forty-five (45) residents received their food from the kitchen. The findings include: 1. Review of facility policy titled Refrigerators and Freezers, revised (MONTH) 2014, revealed all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Observation of the Kitchen on [DATE] at 10:34 AM, revealed in the walk-in refrigerator a used by date of [DATE] of a bag of biscuits, a container of cottage cheese half full with no open date or used by date present. Observation of the reach-in refrigerator on [DATE] at 10:42 AM, revealed a container of ketchup with and expired date of [DATE]. Interview with the Dietary Manager on [DATE] at 10:45 AM, revealed he expected staff to discard any expired foods and ensure all foods were labeled with open dates and used by dates. 2. Review of facility policy titled, Sanitation, last revised (MONTH) 2008, revealed all equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Observation of the kitchen on [DATE] at 11:23 AM, revealed a manual can opener with a build up of brown material on the cutting edge and area surrounding the cutting edge. Interview with the Dietary Manager on [DATE] at 11:25 AM, revealed he expected the manual can opener to be cleaned after each use to prevent any build up. Interview with Regional Nurse on [DATE] at 11:14 AM, revealed she expected the kitchen equipment to be clean and sanitary. She stated she expected foods that were expired and past used by dates to be discarded.

Based on interview, record review, and facility policy review, it was determined the facility failed to complete a discharge summary and recapitulation of the resident's stay for one (1) of three (3) residents' closed records reviewed in the selected sample of fourteen (14) residents (Resident #42). Resident #42 was discharged home on[DATE]; however, the facility did not complete a recapitulation of the resident's stay. The findings include: Review of facility policy titled, Discharge Summary and Plan, last revised (MONTH) (YEAR), revealed the discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing release of resident information. Record review revealed the facility admitted Resident #42 on 06/26/18 and discharged the resident home on 07/06/18. However, further review of this resident's closed record, revealed no documented evidence of a complete recapitulation of this resident's stay. Interview with Unit Manager #1 on 10/04/18 at 10:41 AM, revealed she was the person responsible for doing the recapitulation of stays. She stated they did not have one done for Resident #42. Interview with Regional Minimum Data Set (MDS) Nurse on 10/04/18 at 10:48 AM, revealed she expected the discharge summaries and recapitulation of stay to be done per facility policy and per the federal regulations. Interview with Regional Nurse on 10/04/18 at 10:55 AM, revealed she expected the discharge summaries and the recapitulation of stay to be done as per facility policy and per the federal regulations.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure they reviewed and revised the care plan for one (1) of fourteen (14) sampled residents (Resident #18). Resident #18 sustained falls on 07/27/18 and 09/28/18, however, the facility failed to address the root cause and update the care plan with appropriate interventions. On 07/27/18, the resident attempted to pick up a newspaper from a chair in the hallway, lost his/her balance and tried to catch himself/herself and sustained a fracture to his/her right thumb. Resident #18 sustained a second fall on 09/28/18 after attempting to open a bottom drawer on a table, lost his/her balance and fell on his/her right side, with no injury sustained. However, the facility failed to address the root cause and update the care plan with appropriate interventions. The findings include: Review of the facility policy titled, Falls-Clinical Protocol, last revised (MONTH) 2012, revealed based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Further review of the policy revealed if underlying causes cannot be readily identified or corrected, staff will try various relevant interventions. Record review revealed the facility readmitted Resident #18 on 01/10/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 08/03/18, revealed the facility assessed Resident #18's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of the facility provided fall investigations, revealed on 07/27/18, Resident #18 attempted to pick up a newspaper from a chair in the hallway, lost his/her balance and tried to catch himself/herself and sustained a fracture to his/her right thumb. Review of the interventions for the fall on 07/27/18, revealed the resident was educated to ask for help if needing something that required bending and for physical therapy to evaluate. Further review revealed the resident sustained [REDACTED]. Review of the interventions for the fall on 09/28/18, revealed the resident was educated to ask for help if needing something from the bottom drawer. Review of the Comprehensive Care Plan revealed the same interventions were put in place for both falls and no documented evidence of new interventions put in place for the second fall on 09/28/18. Interview with Resident #18 on 10/04/18 at 2:01 PM, revealed he/she did not remember the fall on 09/28/18. He/she stated, It must have been someone else, I don't remember the fall in my room while reaching for something. She stated she was working with therapy for strength and uses the walker during therapy sessions. Interview with the Director of Nursing (DON) on 10/04/18 at 12:52 PM, revealed he felt the interventions were the same, but appropriate for the resident. He stated updating the care plans is all staffs responsibility. He stated after taking the DON position he noticed the post falls investigations needed improvement and nurses were not always putting appropriate interventions in place. He stated as of 08/22/18, he was working on a self-improvement plan and had noticed a decline in falls. He further stated he was educating staff as new falls occur to ensure appropriate interventions are put in place.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, to promote healing and prevent new ulcers from developing for one (1) of fourteen (14) sampled residents (Resident #17). Resident #17 was admitted with two (2) Stage 4 wounds and a Low Air Loss (LAL) mattress with a setting of Therapy 4 was put in place to promote healing and prevent further ulcers from developing. However, observations on 10/02/18 and 10/03/18, revealed the LAL mattress was set on Therapy 8 instead of Therapy 4. The findings include: Review of the facility policy titled, Support Surfaces Guidelines, last revised (MONTH) 2013, revealed the purpose is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Further review of the policy revealed the use of appropriate support surfaces with interventions such as turning, repositioning, and moisture management can assist in reducing pressure ulcer development. Further, care strategies include the monitoring for other pressure risk factors and providing interventions as indicated. Record review revealed the facility admitted Resident #17 on 04/30/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/06/18, revealed the facility was unable to complete a Brief Interview for Mental Status (BIMS) score, due to Resident #17's cognition was severely impaired, which indicated the resident was not interviewable. Review of Resident #17's Comprehensive Care Plan, dated 05/02/18, revealed an intervention to follow facility protocols for treatment of [REDACTED]. Review of the Physician's Order dated 08/16/18, revealed an order for [REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed to use a LAL mattress with a setting of Therapy 4, hand check daily, every day shift. Further review of the TAR revealed Licensed Practical Nurse (LPN) #1 had initialed the TAR for this assitive device on 10/02/18 and 10/03/18, indicating the LAL was on the ordered setting. However, observations on 10/02/18 at 2:33 PM and 10/03/18 at 9:34 AM, revealed the LAL mattress was set on Therapy 8 instead of Therapy 4 per Physician's Order. Interview with Certified Nurse Aide (CNA) #1 on 10/03/18 at 3:00 PM, revealed only the nurses may change the setting of LAL mattresses. Interview with Licensed Practical Nurse (LPN) #2 on 10/03/18 at 3:05 PM, revealed Resident #17's LAL mattress should be on Therapy 4 and after viewing the setting on Therapy 8, LPN #2 placed it on the ordered setting. She stated the setting is checked on day shift and she is not sure how it was overlooked or if someone had accidentally bumped the setting, causing it to change. Interview with LPN #1 on 10/03/18 at 3:25 PM, revealed she had worked dayshift on 10/02/18 and 10/03/18 and had recalled seeing the LAL mattress setting on Therapy 4. She stated the setting may have been bumped by accident or possibly an aide may have done so while providing care. Interview with the Director of Nursing (DON) on 10/04/18 at 10:55 AM, revealed he expected the residents care plan interventions to be followed by nursing. He stated the CNA's do not change the LAL mattress settings and he expected the nurses to check the settings. He revealed it was currently on the Treatment Administration Record (TAR) to be checked on dayshift and he would ensure it would be updated to include all shifts.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for two (2) of fourteen (14) sampled residents (Resident #1 and #18). Resident #1 was assessed and care planned as high fall risk related to confusion, unaware of safety needs, and history of falls. The resident had two (2) falls in less than a month (07/23/18 and 08/07/18); however, the facility failed to put interventions in place that were appropriate for the resident's cognition/thinking and/or addressed the root cause of the fall per the facility policy. In addition, Resident #18 sustained falls on 07/27/18 and 09/28/18. On 07/27/18, the resident attempted to pick up a newspaper from a chair in the hallway, lost his/her balance and tried to catch himself/herself and sustained a fracture to his/her right thumb; and on 09/28/18 the resident sustained [REDACTED]. However, the facility failed to put intevetnions in place to address the root cause. The findings included: Review of the facility policy titled, Falls-Clinical Protocol, last revised (MONTH) 2012, Treatment/Management section revealed the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature of category of falling, until falling reduces or stops or until a reason is identified for its continuation. 1. Record review revealed the facility admitted Resident #1 on 03/01/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/20/18 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the facility assessed the resident to require extensive assist of one (1) staff for toileting; limited assist of one (1) with transfers and walking; the resident was unsteady and only able to stabilize with human assistance for standing, walking, moving on and off the toilet, and surface to surface transfers. The resident was also assessed to be mobile via wheel chair and transfer with the use of a walker. The resident also takes routine pain, anti-anxiety, anti-diuretic, anti-depressant, and anti-coagulant medications. Review of the facility's Falls Time Line revealed Resident #1 fell on [DATE] at 1:02 AM while attempting to go to the bathroom unassisted and sustained bruising to bilateral buttocks and right hand. The resident utilized a bed-side table to stabilize self and it rolled causing loss of balance. The intervention implemented for this fall was listed on the Time Line form as resident assessed for injury, neuro checks. There was no documented evidence that a Fall Risk Assessment was completed at that time nor was there a new intervention listed on the comprehensive care plan to address the resident using the bedside table to stabilize self. Review of the facility's Falls Time Line revealed Resident #1 fell on [DATE] at 6:00 PM while attempting to transfer unassisted and sustained a bruise to the left scapula. The resident was found in the floor in his/her room and stated he/she was attempting to ambulate utilizing the bed-side table for support. The intervention implemented for this fall was listed on the Time Line form as review safe ambulation and transfer techniques with the resident. There was no documented evidence that a Fall Risk Assessment was completed at that time. Review of the comprehensive care plan revealed the intervention put in place for this fall was Reviewed safe ambulation and transfer techniques with resident even though the resident was assessed as unaware of safety needs, has confusion and cognitive impairment. There was no intervention put in place to address the resident's bedside table moving when he/she tried to stabilize self. Interview with the Director of Nursing on 10/04/18 at 1:22 PM revealed the interventions written on the Falls Time Line for these two (2) falls were not appropriate for this resident. The DON stated he was in the process of putting together a performance improvement plan related to falls due to problems with missing documentation and inappropriate interventions on falls. However, the plan had not been implemented at the time of survey. 2. Record review revealed the facility readmitted Resident #18 on 01/10/17 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 08/03/18, revealed the facility assessed Resident #18's cognition as intact with a BIMS score of fourteen (14), which indicated the resident was interviewable. Review of the facility provided fall investigations, revealed on 07/27/18, Resident #18 attempted to pick up a newspaper from a chair in the hallway, lost his/her balance and tried to catch himself/herself and sustained a fracture to his/her right thumb. Review of the interventions for the fall on 07/27/18, revealed the resident was educated to ask for help if needing something that required bending and for physical therapy to evaluate. Further review revealed the resident sustained [REDACTED]. Review of the interventions for the fall on 09/28/18, revealed the resident was educated to ask for help if needing something from the bottom drawer. Review of the Comprehensive Care Plan revealed the same interventions were put in place for both falls and no documented evidence of new interventions put in place for the second fall on 09/28/18 to address the resident reaching for items that were on the floor or in a bottom drawer which were out of his/her reach unless he/she bent over. Interview with Resident #18 on 10/04/18 at 2:01 PM, revealed he/she did not remember the fall on 09/28/18. He/she stated, It must have been someone else, I don't remember the fall in my room while reaching for something. She stated she was working with therapy for strength and uses the walker during therapy sessions. Interview with the Director of Nursing (DON) on 10/04/18 at 12:52 PM, revealed he felt the interventions were the same, but appropriate for the resident. He stated updating the care plans is all staffs responsibility. He stated after taking the DON position he noticed the post falls investigations needed improvement and nurses were not always putting appropriate interventions in place. He stated he was working on a self-improvement plan.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter One (1), it was determined the facility failed to implement a comprehensive person-centered care plan for two (2) of fourteen (14) sampled residents (Residents #17 and #192). Observations on 10/02/18 and 10/03/18, revealed the facility failed to ensure Resident #17's low air loss (LAL) mattress was set at Therapy 4 per the comprehensive care plan to aid in the healing of pressure wounds for Resident #17. In addition, Resident #192 was care planned to receive [MEDICATION NAME] ([MEDICATION NAME] paatch) as per orders; however, the patch was not applied for three (3) days. The findings include: Interview with the Director of Nursing (DON) on 10/04/18 at 10:55 AM, revealed the facility does not have a specific policy related to following the care plan and staff use the Resident Assessment Instrument (RAI) regarding the implementation of care plans. He stated the facility follows state and federal guidelines related to care plans. Review of the RAI Version 3.0 Manual, Chapter One (1), dated (MONTH) (YEAR), provided by the facility, revealed implementation of the care plan is putting a course of action (specific interventions derived through interdisciplinary individualized care planning) into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the how and when of resident care. 1. Record review revealed the facility admitted Resident #17 on 04/30/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/06/18, revealed the facility was unable to complete a Brief Interview for Mental Status (BIMS) score, due to Resident #17's cognition was severely impaired, which indicated the resident was not interviewable. Review of Resident #17's Comprehensive Care Plan, dated 05/02/18, revealed an intervention to follow facility protocols for treatment of [REDACTED]. Interview with Certified Nurse Aide (CNA) #1 on 10/03/18 at 3:00 PM, revealed only the nurses may change the setting of LAL mattresses. She stated she was unsure what the LAL setting should be on for Resident #17. Interview with Licensed Practical Nurse (LPN) #2 on 10/03/18 at 3:05 PM, revealed Resident #17's LAL mattress should be on Therapy 4 and after viewing the setting on Therapy 8, LPN #2 placed it on the ordered setting. She stated the setting is checked on day shift and she is not sure how it was overlooked or if someone had accidentally bumped the setting, causing it to change. Interview with LPN #1 on 10/03/18 at 3:25 PM, revealed she had worked day shift on 10/02/18 and 10/03/18 and had recalled seeing the LAL mattress setting on Therapy 4. She stated the setting may have been bumped by accident or possibly an aide may have done so while providing care. 2. Record review revealed the facility admitted Resident #192 on 09/30/18 with [DIAGNOSES REDACTED]. Review of the BIMS exam dated 09/30/18 revealed a score of fifteen (15) which indicated the Resident's cognition was intact, and the resident was interviewable. Review of the Comprehensive Care plan dated 10/02/18 revealed Resident #192 has (chronic) pain related to chronic back pain, sciatica with interventions to administer [MEDICATION NAME] ([MEDICATION NAME]) as per orders initiated 10/02/18. However, review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the Nursing Progress Notes dated 10/01/18 at 7:13 AM and 8:08 AM, 10/02/18 at 10:20 AM, and 10/03/18 at 8:15 AM revealed the [MEDICATION NAME] Patch was Not Given as it was not available. Observation in the DON's Office on 10/03/18 at 5:25 PM, revealed there were two (2) boxes of [MEDICATION NAME] Patches laying on his desk. The DON stated the patches were found in the bottom drawer of the treatment cart and he did not know how or when they where put there. Interview with Resident #192 on 10/03/18 at 4:25 PM revealed he/she had been using the [MEDICATION NAME] prior to admission but had not received it since. The resident stated the patch helped when she used it and would make her more comfortable now. Interview with the DON on 10/04/18 at 10:55 AM, revealed he expected the residents care plan interventions to be followed by nursing.