Every finding on record at Dewitt Nursing Home

Based on observation, interviews and facility policy review, the facility failed to ensure expired over the counter (OTC) medications were removed from active medication storage and disposed of to prevent administration to residents, for one of one OTC medication storage cabinet reviewed. The findings include: During an observation of the medication storage room on 02/19/2026 at 11:50 AM, expiration dates were checked for OTC medications. The following medications were in storage with medications in active rotation to be administered to the residents and found to be expired: - Two unopened cough and congestion elixir bottles, with a manufacturer's expiration date of 01/2026. - Two unopened calcium medication bottles, with a manufacturer's expiration date of 09/2025. - One unopened acid reducer medication bottle, with a manufacturer's expiration date of 01/2026. These medications were removed from the cabinet by Licensed Practical Nurse (LPN) #1 and taken to the Director of Nursing's (DONs) office to be disposed of. The DON and Administrator were notified of the concern when LPN #1 took the medications to the DONs office. During an interview on 02/19/2026 at 12:19 PM, LPN #1 verified the expired medications she removed during this observation were taken to the DON for her to dispose of. She stated, if the DON was not at work, and expired OTC medications were found on the medication cart, the nurses would pour them into a sharp's container. LPN #1 stated nursing staff would then report the expired medications to the DON. She then revealed that the DON was usually the person that stocked the medications and checked the expiration dates at the time of stocking, but the nurses helped the DON watch for expired items. During an interview on 02/20/2026 at 12:14 PM, the DON stated she ordered OTC medications, and when the medications were delivered, I stock them and check for expirations at that time. I see that I missed some while stocking OTC medications are stocked frequently. The DON stated if staff found expired prescription and narcotic medications, they would pull them out of the cabinet and place them in a locked cabinet in the medication room until they were sent back to pharmacy, but with OTC medications, they would pour them in a sharp's container. The DON confirmed that OTC medications were disposed of in a sharp's container. The DON stated, if night shift staff found an expired medication and not a narcotic, they would let me know the next morning. If it was a narcotic, they would call the pharmacy to reorder while locking up the expired narcotic until the next morning to turn in when I get to work. Nurses were the only staff to know the code for the medication room. During an interview on 02/20/2026 at 12:41 PM, the Administrator stated OTC medication expiration dates were checked by the DON, and all nursing staff. If the nursing staff found any expired medications, they would take them to the DON so she could destroy them by pouring them into a sharp's container. She understood the expired medications were found and the DON was destroying them. The Administrator then stated the medications were kept behind a locked door and in a locked cabinet in the storage room. A review of an undated facility policy, Storage of Medications, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on record review and interview, the facility failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents in 1 of 1 facility. This deficient practice had the potential to affect all residents of the facility. The total census was 32 residents. The findings are: 1. A review of the Comprehensive Facility Assessment, dated November 2017, was reviewed and did not contain the following required information: a. Documentation of staff involved with developing the assessment, which must include a member of the governing body, the medical director, the administrator, the director of nursing, and direct care staff. b. An initiated and/or revision date of completion to show a minimum of a yearly review c. The resident population including the facility's resident capacity d. The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population e. The care required by the resident population, using evidence-based, data-driven methods that consider an evaluation of diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population consistent with resident assessments to help the facility understand the potential implications regarding the intensity of care and services needed f. Staffing plan to evaluate of the overall number of facility staff needed to ensure available and sufficient number of qualified staff are available to meet each resident's needs based on the facility census and address staffing needs for each resident unit and each shift to ensure coordination and continuity of care g. Competency-based skill set approach to make informed staffing decisions to ensure there are a sufficient number of staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice as identified through the resident assessments and plans of care h. Plan to recruit and retain enough medical personnel who are adequately trained and knowledgeable in the care of residents and/or how management expectations of medical personnel. i. The facility's resources including all buildings and/or other physical structures and vehicles, medical and non-medical equipment necessary to provide for the needs of residents, services provided (physical therapy, pharmacy, behavioral health, etc.), and all personnel, (management, direct care staff, and volunteers) which include employees and contracted employees along with their education and competencies j. Heath information technology resources for managing resident records and sharing information with other organizations k. A contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care, such as the availability of direct care nurse staffing or other resources needed for care of residents. 2. On 09/12/2024, the Administrator was asked to provide all data she had pertaining to the facility's assessment, including the emergency preparedness. She stated she knew she did not have the dietary information regarding the food and those vendors. The Administrator provided more modules for the public emergency service. She was asked for the information regarding the staff training, competencies, resident acuity levels and she stated she was not done completing the modules on the computer and knew she did not have all the required information. She stated she was scheduled to attend a meeting on how to complete the facility assessment later in the month.

48977 Based on observations, interviews, and facility policy review, the facility failed to ensure that medications and/or biologicals were securely locked away. The findings include: On 09/11/24 at 7:30 AM, the Surveyor observed Registered Nurse (RN) #3 enter a resident's room and close the door. The Surveyor noted that the medication cart left unattended in the hallway was unlocked. On 09/11/24 at 7:32 AM, RN #3 stated the unattended medication cart was unlocked and stated someone could have gotten in the unlocked medication cart and taken the medications. On 09/12/24 09:00 AM, the Director of Nursing (DON) stated the nurses should lock the medication cart prior to leaving the cart unattended and staff and/or residents could get into the medication cart if left unlocked. A policy titled Storage of Medications indicated, 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure isolation signage was posted in an area to alert staff, residents and visitors which precautions were required before entering a resident's room who was positive for Coronavirus Disease 2019 (COVID-19) for 1 (Resident #15) of 1 sampled resident who was reviewed for isolation precautions, and failed to ensure the water management program contained the necessary components and was consistently implemented to monitor for Legionella and other water-borne pathogens in 1 of 1 facility. The findings are: 1. On 09/09/2024 at 11:10 AM, the entrance conference was conducted with the Administrator. She was asked if any residents were on transmission-based precautions, and she stated two residents in the facility were positive for COVID-19. The 3.0 Resident Roster, provided by the Administrator the same morning, was reviewed later in the day and did not indicate any residents had infections. On 09/09/2024 at 1:01 PM, Resident #15 was in the room sitting up in a wheelchair and the door was open. There was a tan trash bin with a clear liner on the outside of the doorway. This surveyor stepped to the left of the doorway and observed two different signs posted on the door to the room. One sign indicated the personal protective equipment (PPE) was to be removed outside of the room and placed in the trash, unless a [type] mask was being used for the staff member's protection. The other sign indicated the resident was required to wear a surgical/cloth mask, if capable, when staff was in the room performing care. As this surveyor was standing in the doorway talking with the resident, an unidentified staff member walked up the hallway with a mask on and stated, Ma'am, [Resident #15] has COVID and is not supposed to have that door open. There was no other signage on the resident's door, doorway or walls on either side of the doorway, to indicate the resident was on contact or droplet precautions. There was a yellow isolation cart across the hall and to the side of another resident's doorway. On 09/09/2024, Resident #15's hard chart was reviewed. There was no order on the Physician's Orders, dated 09/01/2024 through 09/30/2024, to indicate the resident was on contact/droplet precautions. An annual Minimum Data Set with an Assessment Reference Date of 08/07/2024 was reviewed and indicated Resident #15 had a Brief Interview for Mental Status score of 9, which indicated moderate cognitive impairment. On 09/10/2024 at 3:49 PM, Resident #15 was sitting in the doorway of the resident's room in a wheelchair with no mask on. There was a beige trash can outside the resident's room with a clear plastic bag in it. There was no isolation signage on the resident's door to indicate the resident was on contact/droplet precautions. On 09/10/2024 at 3:53 PM, Licensed Practical Nurse (LPN) #2 was interviewed with concurring observations and asked if Resident #15 was on isolation precautions and she replied ,yes, droplet for COVID. She was asked how the staff and visitors knew what type of precautions and she stated signs on the door. The nurse was asked to state what the sign on the door indicated regarding PPE, and she stated, how to take off the PPE. On 09/12/2024 at 9:08 AM, the Infection Preventionist (IP) was asked what type of precautions Resident #15 was on and he stated, respiratory precautions. He was asked what PPE was required and he stated, gowns, face shield, face mask and full PPE. He was asked how staff / visitors knew what type of precautions to use for residents on isolation and he stated, by the signage posted outside the door. He was asked who was responsible for putting up the signage for staff / visitors. He stated, he, the DON, or Administrator could do it. 2. On 09/11/2024 at 1:15 PM, the Maintenance Supervisor provided a Legionella Water Management Program policy and a diagram of the water flow. He was asked if this was all he had for the facility's Water Management Program and he stated, Yes. Another surveyor asked, What about your water temperatures? and he stated, I have that in another book. I think things got divided out to others. On 09/11/2024 at 10:00 AM, a Nursing Home Water Temp Check document, provided by the Maintenance Supervisor, was reviewed. 2024 was written under the title and four columns were labeled as follows: date, room, room, room. There were dates in each row under the date section, and each room column had a room number and temperature, but it did not indicate if the temperature was in Celsius or Fahrenheit. The log did not indicate where the temperatures were taken, such as the faucets. The log did not include any temperatures for any hot water heaters, boiler rooms, sinks, showers or the whirlpool, which were indicated on the diagram. On 09/12/2024 at 8:47 AM, the Administrator was asked to provide everything she had regarding the facility's water management program since the Maintenance Supervisor stated items may have been divided out over time to others. There was no information provided regarding the water management team members, no identified areas where Legionella could grow, no identification of situations that could lead to Legionella growth or control measures in the incident of an outbreak. There was no date to indicate when or if the program was reviewed / updated. The Administrator did not provide any other information prior to the surveyor's exit of the building. A Legionella Water Management Program policy, not dated, was reviewed and indicated the purpose of the water management program was to identify areas in the water system where Legionella bacteria could grow and spread and to reduce the risks of the disease. The policy indicated the elements to be included in the water management program to include the team members, a detailed description and diagram of the facility's water system, identified areas in the water system that could encourage Legionella growth, identified situations that could lead to Legionella growth, yearly review, or sooner of the water management program, and specific control measures for Legionella.

Based on observation, interview, and facility policy review, the facility failed to ensure food items were properly stored and labeled in the refrigerator and freezer in 1 of 1 kitchen, and failed to ensure the ice machine was properly cleaned in 1 of 1 kitchen. The findings are: On 09/09/2024, initial kitchen rounds were performed, and the following observations were made: 1. At 11:24 AM, the freezer had clear packages of pancakes with no dates on either side of the wrapper. There was a piece of toast in a clear plastic bag dated 9/3/24, with no indication what the date meant. 2. At 11:34 AM, the Dietary Manager (DM) was interviewed, and concurrent observations were made. She was asked to check the ice machine located in the kitchen. With gloved hands, she took a clean, white paper towel, placed the paper towel on the area where the ice falls inside the ice machine, swiped from right to left, and she stopped mid-center. This surveyor and the DM looked at the paper towel, and there was a transfer of yellow residue to the paper towel. The DM took another clean paper towel and started in the middle of the ice machine where the ice falls, swiped mid-center, all the way left and there was a transfer of yellow residue to the paper towel. The DM was asked to describe the color of the residue, and she stated, Tan. She was asked who cleans the ice machine and she stated she checked it that morning but did not clean the area that she was asked to swipe. She stated maintenance cleans the ice machine yearly. 3. At 11:39 AM, the refrigerator in the kitchen contained the following items: a. A clear plastic bag of cooked hamburger meat dated 9/8/24 with no indication of what the date meant. b. A container of black-eyes peas with a preparation (prep) date of 9/7/24, and the use by date was blank. c. A clear container with a green top labeled pork loin with a prep date of 9/7/24, and the use by date was blank. The green lid on the clear container was not completely sealed. On 09/09/24 at 11:42 AM, the DM was asked to look at the green lid that covered the clear container of pork loin inside the refrigerator in the kitchen. She was asked if the container was sealed, and she stated the container was not properly sealed. She was asked what the use by date was for the container with the green lid and she stated, The policy states we can keep it for three days and then throw it out. She was asked if that date was indicated on the container, and she stated it was not. She was asked if there were use by dates on the other items listed above, and she stated, No ma'am. 4. At 11:51 AM, in the stand-up freezer, there was a bag of frozen chicken breasts, confirmed by the DM, with no date on either side of the bag. An Ice Machine Cleaning Schedule policy, not dated and provided by from DM on 09/12/2024, was reviewed and indicated weekly cleaning of the ice storage compartment, around the edges and areas where ice contact is made would be done and documented on the cleaning schedule log. A Storage policy, updated 11/12/2019 and provided by the DM on 09/12/2024, was reviewed and indicated all foods stored in the refrigerator would be tightly covered, labeled, and dated, and leftovers would be destroyed in 72 hours.

Based on observations, interviews, and record review, the facility failed to ensure nurse staffing was posted to include the census and names direct care staff with the total number of hours worked and actual hours worked per shift by licensed and unlicensed staff. The findings include: On 09/11/24 at 9:34 AM, the Surveyor noted a staff log on a table near the entrance. The Surveyor noted there was one name written on the staffing log. On 09/12/24 at 9:00 AM, the Director of Nursing (DON) stated there was a staff log visible, but it was incomplete. The DON stated the staff log did not have the census listed or all the staff members working at the time. The DON confirmed that the staff logs from previous days were also incomplete and did not have the total number of hours worked and actual hours per shift for licensed and unlicensed staff, and the facility did not have that information required but will from now on. On 09/12/24 at 10:25 AM, the DON provided the Surveyor with documentation that indicated the facility did not have a policy and procedure on staffing.

Based on observations, interviews, and facility policy review, the facility failed to ensure potential hazardous chemicals were securely locked away. The findings include: 1. On 09/09/24 at 11:04 AM, the Surveyor observed an unlocked closet door titled, Janitor on East Hall. The Surveyor noted cleaning chemicals inside the unlocked closet door. 2. On 09/09/24 at 11:04 AM, the Surveyor observed an unlocked Whirlpool room with cleaning chemicals and aerosol can of degreaser. a. On 09/09/24 at 11:05 AM, the Director of Nursing (DON) stated the Whirlpool room and the Janitor's closet doors should be locked when unattended when not in use. 3. On 09/09/24 at 11:17 AM, the Surveyor observed a closet door unlocked with a sign posted on the door that stated, If you open this door-please latch it back this door needs to be locked latched at all times!!on South Hall. The Surveyor noted several cleaning chemicals and aerosol cans in the unlocked closet. a. On 09/09/24 at 11:18 AM, during an interview Housekeeping #6 stated the door with the signage that states it should be latched at all times was not latched. Housekeeping #6 stated cleaning supplies that could be harmful were stored in the unlocked closet. 4. On 09/09/24 at 11:23 AM, the Surveyor observed a closet door unlocked titled, Soiled Linen on North Hall. a. On 09/09/24 at 11:25 AM, during an interview the Director of Nursing stated the unlocked door to the closet labeled Soiled Linen should be locked. 5. On 09/11/24 at 08:10 AM, the Surveyor observed an unattended housekeeping cart with a spray bottle hanging from the handle and the door slightly ajar. a. On 09/11/24 at 08:10 AM, during an interview Housekeeping staff #6 stated the spray bottle was air freshener. Housekeeping staff #6 stated the keys in her possession did not lock or unlock the housekeeping cart therefore she could not lock it. b. On 09/11/24 at 09:30 AM, during an interview the Environmental Supervisor stated the door to the closets titled, Janitor, Soiled Linen , Whirlpool, and door with the signage that states If you open this door-please latch it back This door needs to be locked latched at all times!! should be locked when not in use, because a resident could get hurt or get into the chemicals. The Environmental Supervisor stated some of locks on the housekeeping are broken and, We have never locked them in the year and half that I have been here. A policy titled, Policy and Procedure for Chemical Storage indicated The designated [Environmental Services] EVS area should be as follows: have locks fitted to all doors and restrict access only to cleaning staff.

Based on record review, and interview, the facility failed to ensure care plans were revised at least quarterly and/or when the residents care needs changed for 1 (Resident #24) of 12 (Residents #2, #4, #6, #10, #14, #20, #21, #22, #24, #28, #30 and #31) sampled residents whose care plans were reviewed. The findings are: Resident #24's, Physician's Orders, dated 09/01/2024 through 09/30/2024, were reviewed and indicated a diagnosis of loss of thinking abilities that interfere with daily life (dementia) and right artificial hip joint. There were two orders dated 03/06/2024 for a pain medication. One order indicated one tablet by mouth, and the second order indicated two tablets by mouth, and both were as needed for pain. An order dated 06/25/2024 indicated a patch for pain apply one patch every 72 hours and cover with a [brand name] clear adhesive. The quarterly Minimum Data Set with an Assessment Reference Date of 07/01/2024, was reviewed and indicated the resident had a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment, and the resident was taking an opioid, which is a high-risk pain medication. b. Resident #24's Resident Plan of Care, with a review date of 07/09/2024, was reviewed and indicated a pain patch 12 micrograms per hour and cover with a clear adhesive every 3 days. The plan of care did not include any signs, symptoms or adverse reactions to monitor the resident for. On 09/12/2024 at 1:24 PM, the Director of Nursing was interviewed and asked if Resident #24 had an order for pain patches, a high-risk medication, and she stated yes. She was asked should the medication be care planned and she stated yes. She was asked why, and she stated for possible side effects of the medication to monitor the resident for. She stated the facility did not have a policy for care plans.

Based on interviews, record review, and policy review, the facility failed to provide quarterly personal funds account statements to residents or legal representatives. 1. On 09/11/2024 at 1:30 PM, during an interview the members of the Resident Council stated they do not receive a statement of their personal funds account. a. On 09/12/2024 at 9:00 AM, during an interview the Business Office Manager (BOM) she does not send out quarterly statements to the resident or their legal representatives, but she will print a statement when a resident asks for one. b. A policy titled, Management of Resident's Personal Funds, provided by the BOM on 09/12/2024 at 9:45 AM, did not address quarterly statements. 2. On 09/12/2024 at 9:00 AM, the BOM indicated the they have a separate petty cash that they use to keep resident's money. The BOM indicated that she did not know how much money could be held in an account without drawing interest for Medicaid residents. a. Review of a list titled, Residents In House Account provided by the BOM on 09/12/2024 at 9:56 AM, revealed twenty-one residents who had an in-house account, seven of those residents were Medicaid residents and had balances over $50.00. Resident #23 had a balance of $120.14; Resident #10 had a balance of $51.02; Resident #4 had a balance of $147.14; Resident#15 had a balance of $211.50; Resident #18 had a balance of $99.25; and Resident #6 had a balance of $61.00. 3. A policy titled, Management of Resident's Personal Funds, provided by the BOM on 09/12/2024 at 9:45 AM did not address in-house accounts or petty cash accounts.

Based on interviews, record review, and policy review, the facility failed to provide access to resident personal funds during the evening and weekends. The findings are: 1. On 09/11/2024 at 1:30 PM, the surveyor spoke with members of the Resident Council regarding residents being able to gain access to their trust funds during the evening and weekend. Resident #28 indicated that if you don't get your money on Friday, you don't have any money for the weekend. Resident #10 indicated that if you don't get your money during the week, you won't have any for the weekend. 2. On 09/12/2024 at 9:00 AM, the Business Office Manager (BOM) indicated that as far as she knew the residents didn't get money on the weekend. The BOM indicated the residents get money before the weekend, or they don't get it. a. A policy titled, Management of Resident's Personal Funds, provided by the BOM on 09/12/2024 at 9:45 AM did not address how or when residents can access personal funds.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure dignity was maintained for 2 sampled (Resident #21, #31) sampled residents. The findings include: 1. According to Physician's orders, Resident #31 had a diagnosis of transient cerebral ischemic attack. a. A review of the admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/05/2024 revealed Resident #31 scored 13 on a Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact and had an indwelling catheter. b. A Care Plan for Resident #31 (problem date: 7/05/2024) revealed Resident #31 was experiencing incontinent episodes of bowel and/or bladder. c. On 09/09/24 at 12:53 PM, the Surveyor observed Resident #31 sitting in wheelchair in the room. The Surveyor noted the catheter bag was uncovered and easily visible. d. On 09/09/24 at 1:46 PM, the Surveyor observed Resident #31 sitting in wheelchair in the hallway. The Surveyor noted the catheter bag was uncovered and easily visible. e. On 09/09/24 at 1:46 PM, Certified Nursing Assistant (CNA) #5 confirmed Resident #31's catheter bag was uncovered and visible. CNA #5 stated the catheter bag should be covered. I don't know why the catheter bag does not have a cover. f. On 09/12/24 at 09:00 AM, the Director of Nursing (DON) stated Resident #31 had an indwelling catheter and the catheter had been observed uncovered. The DON stated is it important for an indwelling catheters to be covered to maintain the dignity of the resident 2. According to Physician's Orders, Resident #21 had a diagnosis of vascular dementia. a. A review of the quarterly MDS with the ARD of 6/08/2024 revealed Resident #21 scored 2 on a BIMS, indicating severe cognitive impairment. b. A Care Plan for Resident #21 (problem date: 12/07/2023) revealed Resident #21 had impaired cognitive skills evidenced by short term memory loss related to inability to care for self without assistance and being a fall risk. c. On 09/11/24 at 09:43 AM, the Surveyor observed Certified Nursing Assistant (CNA) #4 pushing Resident #21 to the room in a shower chair. The Surveyor noted that Resident #21 was not fully covered, the right side of upper thigh was exposed. d. On 09/11/24 at 09:44 AM, CNA #4 confirmed Resident #21 was not covered all the way. e. On 09/12/24 at 9:00 AM, the Director of Nursing (DON) stated staff should ensure residents are cover down to the knees when transporting the resident from the shower room to the room in a shower chair to maintain the resident's dignity. f. A policy titled, Dignity, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a helping the resident to keep urinary catheter bag covered.

Based on observation, interview, and record review, the facility failed to ensure oxygen was administered at the physician's ordered flow rate to decrease the potential for respiratory complications for 1 (Resident #20) of 1 sampled resident reviewed for oxygen therapy. The findings are: On 09/09/2024 at 12:36 PM, Resident #20 was sitting up in a recliner with nasal cannula (NC) prongs in the resident's nose. The oxygen concentrator was on, and the flow rate was set at 2.5 liters per minute (l/min). Resident #20's annual Minimum Data Set with an Assessment Reference Date of 07/09/2024 was reviewed and indicated the resident had a Brief Interview for Mental Status score of 9, which indicated moderately cognitively intact and received oxygen therapy. Resident #20's Physician's Orders for 09/01/2024 through 09/30/2024 were reviewed and indicated oxygen 2 liters/NC as needed for shortness of breath. Resident #20's Resident Plan of Care, with a review date 07/09/2024, was reviewed and oxygen use was not indicated. On 09/10/2024 at 3:44 PM, Resident #20 was sitting up in a recliner with nasal cannula prongs in the resident's nose. The O2 concentrator was on and set at 2.5 l/min. On 09/10/2024 at 4:04 PM, during an interview and concurrent observation, Licensed Practical Nurse (LPN) #2 was asked to look at the O2 concentrator to observe the flow rate. She looked at the oxygen concentrator and confirmed the resident's flow rate was set at two and a half liters (2.5l). She confirmed the resident's current physician's ordered oxygen flow rate was 2 liters. She was asked who checks the oxygen flow rate and she stated the nurse on shift checked the rate once a day. She was asked why the oxygen flow rate should be checked and she stated to make sure the flow rate was correct rate. On 09/12/2024 at 1:31 PM, the Director of Nursing was asked if the oxygen flow rate was on the medication administration record (MAR) for the nurses to check. She stated she did not think the MAR indicated the oxygen was to be checked for the correct liters.

Based on record review, and interview, the facility failed to ensure a comprehensive plan of care was updated to include the use of oxygen for 1 (Resident #20) of 1 sampled resident who was reviewed for oxygen use. The findings are: On 09/09/2024 at 12:29 PM, Resident #20 was not in the resident's room and there was an oxygen (O2) concentrator on, and the flow rate was set at 2.5 liters per minute (l/min). At 12:36 PM, the resident was sitting up in a recliner with nasal cannula (NC) prongs in the resident's nose. The oxygen concentrator was on, and the flow rate was set at 2.5 l/min. Resident #20's annual Minimum Data Set (MDS) with an Assessment Reference Date of 07/09/2024 was reviewed and indicated the resident had a Brief Interview for Mental Status score of 9, which indicated moderately cognitively intact and received oxygen therapy. Resident #20's Physician's Orders for 09/01/2024 through 09/30/2024 were reviewed and indicated an order for oxygen at 2 liters/NC as needed for shortness of breath. Resident #20's Resident Plan of Care, with a review date 07/09/2024, was reviewed and oxygen use was not indicated. On 09/12/2024 at 1:15 PM, the Director of Nursing (DON) was interviewed and asked if she was completing the MDS assessments and she stated yes. She was asked when the care plans were updated, and she stated quarterly. She stated the information put in from the MDS triggers what all needs to be care planned. On 09/12/2024, the DON stated the facility did not have a policy for care plans.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident #24) of 1 sampled resident reviewed for abuse. The findings are: On 09/09/2024, the surveyors entered the facility to investigate an allegation of abuse for Resident #24. On 09/09/2024 at 1:12 PM, Resident #24 was sitting up in a recliner in the resident's room. The resident was asked about the alleged incident and Resident #24 stated the resident barely remembered the incident. The resident stated the staff member was assisting the resident to a chair and the resident had difficulty walking. The resident denied any injuries. Resident #24's Physician's Orders, dated 09/01/2024 through 09/30/2024, were reviewed and indicated the resident had a diagnosis of impaired thinking ability (dementia). A quarterly Minimum Data Set with an Assessment Reference Date of 07/10/2024 was reviewed and indicated a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. The Resident Plan of Care, with a review date of 07/10/2024, was reviewed and indicated Resident #24 had an activity of daily living (ADL) self-care deficit and required assistance with walking. On 09/10/2024, a 7734 Incident & Accident Information report, with a submission date of 05/01/2024 at 10:31 [AM], was reviewed and indicated the type of incident was abuse and the specific abuse was physical and verbal. The summary of incident indicated the resident's feelings were hurt and was thrown into a chair. The findings and actions taken indicated the resident was examined, no bruises were found, but the resident was crying and was reassured the incident would be investigated. There was a witness statement from the alleged staff member and a witness statement from the Administrator. There were no body audits completed on non-cognitive residents on the hall. There were no witness statements from other cognitive residents or other staff members. There was no in-service conducted on abuse with the staff members after the incident. There was no indication the alleged staff member was removed from all resident care, only the alleged victim's care, pending the investigation On 09/12/2024 at 2:34 PM, the Director of Nursing (DON) was interviewed and asked who completed the report of alleged abuse for Resident #24 and stated she did. She was asked what happens when an abuse allegation is reported and she stated an investigation is immediately started and the following events take place: they speak to the resident, if known, the person whom the allegation is against, and the person who reports the incident; get witness statements, and the family and police are notified. She stated during the investigation, the alleged person has no access to the resident and is taken off the schedule, at times, until the investigation is completed. She stated the alleged resident who received the abuse and other residents who mentioned if something happened received body audits. The DON was asked if any other staff and cognitively intact residents were interviewed. She stated they try to determine if others saw, heard, or witnessed anything and would interview them. She was asked if she did body audits on the cognitively impaired residents on the hall of the alleged incident and she stated no. She confirmed she was not sure if she interviewed other staff members or cognitively intact residents who resided on the hall of the alleged incident. She stated she thought the alleged staff member was taken off the hall, but did not remember without looking at the report. An Abuse/Neglect Policy and Procedure, with an effective date of 09/24/2024, was reviewed and indicated the facility would attempt to identify and will investigate any reported violation or allegation of same. The abuse policy indicated during the investigation, any individual suspected of resident abuse would be placed on administrative leave without pay and is banned from returning to the facility while being investigated.

Based on observations, interviews, record reviews, and facility policy reviews the facility failed to ensure personal and medical information was protected for 1 sampled (Resident #14) resident. The findings include: According to Physician's orders Resident #14 had a diagnoses of sequelae of cerebral infarction and depression A review of the annual Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 8/21/2024 revealed Resident #14 scored 14 indicating cognitively intact. A Care Plan for Resident #14 (problem date: 8/21/2024) revealed Resident #14 had Activities of Daily Living (ADL) self-care deficit as evidenced by: left side weakness due to Cerebrovascular accident (CVA). On 09/11/24 at 7:30 AM, the Surveyor observed Registered Nurse (RN) #3 enter Resident #14's room and close the door. The Surveyor noted that the Medication Administration Record on the medication cart was open and displayed the resident's personal and medical information. On 09/11/24 at 7:32 AM, RN #3 stated the Medication Administration Record (MAR) was open and the resident's information was visible. RN #3 stated anyone passing could potentially see the resident's date of birth, medical diagnosis, orders, name, and room number. On 09/12/24 at 09:00 AM the Director of Nursing (DON) stated prior to the nurse walking away the MAR should be closed or the tab flipped over the MAR so no one can see the MAR. DON stated if the MAR is not closed or covered someone could walk up and read the MAR. A policy titled Resident Rights documented 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:. privacy and confidentiality;.

Based on observation, record review and interview, failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; 2 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential cross contamination and hot food was maintained at 135 degrees or above to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 32 residents who receive meals from the kitchen. The findings are. The following observation were made on [DATE] in the kitchen: a. At 7:47 AM, on a rack an opened, unsealed bag of coffee containing loose coffee filters. b. At 7:49 AM, there was a wet black/gray residue on the panel of the ice machine. Dietary Employee (DE) #1 wiped the area with a tissue, and the wet black/gray residue easily transferred to the tissue. DE #1 confirmed the black/gray residue on the tissue, and the ice from the ice machine is used to fill beverages served to the residents at mealtimes. c. At 7:53 AM, the following spices were on a rack above the food preparation counter, with no received or open dates: black pepper, Greek seasoning, onion powder, salt seasoning, ground cinnamon, garlic powder, Italian seasoning, bottle of brown seasoning, and a container of oregano with an expiration date of [DATE]. d. At 8:02 AM, the following observations were made on a shelf in the refrigerator. 1. An opened bag of shredded cheese. 2. A bottle of strawberry syrup with an expiration date of [DATE]. e. At 8:07 AM, an uncovered, unsealed, and open box of Italian vegetable blend was on a shelf in the walk-in freezer. f. At 8:43 AM, DE #1 removed a box of dinner rolls from the freezer and placed it on the counter. She picked up a bottle of spray oil and spread it inside a pan. Then opened a box. Without washing her hands, she placed gloves on her hands, removed dinner rolls from a bag inside the box and placed them on a tray to be baked and served to residents for lunch meal. During interview on [DATE] at 12:29 PM, DE #1 confirmed she should you have washed her hands after touching dirty objects and before handling clean equipment. During observation on [DATE] at 9:40 AM, the water and ice machine spout in the kitchenette on east hall had a black/brown flaky residue on them. The Dietary Supervisor wiped the area, and black/brown flaky residue transferred to the tissue. The Dietary Supervisor confirmed the black/gray residue, and the ice from the ice machine is used to fill the water pitchers in the residents rooms. During observation on [DATE] at 10:40 PM, two dented cans were on a rack in the dry storage room. One can of tuna and one can of Lima Beans. The following observations were made on [DATE] at 9:43 AM. a. In the refrigerator a bottle of chocolate syrup and picante sauce was on a shelf unlabeled in reference to whom they belong to with no received or open date. b. In the freezer, [NAME] ice cream, a box of strawberry short cake, and a bag of pancake sausage sticks were unlabeled in reference to whom they belong to with no received or open date. c. A box of rice treats were on top of the freezer in the medication room with an expiration date of [DATE]. During observation on [DATE] at 10:59 AM, DE #2 with gloved hands, pulled her mask up. Without changing gloves, or washing her hands, she picked up a plastic bowl with her thumb inside the bowl. When she was ready to scoop peach halves into the bowl to be served to the resident for lunch. The surveyor immediately asked DE #2 what you should have done after touching dirty objects and before handling clean equipment? she stated, Removed the gloves and washed my hands. During observation on [DATE] at 11:32 AM, the temperature of the mashed potatoes on the steam table by the Dietary Employee (DE) #1 was 110 degrees Fahrenheit. The above food item was not reheated before being served to the residents. Review of the facility policy titled, Hand Washing. showed hands should be washed when starting a shift, after touching anything that may contaminate your hand, and before putting on gloves and when changing gloves between tasks.

Based on record review and interivew, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, 7 days a week, each week. The findings are: On 10/4/23 review of the RN staffing timecards from March 2023 to June 2023 showed, no RN worked at the facility for 3/25/23, 3/26/23, 4/1/23, 4/9/23, 6/4/23, and on 6/11/23 a RN worked only 8:44 AM to 2:54 PM. During interview on 10/4/23 at 4:01 PM, the Director of Nurses (DON) confirmed the findings in A. 49071

48630 Based on observation, and interview the facility failed to ensure that medications were stored properly for 1 medication room and 1 of 2 medication carts. The findings had the potential to affect 32 who reside at the facility. The findings are: The following observations were made on [DATE] at 12:10 PM: a. In the medication room was 1 vial of Ativan 30 ml (milliliters) in the emergency kit, with a prescription number of 6766402, and the resident had expired on [DATE]. b. In medication cart #1, the following was observed: 1. Two opened vials with 15 ml each with no open dates. 2. One vial of tuberculin with an open date of [DATE] and an expiration date of [DATE]. 3. One bottle Novolin R insulin with an open date of [DATE]. 4. One Toujeo pen with an open date of [DATE]. 5. Seven Phenobarbital tablets belonging to a resident who was discharged home on [DATE]. During interview on [DATE] at 12:28 PM, Licensed Practical Nurse (LPN) # 2 said after residents are discharged , expire, or the medication has expired or been discontinued, the Director of Nurses (DON) picks up the narcotics monthly and the other medications are left in the drawer. LPN #2 confirmed that insulin, lidocaine, and tuberculin can be used once opened 28 and 45 days. During interview on [DATE] at 2:11 PM, the DON said the last time the narcotics were sent off for destruction was in April, and confirmed insulin, lidocaine, and Tuberculin last 28 days once opened.

Based on observation, record review and interview, the facility failed to ensure the residents environment was free of potential accident/hazards for 23 residents who are mobile and who reside in the facility. The findings are: The following observations were made on 10/03/2023: a. At 9:40 AM, a can of disinfectant spray was in Resident #16's bathroom. b. At 11:08 AM, a can of disinfectant spray was in Resident #16's bathroom. c. At 12:36 PM, in south hall, a container of germicidal wipes was sitting on top of an isolation cart. d. At 5:11PM, a can of disinfectant spray was in a Resident #16's bathroom. Review of the germicidal wipes label showed WARNING call a poison control center or the doctor for treatment. Eye damage can occur. Review of the disinfectant spray label showed hazardous to humans, extremely flammable, and harmful if absorbed through skin. During interview on 10/04/23 at 11:31 AM, Certified Nursing Assistant (CNA) #4 confirmed the back of the disinfectant spray can said it was hazardous to residents and the spray should not have been stored in Resident #16's bathroom. During interview on 10/04/2023 at 11:33 AM, the DON confirmed the disinfectant spray should not have been stored in Resident #16's bathroom. On 10/04/23 at 11:36 AM, the Surveyor requested a chemical storage policy, and the Administrator confirmed there was no policy.

Based on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by closing the paper medication administration record when not in use. The findings are: On 10/04/2023 at 4:39 PM during a medication pass observation Licensed Practical Nurse (LPN) #3 walked away from the medication cart with the medication administration record left open visible on the medication cart. During interview on 10/04/2023 at 4:45 PM, LPN #3 said the medication administration record should be closed prior to leaving the cart. During interview on 10/04/2023 at 5:00 PM, the Director of Nursing (DON) said prior to leaving the medication cart the medication administration record should be closed. Record review on 10/05/2023 at 8:08 AM of the facility policy titled, HIPAA [Health Insurance Portability and Accountability Act] showed all employees are to protect the residents health information such as, closing the MARs [medication administration records] when the medication cart is unattended.

Complaints # (AR 546), # (AR 556) and # (AR 591) were substantiated (all or in part) in these findings: A. Based on observation, record review and interview, the facility failed to ensure residents with exit seeking behaviors who were at risk for elopement were adequately supervised when exit alarms sounded to prevent potential injury for 1 of 1 (Resident #5) case mix resident who had eloped from the facility since 8/1/15. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #5 who exited the facility and was found outside by a staff member returning from a supper break. This failed practice had the potential to cause more than minimal harm for 10 residents who were at risk for elopement, according to a list provided by the Administrator on 8/28/15. The facility was informed of the Immediate Jeopardy condition on 8/27/15 at 2:20 p.m. The findings are: 1. The facility's policy titled Elopement / Wandering Residents documented, .Procedure .7. All facility exit doors will be kept locked or will have an active alarm system in place .9. Any resident found to be at risk for elopement will be evaluated by the physician and care plan team to determine if utilization of a wander guard monitoring device is the appropriate treatment for [REDACTED]. The immediate area surrounding the facility should be searched by available staff. 7. Incident reports should be completed . 2. Resident #5 had a [DIAGNOSES REDACTED]. no mobility devices. a. The undated Nurses Aide's Information Sheet documented, . Watch resident exit seeking . Wander guard: Yes . (left) ankle . Behavior . Wanderer . Elopement Potential . Comments: Resident is up and about, does have a wander guard on and does attempt to leave. Fully ambulates . b. The Resident Plan of Care dated 6/4/15 documented, Elopement . Resident is at risk for elopement as evidenced by exhibits exit-seeking behavior . wanting to go home, looking for her child she had lost, feeling that she is 38 (years) of age and needs to go home . Use audible monitoring system to alert staff of exit seeking behaviors . c. The Elopement Risk Assessment documented, 1. Is the resident cognitively impaired with poor decision making skills . Yes. 2. Does the resident have a pertinent diagnosis . Yes. 3. Does the resident ambulate independently, with or without the use of assistive devices . Yes . 5. Does the resident verbally express the desire to go home? Yes. 6. Does the resident have a history of elopement at home . Yes . 15. Is the resident wandering / seeking to find spouse and / or family . Yes . Interventions . Personal safety alarm device. Exit and stairwell alarms . Staff aware of resident's wander risk . Summary / Conclusions / Recommendations . 3/6/15 Resident is a very potential risk . 6/4/15 No change. Resident constantly seeks exits to go home or up town. Wander guard intact. Easier to redirect so far. 8/20/15 (Resident #5) constantly seeking exit. Out of facility and brought back in by kitchen staff member. Taken to primary nurse in dining room. No injuries were noted. d. On 8/23/15 at 2:17 p.m., the Administrator and Director of Nursing (DON) were asked to accompany this surveyor to the front entrance. There was a key pad located to the left of the doors, when facing the doors, on the inside of the facility. The Administrator was asked, Does the front entrance require a key pad code to enter or exit the facility? The Administrator stated, Not till 10:00 p.m. at night. It's where the visitors come in. The Administrator and DON were asked, Do you have a wander guard system? The DON stated, It's built into the key pad, if a resident with a wander guard comes to the front door, it activates an automatic door lock. e. On 8/23/15 at 2:42 p.m., the Administrator was asked, Does the facility have video cameras? The Administrator stated, Yes. The Administrator was asked, Which door did (Resident #5) exit out? The Administrator stated, Front door. The Administrator was asked, Can I see the video where she exited? The Administrator stated, Let me go check the chart so I can see when she exited. Six video camera feeds were noted on a flat screen monitor in the Administrator's office. The DON was asked, Which camera shows what view? The DON stated, Number one is the nurses' station, number two is the dining room, number three is the south hall . number six is the front entrance. At 2:47 p.m. the Administrator stated, (Resident #5) exited on 8/20/15 (Thursday). This surveyor, the DON and Administrator viewed and listened to the audio recordings for camera six (front entrance). The following events that occurred during the evening on 8/20/15 were noted on camera six, camera one and camera three: 1) Camera 6: At 6:04:30, Certified Nursing Assistant (CNA) #1 walked into the front lobby, past the nursing station, and went to the staffing log, approximately 18 feet from the front entrance. 2) Camera 6: At 6:04:35, Resident #5 walked behind CNA #1 to the front door and pushed on the door handle. 3) Camera 6: At 6:04:43, Resident #5 exited the building and the exit alarm sounded. 4) Camera 6: At 6:05:09, CNA #1 headed toward the nursing station, out of the front lobby. 5) Camera 6: At 6:05:51, an unidentified family member entered the facility through the front door. 6) Camera 1: At 6:06:08, the unidentified visitor who entered the front door at 6:05:51 was at the nursing station. Ward Clerk #1 got up from behind desk to visitor. Visitor heard to say to Ward Clerk #1, I saw . cross the road and almost fall. Able to hear exit alarm sounding at this time on the video. 7) Camera 6: At 6:06:43, Ward Clerk #1 went to front door, looked out, and then turned back to the nursing station. The alarm was still sounding. 8) Camera 3: At 6:22:15, Resident #5 was taken to her room. The Administrator was asked, Who took (Resident #5) to her room? The Administrator stated, Dietary aide. (Dietary Aide #1) or (Dietary Aide #2), I'm not sure. f. On 8/23/15 at 3:20 p.m., this surveyor accompanied the DON (who was now wearing a wander guard bracelet) to the front door. After pushing on the door handle for approximately 10 seconds, the DON exited the front door. The exit alarm sounded at the front door and at the nursing station. A panel, on the wall across from the nursing station, showed the front door as the cause of the alarm. g. On 8/23/15 at 3:28 p.m., CNA #1 stated she worked on the 3:00 p.m. to 11:00 p.m. shift. CNA #1 was asked, Did you work on Thursday, 8/20/15? CNA #1 stated, Yes. CNA #1 was asked, Did you hear a door alarm go off when (Resident #5) exited the front door and you were at the staffing log? CNA #1 stated, No. I was in the front lobby but I didn't hear no alarm. Someone came and got me and said (Resident #5) was outside. CNA #1 was asked, Who was that? CNA #1 stated, (Dietary Aide #3), the girl in the kitchen was outside in her car and she brought her back in. CNA #1 was asked, Has anyone other than me talked with you about (Resident #5) exiting on 8/20/15? CNA #1 stated, No. h. On 8/23/15 at 3:35 p.m., the DON and Administrator were asked, Do you have a reportable or I & A (incident and accident) for 8/20/15 on (Resident #5)? The Administrator stated, No, the nurse did not do an I & A and she did not get off the grounds so we did not do a reportable and she (nurse) didn't chart it. The DON and Administrator were asked, Did you review the camera after this happened? The Administrator stated, We did on Friday (8/21/15) and we had plans to in-service staff at the beginning of this week. The DON and Administrator were asked, Did the front door lock down when (Resident #5) exited? The Administrator stated, My understanding is yes, but because of that egress for fire safety it opens after 10 seconds when you push on the door handle. The Administrator was asked, What have you done since (Resident #5) exited? The DON stated, Talked to the next ward clerk, (Ward Clerk #2) when she came in on 8/21/15 at 10:30 a.m. and told her and the ward clerk after that (Ward Clerk #3) that they need to watch who was going by the desk. The DON was asked, Did you have them sign anything? The DON stated, No, I didn't. The DON was asked, Why not? The DON stated, I'm just crazy I guess. The DON and Administrator were asked, What else have you done? The DON stated, Kept a close eye on (Resident #5), take her behind the nursing station when she's upset. The DON was asked, Do any 1:1 with her after she exited on 8/20/15? The DON stated, No, but she was transferred to geri psych 8/21/15 and she's not back yet. The DON and Administrator were asked, Did you do any disciplinary counseling with (CNA #1) or (Ward Clerk #1) who did not respond to the exit door alarm? The DON and Administrator stated, No. i. On 8/25/15 at 1:50 p.m., Dietary Aide #3 stated she worked the 11:00 a.m. to 7:30 p.m. shift. Dietary Aide #3 was asked, Have you seen any resident outside the facility who wanders? Dietary Aide #3 stated, Yes. Dietary Aide #3 was asked, Who? Dietary Aide #3 stated, (Resident #5), she was the only one I've ever seen out there. Dietary Aide #3 was asked, Tell me what happened with (Resident #5)? Dietary aide #3 stated, I left on my supper break and when I came back I saw her come into the hospital drive way and she was in front of the south hall, almost at the side walk. She had come around the front of the building. I caught her and took her back in the building. Dietary Aide #3 was asked, What time was this? Dietary Aide #1 stated, Around 6:05 p.m., then I got her to her room it was around 6:20 p.m. We went to the dining room first. Dietary Aide #3 and this surveyor went outside and Dietary Aide #3 showed this surveyor where Resident #5 was found; close to the Administration parking lot on the south side of the building. j. On 8/25/15 at 3:05 p.m., Ward Clerk #1 stated she worked from 2:30 p.m. to 9:00 p.m. Ward Clerk #1 was asked, What do you do as Ward Clerk? Ward Clerk #1 stated, Answer the phone, get residents snacks, water, get mop calls if they make a mess. Ward Clerk #1 was asked, When an exit door alarm goes off, what do you do? Ward Clerk #1 stated, I get up and look at the door to see what lights are flashing. Ward Clerk #1 was asked, Do you do anything else? Ward Clerk #1 stated, If someone has gone out the door I call for someone to come get them. Ward Clerk #1 was asked, Do you go outside and look for residents? Ward Clerk #1 stated, Most of the time I do, but there is always some resident there by the lobby. Ward Clerk #1 was asked, What happened with (Resident #5) on 8/20/15? Ward Clerk #1 stated, (Resident #7) was at the desk crying and I heard the door alarm go off and that was around when the smokers go out and them someone came and told me (Resident #5) had done gone out. (CNA #1) said (Resident #5) did not get out that front door, that she was right there. Ward Clerk #1 was asked, When the visitor told you a resident was out the door, what did you do? Ward Clerk #1 stated, I asked (CNA #1) who went out that door. Ward Clerk #1 was asked, Did you do anything else? Ward Clerk #1 stated, No. Ward Clerk #1 was asked, Has anyone talked with you since this happened? Ward Clerk #1 stated, (Administrator) talked to me yesterday and she said when the light goes off to look at that panel and to be more careful. k. On 8/27/15 at 9:20 a.m., the Maintenance Supervisor and this surveyor measured the distance from the front exit door to where Resident #5 was found by Dietary Aide #3 on 8/20/15. The distance was approximately 110.5 feet. l. On 8/27/15 at 2:25 p.m., Camera #2 video footage that had a view of the dining room was reviewed for 8/20/15. On 8/20/15 at 6:07:48, Resident #5 was observed coming into the dining room with Dietary Aide #3 and Licensed Practical Nurse (LPN) #1. m. The Immediate Jeopardy (IJ) was removed and the scope / severity reduced to E on 8/27/15 when the facility implemented the following Plan of Removal: 1) There are 10 residents are risk for elopement from the facility. 2) Elopement assessments were reviewed on every resident in the facility on Thursday, August 27th. 3) In-services were held with staff starting Sunday, August 23 at 3:00 p.m. at the beginning of the 3:00 p.m. to 11:00 p.m. shift and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on the floor. Training will be done by DON/designee and in-service sign-in sheets used. Training will include an ongoing identification list of residents that are at risk for elopement and what to do when the alarm sounds. When an alarm sounds the staff is to check the door closest to them and make sure no one has exited the door that is not supposed to. The ward clerk is to check the box in front of the nurse's station and then page overhead to notify staff of what door is alarming. 4) The CNA involved in the failure to respond to the exit alarm on 8/20/15 was brought into the office on Sunday, August 23 at 3:20 p.m. to watch the camera footage on the elopement of the resident. The CNA was questioned on why she didn't respond to the alarms. The CNA was counseled on the importance of listening to the sounds of the alarms and responding to the alarms in order to ensure the residents safety. 5) The ward clerk involved in the failure to respond to the exit alarm on 8/20/15 was brought into the office upon her return to work on Monday, August 24 at 7:00 a.m. to watch the camera footage on the elopement of the resident. The ward clerk was questioned on why she did not respond to the alarms to see if a resident had left the building. The ward clerk was counseled on the importance of listening to the sounds of the alarms and responding to the alarms to ensure the residents safety. She was in-serviced on checking to see what alarms are sounding and to announce on the intercom which door is alarming. 6) The DON/designee will monitor the staff to ensure they are following protocol for the alarm system on all shifts. This was started on Monday 8/24/15. There will be periodic times set up that the DON/designee will wear a wander guard and go out the door allowing the alarms to sound and to monitor the response time of the staff on all shifts. A minimum of two times a shift on all shifts for one week, then a minimum of one time a shift on all shifts for two weeks and then a minimum of daily for one month alternating shifts. 7) The nursing home Administrator was in-serviced on Thursday, August 27 at 3:45 p.m. on initiating actions pertaining to resident risk. B. Based on observation, record review and interview, the facility failed to ensure falls were thoroughly investigated to determine the causative factors and to develop appropriate interventions to minimize the potential for reoccurrence for 3 of 3 (Residents #3, #4 and #5) case mix residents who had fallen since 6/1/15. The facility failed to ensure skin tears were thoroughly investigated to determine the cause and failed to develop appropriate interventions to minimize the potential for reoccurrence for 1 of 1 (Resident #2) case mix resident who had skin tears since 6/1/15. The facility failed to ensure non-skid socks were present as care planned to reduce the potential for falls for 1 of 1 (Resident #3) case mix resident who was care planned for non-skid socks. The facility failed to ensure leg or foot braces were maintained in a manner to prevent possible injury and not used when broken for 1 (Resident #4) of 3 (Residents #1, #2 and #4) case mix residents with leg or foot braces. These failed practices had the potential to affect 20 residents who had fallen since 6/1/15, 4 residents who had skin tears since 6/1/15, 2 residents who were care planned for non-skid socks and 3 residents with leg or foot braces, according to lists provided by the Administrator on 8/28/15. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/15 documented the resident scored a 7 (0 - 7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), required supervision for transfers, walking and locomotion, used no mobility devices and had one fall with injury since admission or prior assessment. a. The Fall Risk assessment dated [DATE] documented, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential fall . The resident's total score documented for 5/25/15 was 21. b. The Resident Plan of Care dated 5/21/15 and reviewed on 8/20/15, documented, Falls . At risk for fall related injury as evidenced by resident walking frequently throughout facility on daily basis until tired . resident's gait and balance not steady due to health and being very tired related to inability to sit still or lay down for very long. Fall risk also related to glaucoma (causing) visual problems . Try to keep pathways uncluttered. Staff to be aware of this resident's whereabouts at all times. Staff to continue to provide cueing, supervision, and limited assistance as needed. c. The Incident / Accident Report dated 6/21/15 documented, Location of Incident: doorway of resident room. Date of Incident: 6/21/15 . Time: 12:35 p.m. Location of incident: Resident bedroom. Type of incident . while walking . Detailed description of incident: At nurses station charting. I (heard) CNA state 'Oh God, she's on the floor!' Upon leaving nurses station to observe situation, (looked) down North hall, noted resident sitting on bottom in the doorway to her room . (no) injuries noted . Interventions: Encourage resident to use call light for assistance. Staff to encourage resident in (dining room) for meals and to encourage her to stay in (dining room) until meal time complete . On 8/27/15 at 10:35 a.m., the DON was asked to review the Incident / Accident Report dated 6/21/15. The DON was asked, Do you see any documentation regarding the floor - wet or trip hazards or if the resident was wearing shoes, or just socks? The DON stated, No. The DON was asked, How about the interventions? The DON stated, Call light won't work for a resident with Dementia. The DON was asked, Do you know what caused the fall? The DON stated, No and there's no investigation in the Nurse's Notes. d. The Incident / Accident Report dated 7/11/15 documented, Location of Incident: beside nurses station. Date of Incident: 7/11/15 . Time: 9:45 a.m. Location of incident: Nursing station. Type of incident: Fall . while walking . Detailed description of incident: (Patient) walking by nurses station (and) fell to floor, hit head on floor, (large) purple hematoma to (right) upper forehead . Interventions: Send resident to ER (emergency room ) for (evaluation) . Staff to be more aware when resident appears very tired and to encourage her to sit or lay down and to walk beside as needed . On 8/27/15 at 10:35 a.m., the DON was asked to review the Incident / Accident Report dated 7/11/15. The DON was asked, Did they investigate to see if there was an environmental hazard or what was on the resident's feet, shoe or socks? The DON stated, No. The DON was asked, Does the intervention reflect the cause of the fall? The DON stated, I don't know. e. On 8/25/15 at 10:04 a.m., the resident was ambulating in the hall, wearing regular socks (not non-skid) with no shoes. The resident was wearing blue pants with frayed cuffs and was walking on approximately 1-inch of the bottom of the pants legs. LPN #1 ambulated the resident into her room and attempted to get the resident to lie down. The resident sat on the bed. After a moment, the resident got back out of bed and left the room. f. On 8/25/15 at 1:40 p.m., the resident was ambulating in the hallway with shoes on. The resident was walking on approximately 1-inch of the bottom of her blue pants legs. g. On 8/25/15 at 3:45 p.m., the resident was ambulating in the hallway, walking on the hem of her blue pants. This surveyor asked the Administrator to observe the resident's feet. The Administrator was asked, What do you see? The Administrator stated, Her pants are dragging. The Administrator was asked, Do you think that's a fall hazard? The Administrator stated, Yes, her family is working on getting her some more clothes. h. On 8/25/15 at 3:58 p.m., the resident was ambulating in the hallway. The resident's shirt was tucked in, her blue pants were at the resident's waist, and the resident was no longer walking on the hem of the blue pants. 2. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/18/15 documented the resident scored 8 (8 - 12 indicates moderate cognitive impairment) on the BIMS, required supervision with transfers, had limitation in range of motion in a lower extremity on one side, had no falls since admission or prior assessment and required splint or brace assistance on 3 of the last 7 days. a. The Resident Plan of Care dated 9/20/12 and reviewed on 6/25/15, documented .At risk for fall related injury . Provide environmental adaptations . Splint / brace . Appropriate foot wear . b. The Nurse Aide Information Sheet documented, .Interventions for staff to try . Staff to be aware that (Resident #4) does wear her brace daily . c. The Fall Risk Assessment form dated 6/8/15 documented, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential fall . The resident's total score documented for 6/08/15 was 14. d. The Concerns to be Addressed form dated 7/8/15 documented, .Type of Concern: Supplies . Concern Addressed: Spoke with (family member name) in regards to her shoe that has her brace attached. The shoe has broke(n) and she is unable to wear . Supervisor Signature: (Director of Nursing (DON)) . e. The backside of the July 2015 Restorative Care Flow Record documented, Date: 7/7/15 . Progress Notes: Resident is unable to (because) shoe brace for (right) foot is broken . f. The Incident / Accident Report dated 7/8/15 documented, Location of Incident: (Patient's) bathroom. Date of Incident: 7/8/15. Time: 8:30 a.m. Location of incident: Resident bathroom. Type of incident: Fall . from (wheel chair) . Detailed description of incident: (Patient) found sitting in floor, in bathroom beside toilet (and) (wheel chair), said 'I fell out of my (wheel chair), (no) injuries . Interventions: (Patient) wear shoes or non-skid socks . g. On 8/23/15 at 12:16 p.m., the resident self-propelled out of the dining room, in a wheelchair. The resident was wearing a shoe on the left foot and a regular (not non-skid) sock on the right foot. h. On 8/25/15 at 7:47 a.m., the resident was wearing tan slacks that extended approximately 4 inches past her heels. The resident self-propelled to the nurses' station and stopped. The resident was wearing white regular (not non-skid) socks on both feet. i. On 8/25/15 at 9:30 a.m., 12:00 p.m., 1:43 p.m. and 3:40 p.m., the resident was wearing green pants that did not extend past her feet when self-propelling in the wheel chair and white regular (not non-skid) socks on both feet. j. On 8/26/15 at 2:10 p.m., Licensed Practical Nurse (LPN) #1 was asked, Has (Resident #4) fallen? LPN #1 stated, Yes. LPN #1 was asked, Is she supposed to wear non-skid socks or her shoes when up? LPN #1 stated, Yes. LPN #1 was asked, Do you do care plans for the CNAs and the regular care plan? LPN #1 stated, Yes. LPN #1 was asked, Are non- skid socks on there, on either care plan? LPN #1 looked at the Resident Plan of Care and stated, No. LPN #1 looked at the CNA care plan and stated, No. k. On 8/26/15 at 2:56 p.m., LPN #2 was asked, Are you doing rehab (rehabilitation)? LPN #2 stated, Yes. LPN #2 was asked, For August 2015, what rehab is she (Resident #4) getting? LPN #2 stated, Three times a week we walk her . she's got a brace that is broken and needs some parts . Her brace is taped up and doesn't look safe. I won't walk her with the brace like that but some other rehab nurse does. LPN #2 was asked to get the resident's brace. LPN #2 showed this surveyor a left AFO brace with an attached black shoe. The shoe was noted to have paper tape encircling the upper third of the shoe and the sole on the shoe was not attached to the insole of the shoe. The bottom of the brace was able to slide in and out from between the insole of the shoe and sole of the shoe. LPN #2 was asked, Any ambulation of the resident in August (2015) by you? LPN #2 stated, Yes on the 19th 8/19/15). LPN #2 was asked, Did you walk her with or without the brace? LPN #2 stated, With it. l. On 8/26/15 at 4:00 p.m., CNA #2 was asked, Do you work with (Resident #4)? CNA #2 stated, Yes. CNA #2 was asked, Has she fallen? CNA #2 stated, No. CNA #2 was asked, Is she supposed to wear non-skid socks or shoes when up? CNA #2 stated, No. m. On 8/26/15 at 4:15 p.m., CNA #1 was asked, Do you work with (Resident #4)? CNA #1 stated, Yes. CNA #1 was asked, Has she fallen? CNA #1 stated, Not that I'm aware of. CNA #1 was asked, Is she supposed to wear non-skid socks or shoes when up? CNA #1 stated, She should have her shoes on with the brace but it's broken. n. On 8/26/15 at 4:32 p.m., CNA #3 was asked, Do you work with (Resident #4)? CNA #3 stated, Yes. CNA #3 was asked, Has she fallen? CNA #3 stated, Not with me. CNA #3 was asked, Is she supposed to wear non-skid socks or shoes when up? CNA #3 stated, I think so. o. On 8/27/15 at 10:35 a.m., the DON and Administrator were asked, Do you know of any resident whose foot / leg brace is broken? The DON and Administrator stated, Yes. The DON was asked, RNA (Restorative Nursing Assistant) ambulates the resident 3 times a week, does the resident require the brace to ambulate? The DON stated, Yes. The DON was asked, Did you know some staff are ambulating and transferring the resident using the broken brace? The DON stated, No. The DON was asked to review the Incident / Accident Report dated 7/8/15. The DON was asked, What happened on 7/8/15? The DON stated, Resident fell out of her wheelchair. The DON was asked, Was her brace on or off? The DON stated, It doesn't say on the I and A. The Nurse's Notes say (Resident #4) did not have shoes on, had socks on, and that resident slid out of wheel chair. The DON was asked, What will non-skid socks or shoes do to prevent the resident from falling out of the wheel chair? The DON stated, It's not clear that it will. The DON and Administrator were asked, Can you find an intervention of non-skid socks or shoes on the Resident Plan of Care or Nurse Aide Information Sheet? The DON and Administrator stated, No. p. The orthotic company letter dated 8/28/15 documented, .(Resident #4) has been in a metal double upright AFO (Ankle Foot Orthosis) for many years. She has severe Supination of the ankle and this brace provides her with support and stability she needs. The brace is used to support her ankle while ambulating or transferring. With the supination her ankle would be very weak and could cause her to fall more often . 3. Resident #5 had a [DIAGNOSES REDACTED]. a. The Fall Risk assessment dated [DATE] documented, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential fall . The form documented a total score 6/4/15 of 20. b. The Resident Care Plan dated 6/4/15 did not include falls as a potential problem. c. The undated Nurses Aide's Information Sheet documented, Resident need to be supervised when toileting . Fall Risk . Watch resident exit seeking . Wander guard: Yes . (left) ankle . Behavior . Wanderer . Elopement Potential . Comments: Resident is up and about, does have a wander guard on and does attempt to leave. Fully ambulates . Resident is a fall risk due to exit seeking . Staff to watch (Resident #5) for the following behaviors . (Resident #5) is a High Fall Risk due to behavior of going room to room at night, entering and verbally and physically threatening other residents and her confusion as well as incontinence and attempts to elope. Voiding at times beside or behind her bed. d. The Incident / Accident Report dated 8/8/15 documented, .Location of Incident: Front of laundry room across from breeze way. Date of Incident: 8/8/15. Time: 7:50 p.m. Location of incident: Other. Type of incident . sit down on bottom, laundry personnel caught. Detailed description of incident: 8/8/15 at 7:50 p.m. Received call stat (immediately) down to laundry room. Laundry personnel had caught resident and sit down hard on bottom. Able to arouse but very lethargic. Resident had been verbally and physically abusive earlier and received Geodon IM (intramuscularly) 10 mg (milligrams). Assisted to stretcher and taken to emergency room for evaluation and possible x-ray . Interventions: Get to bed quickly or quicker after medication intervention. Status of incident victim: Uninjured . DON signature: (Blank) . e. On 8/27/15 at 9:50 a.m., Laundry Employee #1 was asked, Do you recall (Resident #5) falling on 8/8/15? Laundry Employee #1 stated, Yes. Laundry Employee #1 was asked, What happened? Laundry Employee #1 stated, She came to the laundry room and took a broom and started sweeping the rug in front of the South side door. I closed the laundry room and I went to the nursing station to ask them to have someone get my broom. I went back down there and started folding clothes and I heard the broom hit the door. So I turned around and she'd dropped the broom and was in the middle of falling. She fell flat on her butt and I caught her head so her head did not hit . f. On 8/27/15 at 10:35 a.m., the DON was asked to review the Incident / Accident Report dated 8/8/15. The DON was asked, Do you know what caused the fall, what the resident had been doing prior to the fall? The DON stated, Not according to the I and A. The DON was asked, Will the intervention of put resident to bed address the cause of the fall? The DON stated, No. 4. Resident #2 had a [DIAGNOSES REDACTED]. a. The Incident / Accident Report dated 8/8/15 documented, .Location of Incident: (Blank line). Date of Incident: 8/8/15. Time: 1:30 p.m. Location of incident: (Blank check box). Type of incident: (Blank check box). Detailed description of incident: Noticed 1 cm (centimeter) ST (skin tear) to (left) upper hand, dark purplish bruising, said 'It's a little sore', moves wrist (with

Complaint # (AR 591) was substantiated (all or in part) in these findings: Based on observation, record review, and interview, the facility Administration and Nursing Administration failed to ensure residents with exit seeking behaviors who were at risk for elopement were adequately supervised when exit alarms sounded to prevent potential injury for 1 of 1 (Resident #5) case mix resident who had eloped from the facility since 8/1/15. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #5 who exited the facility and was found outside by a staff member returning from a supper break. This failed practice had the potential to cause more than minimal harm for 10 residents who were at risk for elopement, according to the list provided by the Administrator on 8/28/15. The facility was informed of the Immediate Jeopardy condition on 8/27/15 at 2:20 p.m. The findings are: 1. The facility's job description titled Nursing Home Administrator documented, .Functions .3. Ability to enforce the facility's policies and procedures .8. Ability to supervise the recruitment, employment, performance, evaluation, promotion, and discharge of all staff . 2. The facility's job description titled Director of Nursing documented, .Responsibilities. Administrative . Develops and revises, as necessary, policies and procedures for the nursing department . Clinical . Oversees and assures the appropriateness of nursing assessment, care planning, and interventions for all residents . Identified and promotes correction of problems in service provisions or poor quality of resident care . 3. The facility's policy titled Elopement / Wandering Residents documented, .Procedure .7. All facility exit doors will be kept locked or will have an active alarm system in place .9. Any resident found to be at risk for elopement will be evaluated by the physician and care plan team to determine if utilization of a wander guard monitoring device is the appropriate treatment for [REDACTED]. 6. The immediate area surrounding the facility should be searched by available staff. 7. Incident reports should be completed . 4. Resident #5 had a [DIAGNOSES REDACTED]. no mobility devices. a. The undated Nurses Aide's Information Sheet documented, . Watch resident exit seeking . Wander guard: Yes . (left) ankle . Behavior . Wanderer . Elopement Potential . Comments: Resident is up and about, does have a wander guard on and does attempt to leave. Fully ambulates . b. The Resident Plan of Care dated 6/4/15 documented, Elopement . Resident is at risk for elopement as evidenced by exhibits exit-seeking behavior . wanting to go home, looking for her child she had lost, feeling that she is 38 (years) of age and needs to go home . Use audible monitoring system to alert staff of exit seeking behaviors . c. The Elopement Risk Assessment documented, 1. Is the resident cognitively impaired with poor decision making skills . Yes. 2. Does the resident have a pertinent diagnosis . Yes. 3. Does the resident ambulate independently, with or without the use of assistive devices . Yes . 5. Does the resident verbally express the desire to go home? Yes. 6. Does the resident have a history of elopement at home . Yes . 15. Is the resident wandering / seeking to find spouse and / or family . Yes . Interventions . Personal safety alarm device. Exit and stairwell alarms . Staff aware of resident's wander risk . Summary / Conclusions / Recommendations . 3/6/15 Resident is a very potential risk . 6/4/15 No change. Resident constantly seeks exits to go home or up town. Wander guard intact. Easier to redirect so far. 8/20/15 (Resident #5) constantly seeking exit. Out of facility and brought back in by kitchen staff member. Taken to primary nurse in dining room. No injuries were noted. d. On 8/23/15 at 2:17 p.m., the Administrator and Director of Nursing (DON) were asked to accompany this surveyor to the front entrance. There was a key pad located to the left of the doors, when facing the doors, on the inside of the facility. The Administrator was asked, Does the front entrance require a key pad code to enter or exit the facility? The Administrator stated, Not till 10:00 p.m. at night. It's where the visitors come in. The Administrator and DON were asked, Do you have a wander guard system? The DON stated, It's built into the key pad, if a resident with a wander guard comes to the front door, it activates an automatic door lock. e. On 8/23/15 at 2:42 p.m., the Administrator was asked, Does the facility have video cameras? The Administrator stated, Yes. The Administrator was asked, Which door did (Resident #5) exit out? The Administrator stated, Front door. The Administrator was asked, Can I see the video where she exited? The Administrator stated, Let me go check the chart so I can see when she exited. Six video camera feeds were noted on a flat screen monitor in the Administrator's office. The DON was asked, Which camera shows what view? The DON stated, Number one is the nurses' station, number two is the dining room, number three is the south hall . number six is the front entrance. At 2:47 p.m. the Administrator stated, (Resident #5) exited on 8/20/15 (Thursday). This surveyor, the DON and Administrator viewed and listened to the audio recordings for camera six (front entrance). The following events that occurred during the evening on 8/20/15 were noted on camera six, camera one and camera three: 1) Camera 6: At 6:04:30, Certified Nursing Assistant (CNA) #1 walked into the front lobby, past the nursing station, and went to the staffing log, approximately 18 feet from the front entrance. 2) Camera 6: At 6:04:35, Resident #5 walked behind CNA #1 to the front door and pushed on the door handle. 3) Camera 6: At 6:04:43, Resident #5 exited the building and the exit alarm sounded. 4) Camera 6: At 6:05:09, CNA #1 headed toward the nursing station, out of the front lobby. 5) Camera 6: At 6:05:51, an unidentified family member entered the facility through the front door. 6) Camera 1: At 6:06:08, the unidentified visitor who entered the front door at 6:05:51 was at the nursing station. Ward Clerk #1 got up from behind desk to visitor. Visitor heard to say to Ward Clerk #1, I saw . cross the road and almost fall. Able to hear exit alarm sounding at this time on the video. 7) Camera 6: At 6:06:43, Ward Clerk #1 went to front door, looked out, and then turned back to the nursing station. The alarm was still sounding. 8) Camera 3: At 6:22:15, Resident #5 was taken to her room. The Administrator was asked, Who took (Resident #5) to her room? The Administrator stated, Dietary aide. (Dietary Aide #1) or (Dietary Aide #2), I'm not sure. f. On 8/23/15 at 3:20 p.m., this surveyor accompanied the DON (who was now wearing a wander guard bracelet) to the front door. After pushing on the door handle for approximately 10 seconds, the DON exited the front door. The exit alarm sounded at the front door and at the nursing station. A panel, on the wall across from the nursing station, showed the front door as the cause of the alarm. g. On 8/23/15 at 3:28 p.m., CNA #1 stated she worked on the 3:00 p.m. to 11:00 p.m. shift. CNA #1 was asked, Did you work on Thursday, 8/20/15? CNA #1 stated, Yes. CNA #1 was asked, Did you hear a door alarm go off when (Resident #5) exited the front door and you were at the staffing log? CNA #1 stated, No. I was in the front lobby but I didn't hear no alarm. Someone came and got me and said (Resident #5) was outside. CNA #1 was asked, Who was that? CNA #1 stated, (Dietary Aide #3), the girl in the kitchen was outside in her car and she brought her back in. CNA #1 was asked, Has anyone other than me talked with you about (Resident #5) exiting on 8/20/15? CNA #1 stated, No. h. On 8/23/15 at 3:35 p.m., the DON and Administrator were asked, Do you have a reportable or I & A (incident and accident) for 8/20/15 on (Resident #5)? The Administrator stated, No, the nurse did not do an I & A and she did not get off the grounds so we did not do a reportable and she (nurse) didn't chart it. The DON and Administrator were asked, Did you review the camera after this happened? The Administrator stated, We did on Friday (8/21/15) and we had plans to in-service staff at the beginning of this week. The DON and Administrator were asked, Did the front door lock down when (Resident #5) exited? The Administrator stated, My understanding is yes, but because of that egress for fire safety it opens after 10 seconds when you push on the door handle. The Administrator was asked, What have you done since (Resident #5) exited? The DON stated, Talked to the next ward clerk, (Ward Clerk #2) when she came in on 8/21/15 at 10:30 a.m. and told her and the ward clerk after that (Ward Clerk #3) that they need to watch who was going by the desk. The DON was asked, Did you have them sign anything? The DON stated, No, I didn't. The DON was asked, Why not? The DON stated, I'm just crazy I guess. The DON and Administrator were asked, What else have you done? The DON stated, Kept a close eye on (Resident #5), take her behind the nursing station when she's upset. The DON was asked, Do any 1:1 with her after she exited on 8/20/15? The DON stated, No, but she was transferred to geri psych 8/21/15 and she's not back yet. The DON and Administrator were asked, Did you do any disciplinary counseling with (CNA #1) or (Ward Clerk #1) who did not respond to the exit door alarm? The DON and Administrator stated, No. i. On 8/25/15 at 1:50 p.m., Dietary Aide #3 stated she worked the 11:00 a.m. to 7:30 p.m. shift. Dietary Aide #3 was asked, Have you seen any resident outside the facility who wanders? Dietary Aide #3 stated, Yes. Dietary Aide #3 was asked, Who? Dietary Aide #3 stated, (Resident #5), she was the only one I've ever seen out there. Dietary Aide #3 was asked, Tell me what happened with (Resident #5)? Dietary aide #3 stated, I left on my supper break and when I came back I saw her come into the hospital drive way and she was in front of the south hall, almost at the side walk. She had come around the front of the building. I caught her and took her back in the building. Dietary Aide #3 was asked, What time was this? Dietary Aide #1 stated, Around 6:05 p.m., then I got her to her room it was around 6:20 p.m. We went to the dining room first. Dietary Aide #3 and this surveyor went outside and Dietary Aide #3 showed this surveyor where Resident #5 was found; close to the Administration parking lot on the south side of the building. j. On 8/25/15 at 3:05 p.m., Ward Clerk #1 stated she worked from 2:30 p.m. to 9:00 p.m. Ward Clerk #1 was asked, What do you do as Ward Clerk? Ward Clerk #1 stated, Answer the phone, get residents snacks, water, get mop calls if they make a mess. Ward Clerk #1 was asked, When an exit door alarm goes off, what do you do? Ward Clerk #1 stated, I get up and look at the door to see what lights are flashing. Ward Clerk #1 was asked, Do you do anything else? Ward Clerk #1 stated, If someone has gone out the door I call for someone to come get them. Ward Clerk #1 was asked, Do you go outside and look for residents? Ward Clerk #1 stated, Most of the time I do, but there is always some resident there by the lobby. Ward Clerk #1 was asked, What happened with (Resident #5) on 8/20/15? Ward Clerk #1 stated, (Resident #7) was at the desk crying and I heard the door alarm go off and that was around when the smokers go out and them someone came and told me (Resident #5) had done gone out. (CNA #1) said (Resident #5) did not get out that front door, that she was right there. Ward Clerk #1 was asked, When the visitor told you a resident was out the door, what did you do? Ward Clerk #1 stated, I asked (CNA #1) who went out that door. Ward Clerk #1 was asked, Did you do anything else? Ward Clerk #1 stated, No. Ward Clerk #1 was asked, Has anyone talked with you since this happened? Ward Clerk #1 stated, (Administrator) talked to me yesterday and she said when the light goes off to look at that panel and to be more careful. k. On 8/27/15 at 9:20 a.m., the Maintenance Supervisor and this surveyor measured the distance from the front exit door to where Resident #5 was found by Dietary Aide #3 on 8/20/15. The distance was approximately 110.5 feet. l. On 8/27/15 at 2:25 p.m., Camera #2 video footage that had a view of the dining room was reviewed for 8/20/15. On 8/20/15 at 6:07:48, Resident #5 was observed coming into the dining room with Dietary Aide #3 and Licensed Practical Nurse (LPN) #1. m. The Immediate Jeopardy (IJ) was removed and the scope / severity reduced to D on 8/27/15 when the facility implemented the following Plan of Removal: 1) There are 10 residents are risk for elopement from the facility. 2) Elopement assessments were reviewed on every resident in the facility on Thursday, August 27th. 3) In-services were held with staff starting Sunday, August 23 at 3:00 p.m. at the beginning of the 3:00 p.m. to 11:00 p.m. shift and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on the floor. Training will be done by DON/designee and in-service sign-in sheets used. Training will include an ongoing identification list of residents that are at risk for elopement and what to do when the alarm sounds. When an alarm sounds the staff is to check the door closest to them and make sure no one has exited the door that is not supposed to. The ward clerk is to check the box in front of the nurse's station and then page overhead to notify staff of what door is alarming. 4) The CNA involved in the failure to respond to the exit alarm on 8/20/15 was brought into the office on Sunday, August 23 at 3:20 p.m. to watch the camera footage on the elopement of the resident. The CNA was questioned on why she didn't respond to the alarms. The CNA was counseled on the importance of listening to the sounds of the alarms and responding to the alarms in order to ensure the residents safety. 5) The ward clerk involved in the failure to respond to the exit alarm on 8/20/15 was brought into the office upon her return to work on Monday, August 24 at 7:00 a.m. to watch the camera footage on the elopement of the resident. The ward clerk was questioned on why she did not respond to the alarms to see if a resident had left the building. The ward clerk was counseled on the importance of listening to the sounds of the alarms and responding to the alarms to ensure the residents safety. She was in-serviced on checking to see what alarms are sounding and to announce on the intercom which door is alarming. 6) The DON/designee will monitor the staff to ensure they are following protocol for the alarm system on all shifts. This was started on Monday 8/24/15. There will be periodic times set up that the DON/designee will wear a wander guard and go out the door allowing the alarms to sound and to monitor the response time of the staff on all shifts. A minimum of two times a shift on all shifts for one week, then a minimum of one time a shift on all shifts for two weeks and then a minimum of daily for one month alternating shifts. 7) The nursing home Administrator was in-serviced on Thursday, August 27 at 3:45 p.m. on initiating actions pertaining to resident risk.

Based on observation, record review and interview, the facility Quality Assurance committee failed to identify and correct quality deficiencies as evidenced by the facility's failure to ensure interventions to decrease the risk of falls and minimize injuries were developed based on causative factors and resident cognitive status; were consistently implemented; and were added to the plan of care to facilitate staff awareness and enhance fall prevention efforts by the staff for 4 of 4 (Residents #1, #4 #7 and #10) case mix residents at risk for falls. This failed practice resulted in a pattern of harm for Resident #1 who suffered a [MEDICAL CONDITION] 2/1/13 and had no new interventions in place to possibly prevent falls or major injuries. This failed practice had the potential to to cause more than minimal harm for 22 residents who were at risk for falls, as identified on a list received from the Director of Nursing on 7/26/13 at 1:35 p.m. The findings are: 1. On 8/8/13 at 5:15 p.m., the Administrator was asked who kept track of falls for the facility. The Administrator stated, the Assistant Director of Nursing (ADON) keeps up with falls. She keeps up with the interventions to see if they will work or come up with new interventions. On 8/9/13 at 11:20 a.m. the DON was asked, "When you have a person with multiple falls do you or anyone else track or trend to see if there were causative factors related to the falls." The DON stated, "I don't. I don't know if (ADON) has that trended anywhere, but I will look." At 11:50 a.m., the DON stated, "All she (ADON) has is how many falls a resident has per month." At 3:00 p.m. the Administrator was asked, "What type of information is taken to your quarterly Quality Assurance meetings?" The Administrator stated, "All department heads come to the meeting and we go over everything that has happened in the last three months, staffing, falls, resident happiness over meals, infection control, etc." The Administrator was asked, "In what form are resident falls presented at the meetings?" The Administrator stated, "(DON) goes over the falls, the fall log, number of falls and if there are injuries." The Administrator was asked if the residents were looked at individually. The Administrator answered, "If there has been an injury, otherwise no." 2. The Fall Prevention Policy received from the Director of Nursing on 7/26/13 at 1:35 p.m. documented, "POLICY: Residents who have a history of frequent falls or have high risk factors for falling will be identified in an effort to prevent falls. PROCEDURE ...The resident's Plan of Care will be updated to include fall prevention measures. Comfort measures, including an appropriate and comfortable chair, pain relief, toileting and ambulation with assistance, should be tried and evaluated frequently to prevent the resident trying to rise on his/her own without help. Residents in the Fall Prevention program will be monitored closely." 3. Resident #1 had [DIAGNOSES REDACTED]. a. An Incident/Accident (I&A) Report dated 12/5/12 at 4:30 p.m. documented, Type of incident: slid to floor. Description of incident: The resident stood up from recliner in room and slid down to the floor. No injuries. Assisted up to feet easily, toileted and to bed per request. Interventions: Remind resident to call for assist as needed. Call light within reach. Resident to call when she needs up due to present weakness due to illness. The Minimum Data Set (MDS) with assessment reference date 7/25/12 documented the resident had scored 7 (0-7 indicates severly impaired) on a Brief Interview for Mental Status (BIMS). b. The Incident/Accident Report dated 1/1/13 at 1:50 p.m. documented, "Location of incident: Other: Hallway... Type of incident: Fall... from w/c... Description of incident: Resident witnessed falling from w/c onto floor. Skin tear noted to (left) hand... Interventions: Cleaned hand (with) soap and water and steri-stripped..." There were no new interventions to prevent falls or discussion of causative factors documented on the report or on the Resident Plan of Care. On 8/9/13 at 10:05 a.m. the Director of Nursing (DON) was asked, "When Resident #1 had the fall on 1/1/13 why was the resident trying to get up or what was the resident trying to do and what intervention was put into place to prevent reoccurance?" The DON stated, "I don't know." The DON looked through the resident's clinical record as she was asked questions. She was unable to locate a documented intervention to prevent reoccurance of falls after the 1/1/13 fall. c. The FALL RISK ASSESSMENT form dated 1/18/13 documented a total score of 8 (10 or above represents high risk) for falls. The form did not document the resident's confusion, that the resident was ambulatory and incontient, documented 2 of the four medications that could cause falls and did not identify any of the 4 diseases that the resident had that could cause falls. d. The Incident/Accident Report dated 2/1/13 at 10:35 a.m. documented, "Location of incident: East Hall near nurse's station... Type of incident: Fall... Other (describe) while standing up from w/c... Description of incident: Heard (resident) yelling 'help me' found (resident) lying supine in front of w/c. (resident) doesn't know how she fell . Another (resident) states she stood up (and) fell and hit head. c/o (right) leg pain... Interventions: Instruction (resident) to lock wheels before getting up... chair alarm." 1) A Pain assessment dated [DATE] documented, "...Pain location... (Right) leg... Cause of pain: fall... Severity of Pain... 8 (scale of 1 to 10)... Non-verbal indicators: Grimacing, Guarding, Moaning... Sent to ER (emergency room )." 2) Nurses notes dated 2/1/13 at 10:35 a.m., documented the resident was assisted onto a stretcher and transported to the emergency room . Nurses notes documented at 12:00 noon (resident) "is being sent to (Hospital) in Little Rock for broken (R) (right) hip." 3) Physician orders [REDACTED]. e. Nurses notes dated 2/7/13 at 4:00 p.m. documented, "... arrived via ambulance to room, Resident confused and anxiousness noted at this time. Dx ORIF (R)." f. Nurses Notes documented the following regarding the resident's cognitive status from 2/13/13 - 2/25/13: 1) Nurses Notes dated 2/13/13 documented, "...verbally responsive however very confused." 2) Nurses Notes dated 2/15/13 documented, "...confusion varies at times." 3) Nurses Notes dated 2/18/13 documented, "...confusion more noted this am. Resident continues to get self up with no regard to safety. Was up for breakfast, placed self back in bed. Resident is non compliant regarding safety." 4) Nurses Notes dated 2/19/13 documented, "...continues to give no regard to safety. Resident reminded not to get up on her own." 5) Nurses Notes dated 2/20/13 documented, "Resident gives no regard to safety although told of risks per falling. Resident continues to get self up frequently bed to chair or chair to bed." 6) Nurses Notes 2/24/13 documented, "...encouraged not to get up by herself. encouraged to use call light." 7) Nurses Notes dated 2/25/13 documented, "Continues to give no regard to safety." g. The Incident/Accident Report dated 2/26/13 at 2:40 a.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... while walking... Description of incident: Resident was found sitting on bottom, beside bed. Asked resident what was she doing at time of fall, stated 'I just stood up and my foot slipped' ...Call light was lying on bed at time of fall. Interventions: Instructed resident to use call light system before attempting to ambulate per self..." 1) Nurses Notes dated 2/26/13 documented the fall, "...had been incontinent of bowel...resident verbally expressed need to empty bladder", and resident was reminded to use the call light to request assistance at 2:45 a.m. and at 3:30 a.m. 2) Nurses Notes dated 2/26/13 at 9:00 a.m. documented, "confusion noted this a.m. Resident sitting on bed. Had a large BM all over the bed." h. The Resident Plan of Care documented, "2/28/13 - Resident conts (continues) to get up (without) assistance (at) (times) - with freq (frequent) reminding s/p (status [REDACTED]." i. The Incident/Accident Report dated 3/1/13 at 6:24 a.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... while walking... Description of incident: CNA found resident sitting in floor on safety mat, stated that she was trying to get back in her bed (and) missed, landing on floor mat on her bottom. Denies hitting head. Stated that she was experiencing sacral pain, able to move all extremities (and) bear weight. Interventions: Reminded resident to use call light system before attempting to transfer self..." 1) Nurses Notes dated 3/1/13 at 6:24 a.m. documented, "CNA (Certified Nursing Assistant) entered resident's room, found resident sitting on safety mat beside bed, feces on blankets on bed and on floor. Resident stated 'I was trying to get back in the bed, and I missed it and landed here.' Able to move all extrematies and bear weight, c/o pain and pointed to sacral area." 2) Nurses note dated 3/1/13 at 8:00 a.m. documented, "...very confused at times...Resident now has a chair and bed alarm." j. The Resident Plan of Care documented, "3/4/13 Please assist (with) ambulation (with) a walker - wt (weight) bearing as tolerated. Please assist (with) hip abductor strengthening exercises." 1) Nurses Notes dated 3/3/13 at 2:30 a.m. documented: The resident was lying in bed using left hand to bang on the wall beside the bed; Call light beside resident in reach; Resident stated that she was trying to let someone know that she needed to use the bedside commode; and Resident reminded that using the call light system was the appropriate and most effective way to request assistance. 2) Nurses Notes dated 3/6/13 documented, "gives no regard to safety." k. The Incident/Accident Report dated 3/8/13 at 2:35 p.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... standing ...sat in floor... Description of incident: Resident removed bed alarm (and) threw it into chair beside bed. Resident states she was coming back from b/rm (bathroom) and couldn't make it back to bed (and) sat in floor - Denies hitting head... resident was asst (assisted) out of sitting posit (position) on floor - to recliner then to bed. Resident stated back was hurting but states as soon as I stretch out it will quit - Bed alarm placed back on bed (and) call light clipped to her shirt - Blood blister type area noted on outside of (left) little finger. Shoes on. No water in floor. Interventions: staff is to ck (check) resident frequently (and) asst (assist) to b/rm answer call light promptly." Nurses Notes dated 3/8/13 at 2:45 p.m., documented: Resident removed bed alarm and threw into her chair beside bed; Resident states she was coming back from bathroom and could not make it back to her bed and sat in the floor; and Staff reminded to check resident frequently and assist to bathroom-answer call light promptly. l. Nurses Notes dated 3/9/13 and 3/10/13 documented, "...very confused at times." Nurses Notes dated 3/11/13 documented "...confused- Resident thought she was home today." m. The Incident/Accident Report dated 4/14/13 at 1:45 p.m. documented, "Type of incident: Fall... from w/c... Description of incident: Resident got up from wheelchair fell to the floor scraping her (right) side of her back approx (approximately) 4 1/2 (inch). Skin intact. (No) bleeding. Call light not used. Interventions: Resident to be reminded to use c/l (call light) before getting up. ROM (range of motion) good to all extremities. Ambulated (with) assist to bed." Nurses note dated 4/14/13 2:00 p.m. documented, "Resident gives no regard to safety. Resident got up from wheelchair and fell ." There was no documentation of the use of chair alarm on resident's wheelchair in the nurses notes. n. The Incident/Accident Report dated 4/20/13 at 7:40 a.m. documented, "Location of incident: Shower... Type of incident: Other (describe) Got up by self (and) almost fell CNA caught her... Description of incident: CNA had res in shower when CNA was turned around to get res clothes (and) res tried to get up (and) almost fell when CNA caught res. Res bumped (left) shin on w/ causing an L-shaped skin tear. Also found an L-shaped skin tear to (right) elbow (and) 2 U-shaped skin tears noted to back of (upper) (left) arm - area cleaned (and) steri strips applied. Interventions: Don't take your eyes off of res when in shower." o. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/13 documented the resident scored 6 (0-7 indicates severe cognitive impairment) Brief Interview for Mental Status (BIMS); was independent in bed mobility; required limited physical assistance of one person for transfers, walking and locomotion; was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, while walking, while turning around while walking, when moving on and off the toilet and during surface-to-surface transfers; used a wheelchair for mobility; and had experienced one fall with major injury since admission or prior assessment. The Resident Plan of Care with a review date of 4/26/13 documented, "Falls... Problem date: 7/25/12... At risk for fall related injury Disease process / condition ...(Goal) Resident will not sustain a fall related injury by utilizing fall precautions through next review date... (Approaches) Use fall risk screen to identify risks. Report falls to physician and responsible party. Observe for any side effects of any drugs that can cause: (If noted report to nurse) Gait disturbance, Orthostatic [MEDICAL CONDITION], Weakness, Sedation, Light headedness, Dizziness. Call light in reach. Area free of clutter. Provide/monitor use of adaptive devices: Wheelchair. Remind resident and reinforce safety awareness; Lock brakes on bed, etc. chair, before transferring..." p. Nurses Notes dated 4/27/13 at 4:00 p.m. documented, "Resident shaking, getting up without assistance, states she needs to go home because they are closing down this place... Resident reassured by staff." q. The Incident/Accident Report dated 5/17/13 at 12:10 p.m. documented, "Location of incident: Resident bathroom... Type of incident: Fall... while walking... Description of incident: Resident walked to bathroom w/o (without) asking for assistance, while walking back fell (and) slipped in urine in floor, as reported by CNA... found in floor in doorway of bathroom lying on back, lg (large) baseball size hematoma obs (observed) to back of head. Resident moves all extremities w/o difficulty... stated head was sore (and) hurting, (no) other c/o (complaints of) pain... called EMTs (emergency medical technician) (and) resident transferred to gurney by EMTs, transferred to (hospital) ER (emergency room )... Interventions: Inform all CNAs (and) nurses to check bed alarms frequently to make sure they are plugged in." Nurses notes 5/17/13 documented, "Resident on floor. Urine all over bathroom floor. Witnessed by resident's sister who reported that resident got up and went to bathroom and was coming out when she fell . Resident in floor with lower extremities up to waist in urine in bathroom. Resident is usually confused and forgetful frequently. Large soft hematoma to the back center of head. Felt size of a soft ball. EMT's (emergency medical technicians) called Resident placed on stretcher with neck brace. taken to ER." r. The Resident Plan of Care documented, "5/23/13 PT (physical therapy) (with) restorative... ROM (range of motion) exercises Limit leg exercises d/t (due to) [MEDICAL CONDITION] ([MEDICAL CONDITION]..." s. The Incident/Accident Report dated 7/1/13 at 5:20 a.m. documented, "Location of incident: Resident bathroom... Type of incident: Fall... from commode... Description of incident: resident was sitting on commode. Decided to stand up (without) assistance fell causing skin tears on both arms didn't hit head." There were no interventions documented on the report or on the Resident Plan of Care to prevent further falls. s. Observations of the resident: On 7/22/13 at 2:48 p.m., the resident was in the activity room at a table in a wheelchair. The wheelchair had an alarm in place. On 7/23/13 at 4:10 p.m., the resident was up in a wheelchair in the hallway with an alarm attached to the back of the chair. On 7/24/13 at 9:05 a.m., the resident was up in the recliner with the bed and chair alarm intact. At 12 noon, the resident was in bed with bed alarm in place. At 2:00 p.m., the resident was up in wheelchair at an activity with chair alarm in place. At 5:00 p.m., the resident was in bed with bed alarm in place and call light in reach. t. On 7/26/13 at 11:45 a.m., the DON was asked, "(Resident #1) has a BIMS of 6; do you think she understands instructions?" The DON stated, "Probably not." The DON was asked, "Do you think (Resident #1) understands the interventions you put in place?" The DON stated, "Probably not." The DON was asked if different interventions were put in place after each fall. The DON reviewed all of the resident ' s Incident and Accident reports then stated, "Not (interventions) on the falls, no ma'am." The DON stated, "They (interventions) either remind (Resident #1) not to get up on her own, or be more cautious, and to use the call light." The DON stated, "Telling them or reminding the resident is not an intervention." On 8/9/13 at 9:50 a.m., Licensed Practical Nurse (LPN) #4 was asked, "After (Resident #1) fell on [DATE] did the facility put any interventions in place." LPN #4 stated, "I don't remember when they put mat by the bed and alarms if it was then or not. LPN #4 was asked if the resident could use or mentally remember to use call light. LPN #4 stated, "She does at times and at other times she does not. There are times she would remember if you went and reminded her everytime you went in. We also started to bring her out of room." The LPN was asked when was that started and she stated, "I can't really remember when we started." u. On 8/9/13 at 10:05 a.m., the DON looked through the resident's clinical record as she was asked the following questions by the surveyor: "Concerning the fall on 2/26/23, there was no documentation related to the bed alarm. Did the resident have a bed alarm?" "On 3/1/13 and 3/8/13, why was the resident alone in the bathroom. If Resident got up on own, where was alarm? There was no documentation on I & A or Nurses Notes and for the fall on 4/14/13, the resident fell from a wheelchair with no documentation of an alarm." "On 5/17/13, the resident fell returning from bathroom. Why was resident alone in the bathroom and again, no documentation of an alarm?" "For the fall on 7/1/13 in the bathroom, there is no documentation of an alarm or why the resident was alone in the bathroom?" After being asked the above questions, the DON stated, "I am going to look and see if I can find anything about this." v. On 8/9/13 at 11:05 a.m., the DON stated, "I looked through the fall stuff that the ADON (Assisted Director of Nursing) did and did not find any more information on the questions you asked or anything additional about interventions, or why resident was getting up from the wheelchair on 1/1/13 and 2/1/13." At 11:20 a.m. the DON was asked, "When you have a person with multible falls did you or anyone else track or trend to see if there were causative factors related to the falls. The DON stated, "I don't. I don't know if (ADON) has that trended anywhere, but I will look. At 11:50 a.m., the DON stated, "All she (ADON) has is how many falls a resident has per month." At 2:30 p.m., the DON provided a copy of a Nurse Aide's Information Sheet for Resident #1 that documented as updated on 2/12/13. The following items had been added to the sheet as updates, per the DON: Do not wake up at night to check; Bedside commode; Non-weight bearing; Wheel chair for long distance; Recent Rt [MEDICAL CONDITION] Non-weight bearing on Rt leg; and low bed with mat. There was no documentation on the sheet to inform CNAs that the resident was to have an alarm in place. 4. Resident #7 had [DIAGNOSES REDACTED]. The Initial Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/14/13 documented the resident scored 0 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), was sometimes understood and sometimes understood others, required supervision with setup help only for bed mobility, was totally dependent on the physical assistance of two-plus people for transfers, did not walk, was totally dependent on the physical assistance of one person for locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position, used a wheelchair for mobility, had experienced one fall without injury since prior assessment or admission and use bed rails as a restraint daily. a. The Resident Plan of Care dated 5/14/13 documented, "Falls... At risk for fall related injury... Provide environmental adaptations: Low / platform bed. Call light within reach. Adequate glare free lighting. Area free of clutter... Remind resident and reinforce safety awareness. Lock brakes on bed, chair, etc before transferring. When rising from a lying position, sit on side of bed for a few minutes before transferring / standing. Appropriate footwear. (Resident) placed in low bed (with) mat (left) side against the wall. Top 2 (side rails) (up) ...to enable him (with) repositioning self... Restraint... Restraint Type: Top 2 side rails up while resident is in bed to enable him to reposition self in bed... Restraint per physicians order... Provide safe environment, call light (and) personal items within reach, bed in low position. Top 2 (side rails) up for resident to use to reposition self in bed..." a. The Incident / Accident report dated 5/18/13 at 5:10 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from bed rails up... low position... Description of incident: Bed alarm sounded, nursing staff found resident lying on safety mat next to bed, Side rails up (times) 4, side rail padding intact to (right) side of bed, rail padding off of (left) side of bed against wall... asked resident how he rolled out of bed, resident stated 'I don't know, but it was tough'... Interventions: (blank)... Treatment Order Received: Continue to monitor resident..." There were no new interventions documented on the Resident Plan of Care or on the Incident/Accident Report. b. The Incident / Accident Report dated 5/29/13 at 4:15 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from bed, rails up... low position... Description of incident: Called to room by (Certified Nursing Assistant) (Resident) (lying) on mat on (left) side. Asked how he got OOB (out of bed). States 'very carefully'... Side rails (up) (times) 2, bed alarm in place. Interventions: move bed against wall (with) affected side out..." c. The Incident / Accident report dated 5/31/13 at 2:44 p.m. documented, "...Type of incident: Fall... Other (describe): Resident out of bed on knees on grey mat... Description of incident: Resident on both knees to grey mat... Interventions ...Encourage resident to wait for assistance..." There were no new interventions documented on the Resident Plan of Care. d. The Incident / Accident report dated 6/2/13 at 5:00 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall... low position... Other (describe) Geri-ch (chair)... Description of incident: Left in rm (room) per lab techs (technicians) by himself. Slipped down to floor from G (Geri)/ chair... Interventions: Inform workers not to be leaving (resident) by himself in rm (room) to return him to front of NS (nurses' station)..." There were no new interventions documented on the Resident Plan of Care. e. The Incident / Accident report dated 6/3/13 at 1:50 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall - climbed out of bed... rails up top... Description of incident: residents bed in lower position (with) mat beside bed. Crawled OOB (and) had upper torso on bed (with) right knee on mat - bed alarm was in place (and) working - does not remember to use call light - CNA close by (and) heard resident... Interventions: (blank). There were no new interventions to prevent falls documented on the report or on the Resident Plan of Care. f. The Incident / Accident report dated 6/5/13 at 6:00 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall... Other (describe) from G-chair (Geri-chair)... Description of incident: Resident taken into room upon request. (up) in G-chair. Feet elevated. Alarm in place. Alarm going off. CNA entered room. (Resident) on floor states ' I put feet down. I was getting into bed ' ... Interventions: Keep (resident) (at) nurses' station while (up) in G-chair..." This previously developed intervention was not added to the Resident Plan of Care to ensure staff who cared for the resident were aware. g. The Incident / Accident report dated 6/24/13 at 3:20 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from bed... low position... Description of incident: CNA... called for nurse to room. (Resident) sitting on mat beside bed (with) legs extended (with) bed alarm unplugged in hands. States, 'I just rolled OOB.' ...Interventions: Instruct (resident) not to get OOB (and) not to unplug bed alarm..." There were no new interventions documented on the Resident Plan of Care, other than instructing the severely cognitively impaired resident not to get out of bed or unplug the alarm. h. The Incident / Accident report dated 7/19/13 at 1:20 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from w/c (wheelchair)... Other (describe) Geri-chair... Description of incident: (Resident) was trying to get out of Geri-chair to go outside, to his red truck, and fell on floor. CNAs found (resident) on floor on his knees (and) called nurse quickly... Interventions: Assisted (resident) back into bed (times) two assist, checked VS (vital signs), assess pain level, assessed for bruises... Treatment Order Received: Keep a close eye on resident..." There were no new interventions documented on the Resident Plan of Care. i. On 7/26/13 at 11:30 a.m., the Director of Nursing (DON) was informed the resident had a BIMS score of 0 (severe cognitive impairment) and asked if she thought the resident was capable of understanding any instruction. She stated, "No." The DON was shown the reports and asked if there were appropriate fall prevention interventions for each incident; she stated, "No. 5. Resident #4 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/10/13 documented the resident was admitted [DATE], had severely impaired cognitive skills per staff assessment of mental status, was rarely understood and rarely understood others, was independent in bed mobility, was totally dependent on the physical assistance of two-plus people for transfers and walking, was totally dependent on the physical assistance of one person for locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet and during surface-to-surface transfers and had experienced 2 or more falls without injury since admission or prior assessment. a. The Resident Plan of Care dated 7/10/13 documented, "Falls... Problem Date 7/10/13... At risk for fall related injury as evidenced by: Previous Fall, Fall Risk factors present as determined by Fall Risk Screen ...(Goal) Resident will not sustain a fall related injury by utilizing fall precautions through next review date. (Approaches) ...Observe for side effects of any drugs that can cause: (if noted, report to nurse) Weakness Sedation Change in Mental Status. Provide environmental adaptations: Low / platform bed. Call light within reach. Adequate glare free lighting. Area free of clutter. Other: (blank). Remind resident and reinforce safety awareness: Lock brakes on bed, chair, etc. before transferring. When rising from a lying position, sit on side of bed for a few minutes before transferring / standing..." b. The Incident / Accident report dated 7/4/13 at 5:23 a.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall, from bed, rails down, low position... Description of incident: (Resident) head on bed. Knees / shin / feet on floor. Undergarment wet. Mat not in place beside bed. CNA (name). Bed was low. Interventions: Instructed to keep bed low (and) put mat beside bed at all times. Check (resident) frequently for wetness as is known for getting up when wet..." This new intervention was not documented on the Resident Plan of Care. c. The Incident / Accident report dated 7/5/13 at 6:50 p.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall from bed.... low position... onto mat... Description of incident: Resident noted sitting in floor (at) bedside in upright position. Side rails were up (times) 2 bed was in lowest position and floor mat was in place. Interventions: Assess for injury then assisted back into bed by staff (times) 2. No injuries noted...." There were no new interventions to prevent falls documented on the report or on the Resident Plan of Care. d. The Incident / Accident Report dated 7/8/13 at 3:50 p.m. documented, Location of incident: Resident bedroom... Type of incident: Fall... Description of incident: Sitting (with) bed alarm in place bed low position (with) safety mat... Interventions: Given prn (as needed) med. Keep door open..." The intervention to prevent falls was not documented on the Resident Plan of Care. e. On 7/26/13 at 11:46 a.m., the Director of Nursing was asked about the resident's falls and no new intervention on 7/5/13. She stated, "She has a low bed." 6. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/12/13 documented the resident was usually understood, sometimes understood others, was severely impaired in cognitive skill for daily decision making per staff assessment of mental status, was independent in bed mobility, required the limited physical assistance of one person for transfers, walking and locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, while walking, while turning around while walking, when moving on and off the toilet and during surface-to-surface transfers and had experienced 2 or more falls without injury since admission or prior assessment. a. The Resident Plan of Care dated 7/19/13 documented, "Falls... Problem Date: 4/4/13... At risk for fall related injury: Fall Risk factors present as determined by Fall Risk Screen, Fall Risk Scores: Date 3-29-2013 Score: 15 Related to: Disease process/condition... Confusion / Mental status change... (Goal) Resident will not sustain a fall related injury by utilizing fall precautions through next revie

Based on record review and interview, the facility failed to ensure interventions to decrease the risk of falls and minimize injuries were developed based on causative factors and resident cognitive status; were consistently implemented; and were added to the plan of care to facilitate staff awareness and enhance fall prevention efforts by the staff for 4 of 4 (Residents #1, #4 #7 and #10) case mix residents at risk for falls. This failed practice resulted in a pattern of harm for Resident #1 who suffered a fractured hip 2/1/13 and had no new interventions in place to prevent further falls or major injuries. This failed practice had the potential to to cause more than minimal harm for 22 residents who were at risk for falls, as identified on a list received from the Director of Nursing on 7/26/13 at 1:35 p.m. The findings are: 1. The Fall Prevention Policy received from the Director of Nursing on 7/26/13 at 1:35 p.m. documented, "POLICY: Residents who have a history of frequent falls or have high risk factors for falling will be identified in an effort to prevent falls. PROCEDURE ...The resident's Plan of Care will be updated to include fall prevention measures. Comfort measures, including an appropriate and comfortable chair, pain relief, toileting and ambulation with assistance, should be tried and evaluated frequently to prevent the resident trying to rise on his/her own without help. Residents in the Fall Prevention program will be monitored closely." 2. Resident #1 had [DIAGNOSES REDACTED]. a. An Incident/Accident (I&A) Report dated 12/5/12 at 4:30 p.m. documented, "Type of incident: slid to floor. Description of incident: The resident stood up from recliner in room and slid down to the floor. No injuries. Assisted up to feet easily, toileted and to bed per request. Interventions: Remind resident to call for assist as needed. Call light within reach. Resident to call when she needs up due to present weakness due to illness." The Minimum Data Set (MDS) with assessment reference date of 7/25/12 documented the resident scored 7 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS). b. The Incident/Accident Report dated 1/1/13 at 1:50 p.m. documented, "Location of incident: Other: Hallway... Type of incident: Fall... from w/c... Description of incident: Resident witnessed falling from w/c onto floor. Skin tear noted to (left) hand... Interventions: Cleaned hand (with) soap and water and steri-stripped..." There were no new interventions to prevent falls or discussion of causative factors documented on the report or on the Resident Plan of Care. On 8/9/13 at 10:05 a.m. the Director of Nursing (DON) was asked, "When Resident #1 had the fall on 1/1/13 why was the resident trying to get up or what was the resident trying to do and what intervention was put into place to prevent reoccurance?" The DON stated, "I don't know." The DON looked through the resident's clinical record as she was asked questions. She was unable to locate a documented intervention to prevent reoccurance of falls after the 1/1/13 fall. c. The FALL RISK ASSESSMENT form dated 1/18/13 documented a total score of 8 (10 or above represents high risk) for falls. The form did not document the resident's confusion, that the resident was ambulatory and incontinent, documented 2 of the four medications that could cause falls and did not identify any of the 4 diseases that the resident had that could cause falls. d. The Incident/Accident Report dated 2/1/13 at 10:35 a.m. documented, "Location of incident: East Hall near nurse's station... Type of incident: Fall... Other (describe) while standing up from w/c... Description of incident: Heard (resident) yelling 'help me' found (resident) lying supine in front of w/c. (resident) doesn't know how she fell . Another (resident) states she stood up (and) fell and hit head. c/o (right) leg pain... Interventions: Instruction (resident) to lock wheels before getting up... chair alarm." 1) A Pain assessment dated [DATE] documented, "...Pain location... (Right) leg... Cause of pain: fall... Severity of Pain... 8 (scale of 1 to 10)... Non-verbal indicators: Grimacing, Guarding, Moaning... Sent to ER (emergency room )." 2) Nurses notes dated 2/1/13 at 10:35 a.m., documented the resident was assisted onto a stretcher and transported to the emergency room . Nurses notes documented at 12:00 noon (resident) "is being sent to (Hospital) in Little Rock for broken (R) (right) hip." 3) Physician orders [REDACTED]. e. Nurses notes dated 2/7/13 at 4:00 p.m. documented, "...arrived via ambulance to room, Resident confused and anxiousness noted at this time. Dx ORIF (R)." f. Nurses Notes documented the following regarding the resident's cognitive status from 2/13/13 - 2/25/13: 1) Nurses Notes dated 2/13/13 documented, "...verbally responsive however very confused." 2) Nurses Notes dated 2/15/13 documented, "...confusion varies at times." 3) Nurses Notes dated 2/18/13 documented, "...confusion more noted this am. Resident continues to get self up with no regard to safety. Was up for breakfast, placed self back in bed. Resident is non compliant regarding safety." 4) Nurses Notes dated 2/19/13 documented, "...continues to give no regard to safety. Resident reminded not to get up on her own." 5) Nurses Notes dated 2/20/13 documented, "Resident gives no regard to safety although told of risks per falling. Resident continues to get self up frequently bed to chair or chair to bed." 6) Nurses Notes 2/24/13 documented, "...encouraged not to get up by herself. encouraged to use call light." 7) Nurses Notes dated 2/25/13 documented, "Continues to give no regard to safety." g. The Incident/Accident Report dated 2/26/13 at 2:40 a.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... while walking... Description of incident: Resident was found sitting on bottom, beside bed. Asked resident what was she doing at time of fall, stated 'I just stood up and my foot slipped' ...Call light was lying on bed at time of fall. Interventions: Instructed resident to use call light system before attempting to ambulate per self..." 1) Nurses Notes dated 2/26/13 documented the fall, "...had been incontinent of bowel...resident verbally expressed need to empty bladder", and resident was reminded to use the call light to request assistance at 2:45 a.m. and at 3:30 a.m. 2) Nurses Notes dated 2/26/13 at 9:00 a.m. documented, "confusion noted this a.m. Resident sitting on bed. Had a large BM all over the bed." h. The Resident Plan of Care documented, "2/28/13 - Resident conts (continues) to get up (without) assistance (at) (times) - with freq (frequent) reminding s/p (status [REDACTED]." i. The Incident/Accident Report dated 3/1/13 at 6:24 a.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... while walking... Description of incident: CNA found resident sitting in floor on safety mat, stated that she was trying to get back in her bed (and) missed, landing on floor mat on her bottom. Denies hitting head. Stated that she was experiencing sacral pain, able to move all extremities (and) bear weight. Interventions: Reminded resident to use call light system before attempting to transfer self..." 1) Nurses Notes dated 3/1/13 at 6:24 a.m. documented, "CNA (Certified Nursing Assistant) entered resident's room, found resident sitting on safety mat beside bed, feces on blankets on bed and on floor. Resident stated 'I was trying to get back in the bed, and I missed it and landed here.' Able to move all extrematies and bear weight, c/o pain and pointed to sacral area." 2) Nurses note dated 3/1/13 at 8:00 a.m. documented, "...very confused at times...Resident now has a chair and bed alarm." j. The Resident Plan of Care documented, "3/4/13 Please assist (with) ambulation (with) a walker - wt (weight) bearing as tolerated. Please assist (with) hip abductor strengthening exercises." 1) Nurses Notes dated 3/3/13 at 2:30 a.m. documented: The resident was lying in bed using left hand to bang on the wall beside the bed; Call light beside resident in reach; Resident stated that she was trying to let someone know that she needed to use the bedside commode; and Resident reminded that using the call light system was the appropriate and most effective way to request assistance. 2) Nurses Notes dated 3/6/13 documented, "gives no regard to safety." k. The Incident/Accident Report dated 3/8/13 at 2:35 p.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... standing ...sat in floor... Description of incident: Resident removed bed alarm (and) threw it into chair beside bed. Resident states she was coming back from b/rm (bathroom) and couldn't make it back to bed (and) sat in floor - Denies hitting head... resident was asst (assisted) out of sitting posit (position) on floor - to recliner then to bed. Resident stated back was hurting but states as soon as I stretch out it will quit - Bed alarm placed back on bed (and) call light clipped to her shirt - Blood blister type area noted on outside of (left) little finger. Shoes on. No water in floor. Interventions: staff is to ck (check) resident frequently (and) asst (assist) to b/rm answer call light promptly." Nurses Notes dated 3/8/13 at 2:45 p.m., documented: Resident removed bed alarm and threw into her chair beside bed; Resident states she was coming back from bathroom and could not make it back to her bed and sat in the floor; and Staff reminded to check resident frequently and assist to bathroom-answer call light promptly. l. Nurses Notes dated 3/9/13 and 3/10/13 documented, "...very confused at times." Nurses Notes dated 3/11/13 documented "...confused- Resident thought she was home today." m. The Incident/Accident Report dated 4/14/13 at 1:45 p.m. documented, "Type of incident: Fall... from w/c... Description of incident: Resident got up from wheelchair fell to the floor scraping her (right) side of her back approx (approximately) 4 1/2 (inch). Skin intact. (No) bleeding. Call light not used. Interventions: Resident to be reminded to use c/l (call light) before getting up. ROM (range of motion) good to all extremities. Ambulated (with) assist to bed." Nurses note dated 4/14/13 2:00 p.m. documented, "Resident gives no regard to safety. Resident got up from wheelchair and fell ." There was no documentation of the use of chair alarm on resident's wheelchair in the nurses notes. n. The Incident/Accident Report dated 4/20/13 at 7:40 a.m. documented, "Location of incident: Shower... Type of incident: Other (describe) Got up by self (and) almost fell CNA caught her... Description of incident: CNA had res in shower when CNA was turned around to get res clothes (and) res tried to get up (and) almost fell when CNA caught res. Res bumped (left) shin on w/ causing an L-shaped skin tear. Also found an L-shaped skin tear to (right) elbow (and) 2 U-shaped skin tears noted to back of (upper) (left) arm - area cleaned (and) steri strips applied. Interventions: Don't take your eyes off of res when in shower." o. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/13 documented the resident scored 6 (0-7 indicates severe cognitive impairment) Brief Interview for Mental Status (BIMS); was independent in bed mobility; required limited physical assistance of one person for transfers, walking and locomotion; was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, while walking, while turning around while walking, when moving on and off the toilet and during surface-to-surface transfers; used a wheelchair for mobility; and had experienced one fall with major injury since admission or prior assessment. The Resident Plan of Care with a review date of 4/26/13 documented, "Falls... Problem date: 7/25/12... At risk for fall related injury Disease process / condition ...(Goal) Resident will not sustain a fall related injury by utilizing fall precautions through next review date... (Approaches) Use fall risk screen to identify risks. Report falls to physician and responsible party. Observe for any side effects of any drugs that can cause: (If noted report to nurse) Gait disturbance, Orthostatic Hypotension, Weakness, Sedation, Light headedness, Dizziness. Call light in reach. Area free of clutter. Provide/monitor use of adaptive devices: Wheelchair. Remind resident and reinforce safety awareness; Lock brakes on bed, etc. chair, before transferring..." p. Nurses Notes dated 4/27/13 at 4:00 p.m. documented, "Resident shaking, getting up without assistance, states she needs to go home because they are closing down this place... Resident reassured by staff." q. The Incident/Accident Report dated 5/17/13 at 12:10 p.m. documented, "Location of incident: Resident bathroom... Type of incident: Fall... while walking... Description of incident: Resident walked to bathroom w/o (without) asking for assistance, while walking back fell (and) slipped in urine in floor, as reported by CNA... found in floor in doorway of bathroom lying on back, lg (large) baseball size hematoma obs (observed) to back of head. Resident moves all extremities w/o difficulty... stated head was sore (and) hurting, (no) other c/o (complaints of) pain... called EMTs (emergency medical technician) (and) resident transferred to gurney by EMTs, transferred to (hospital) ER (emergency room )... Interventions: Inform all CNAs (and) nurses to check bed alarms frequently to make sure they are plugged in." Nurses notes 5/17/13 documented, "Resident on floor. Urine all over bathroom floor. Witnessed by resident's sister who reported that resident got up and went to bathroom and was coming out when she fell . Resident in floor with lower extremities up to waist in urine in bathroom. Resident is usually confused and forgetful frequently. Large soft hematoma to the back center of head. Felt size of a soft ball. EMT's (emergency medical technicians) called Resident placed on stretcher with neck brace. taken to ER." r. The Resident Plan of Care documented, "5/23/13 PT (physical therapy) (with) restorative... ROM (range of motion) exercises Limit leg exercises d/t (due to) DVT (deep vein thrombosis)..." s. The Incident/Accident Report dated 7/1/13 at 5:20 a.m. documented, "Location of incident: Resident bathroom... Type of incident: Fall... from commode... Description of incident: resident was sitting on commode. Decided to stand up (without) assistance fell causing skin tears on both arms didn't hit head." There were no interventions documented on the report or on the Resident Plan of Care to prevent further falls. s. Observations of the resident: On 7/22/13 at 2:48 p.m., the resident was in the activity room at a table in a wheelchair. The wheelchair had an alarm in place. On 7/23/13 at 4:10 p.m., the resident was up in a wheelchair in the hallway with an alarm attached to the back of the chair. On 7/24/13 at 9:05 a.m., the resident was up in the recliner with the bed and chair alarm intact. At 12 noon, the resident was in bed with bed alarm in place. At 2:00 p.m., the resident was up in wheelchair at an activity with chair alarm in place. At 5:00 p.m., the resident was in bed with bed alarm in place and call light in reach. t. On 7/26/13 at 11:45 a.m., the DON was asked, "(Resident #1) has a BIMS of 6; do you think she understands instructions?" The DON stated, "Probably not." The DON was asked, "Do you think (Resident #1) understands the interventions you put in place?" The DON stated, "Probably not." The DON was asked if different interventions were put in place after each fall. The DON reviewed all of the resident's Incident and Accident reports then stated, "Not (interventions) on the falls, no ma'am." The DON stated, "They (interventions) either remind (Resident #1) not to get up on her own, or be more cautious, and to use the call light." The DON stated, "Telling them or reminding the resident is not an intervention." On 8/9/13 at 9:50 a.m., Licensed Practical Nurse (LPN) #4 was asked, "After (Resident #1) fell on [DATE] did the facility put any interventions in place." LPN #4 stated, "I don't remember when they put the mat by the bed and alarms, if it was then, or not." LPN #4 was asked if the resident could use or mentally remember to use call light. LPN #4 stated, "She does at times and at other times she does not. There are times she would remember if you went and reminded her everytime you went in. We also started to bring her out of the room." The LPN was asked when was that started and she stated, "I can't really remember when we started." u. On 8/9/13 at 10:05 a.m., the DON looked through the resident's clinical record as she was asked the following questions by the surveyor: "Concerning the fall on 2/26/23, there was no documentation related to the bed alarm. Did the resident have a bed alarm?" "On 3/1/13 and 3/8/13, why was the resident alone in the bathroom. If Resident got up on own, where was alarm? There was no documentation on I & A or Nurses Notes and for the fall on 4/14/13, the resident fell from a wheelchair with no documentation of an alarm." "On 5/17/13, the resident fell returning from bathroom. Why was resident alone in the bathroom and again, no documentation of an alarm?" "For the fall on 7/1/13 in the bathroom, there is no documentation of an alarm or why the resident was alone in the bathroom?" After being asked the above questions, the DON stated, "I am going to look and see if I can find anything about this." v. On 8/9/13 at 11:05 a.m., the DON stated, "I looked through the fall stuff that the ADON (Assisted Director of Nursing) did and did not find any more information on the questions you asked or anything additional about interventions, or why resident was getting up from the wheelchair on 1/1/13 and 2/1/13." At 11:20 a.m. the DON was asked, "When you have a person with multiple falls, do you or anyone else track or trend to see if there were causative factors related to the falls. The DON stated, "I don't. I don't know if (ADON) has that trended anywhere, but I will look. At 11:50 a.m., the DON stated, "All she (ADON) has is how many falls a resident has per month." At 2:30 p.m., the DON provided a copy of a Nurse Aide's Information Sheet for Resident #1 that documented as updated on 2/12/13. The following items had been added to the sheet as updates, per the DON: Do not wake up at night to check; Bedside commode; Non-weight bearing; Wheel chair for long distance; Recent Rt hip fracture Non-weight bearing on Rt leg; and low bed with mat. There was no documentation on the sheet to inform CNAs that the resident was to have an alarm in place. 3. Resident #7 had [DIAGNOSES REDACTED]. The Initial Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/14/13 documented the resident scored 0 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS), was sometimes understood and sometimes understood others, required supervision with setup help only for bed mobility, was totally dependent on the physical assistance of two-plus people for transfers, did not walk, was totally dependent on the physical assistance of one person for locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position, used a wheelchair for mobility, had experienced one fall without injury since prior assessment or admission and use bed rails as a restraint daily. a. The Resident Plan of Care dated 5/14/13 documented, "Falls... At risk for fall related injury... Provide environmental adaptations: Low / platform bed. Call light within reach. Adequate glare free lighting. Area free of clutter... Remind resident and reinforce safety awareness. Lock brakes on bed, chair, etc before transferring. When rising from a lying position, sit on side of bed for a few minutes before transferring / standing. Appropriate footwear. (Resident) placed in low bed (with) mat (left) side against the wall. Top 2 (side rails) (up) ...to enable him (with) repositioning self... Restraint... Restraint Type: Top 2 side rails up while resident is in bed to enable him to reposition self in bed... Restraint per physicians order... Provide safe environment, call light (and) personal items within reach, bed in low position. Top 2 (side rails) up for resident to use to reposition self in bed..." a. The Incident / Accident report dated 5/18/13 at 5:10 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from bed rails up... low position... Description of incident: Bed alarm sounded, nursing staff found resident lying on safety mat next to bed, Side rails up (times) 4, side rail padding intact to (right) side of bed, rail padding off of (left) side of bed against wall... asked resident how he rolled out of bed, resident stated 'I don't know, but it was tough'... Interventions: (blank)... Treatment Order Received: Continue to monitor resident..." There were no new interventions documented on the Resident Plan of Care or on the Incident/Accident Report. b. The Incident / Accident Report dated 5/29/13 at 4:15 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from bed, rails up... low position... Description of incident: Called to room by (Certified Nursing Assistant) (Resident) (lying) on mat on (left) side. Asked how he got OOB (out of bed). States 'very carefully'... Side rails (up) (times) 2, bed alarm in place. Interventions: move bed against wall (with) affected side out..." c. The Incident / Accident report dated 5/31/13 at 2:44 p.m. documented, "...Type of incident: Fall... Other (describe): Resident out of bed on knees on grey mat... Description of incident: Resident on both knees to grey mat... Interventions ...Encourage resident to wait for assistance..." There were no new interventions documented on the Resident Plan of Care. d. The Incident / Accident report dated 6/2/13 at 5:00 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall... low position... Other (describe) Geri-ch (chair)... Description of incident: Left in rm (room) per lab techs (technicians) by himself. Slipped down to floor from G (Geri)/ chair... Interventions: Inform workers not to be leaving (resident) by himself in rm (room) to return him to front of NS (nurses' station)..." There were no new interventions documented on the Resident Plan of Care. e. The Incident / Accident report dated 6/3/13 at 1:50 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall - climbed out of bed... rails up top... Description of incident: residents bed in lower position (with) mat beside bed. Crawled OOB (and) had upper torso on bed (with) right knee on mat - bed alarm was in place (and) working - does not remember to use call light - CNA close by (and) heard resident... Interventions: (blank). There were no new interventions to prevent falls documented on the report or on the Resident Plan of Care. f. The Incident / Accident report dated 6/5/13 at 6:00 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall... Other (describe) from G-chair (Geri-chair)... Description of incident: Resident taken into room upon request. (up) in G-chair. Feet elevated. Alarm in place. Alarm going off. CNA entered room. (Resident) on floor states ' I put feet down. I was getting into bed ' ... Interventions: Keep (resident) (at) nurses' station while (up) in G-chair..." This previously developed intervention was not added to the Resident Plan of Care to ensure staff who cared for the resident were aware. g. The Incident / Accident report dated 6/24/13 at 3:20 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from bed... low position... Description of incident: CNA... called for nurse to room. (Resident) sitting on mat beside bed (with) legs extended (with) bed alarm unplugged in hands. States, 'I just rolled OOB.' ...Interventions: Instruct (resident) not to get OOB (and) not to unplug bed alarm..." There were no new interventions documented on the Resident Plan of Care, other than instructing the severely cognitively impaired resident not to get out of bed or unplug the alarm. h. The Incident / Accident report dated 7/19/13 at 1:20 p.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall from w/c (wheelchair)... Other (describe) Geri-chair... Description of incident: (Resident) was trying to get out of Geri-chair to go outside, to his red truck, and fell on floor. CNAs found (resident) on floor on his knees (and) called nurse quickly... Interventions: Assisted (resident) back into bed (times) two assist, checked VS (vital signs), assess pain level, assessed for bruises... Treatment Order Received: Keep a close eye on resident..." There were no new interventions documented on the Resident Plan of Care. i. On 7/26/13 at 11:30 a.m., the Director of Nursing (DON) was informed the resident had a BIMS score of 0 (severe cognitive impairment) and asked if she thought the resident was capable of understanding any instruction. She stated, "No." The DON was shown the reports and asked if there were appropriate fall prevention interventions for each incident; she stated, "No. 4. Resident #4 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 7/10/13 documented the resident was admitted [DATE], had severely impaired cognitive skills per staff assessment of mental status, was rarely understood and rarely understood others, was independent in bed mobility, was totally dependent on the physical assistance of two-plus people for transfers and walking, was totally dependent on the physical assistance of one person for locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet and during surface-to-surface transfers and had experienced 2 or more falls without injury since admission or prior assessment. a. The Resident Plan of Care dated 7/10/13 documented, "Falls... Problem Date 7/10/13... At risk for fall related injury as evidenced by: Previous Fall, Fall Risk factors present as determined by Fall Risk Screen ...(Goal) Resident will not sustain a fall related injury by utilizing fall precautions through next review date. (Approaches) ...Observe for side effects of any drugs that can cause: (if noted, report to nurse) Weakness Sedation Change in Mental Status. Provide environmental adaptations: Low / platform bed. Call light within reach. Adequate glare free lighting. Area free of clutter. Other: (blank). Remind resident and reinforce safety awareness: Lock brakes on bed, chair, etc. before transferring. When rising from a lying position, sit on side of bed for a few minutes before transferring / standing..." b. The Incident / Accident report dated 7/4/13 at 5:23 a.m. documented, "...Location of incident: Resident bedroom... Type of incident: Fall, from bed, rails down, low position... Description of incident: (Resident) head on bed. Knees / shin / feet on floor. Undergarment wet. Mat not in place beside bed. CNA (name). Bed was low. Interventions: Instructed to keep bed low (and) put mat beside bed at all times. Check (resident) frequently for wetness as is known for getting up when wet..." This new intervention was not documented on the Resident Plan of Care. c. The Incident / Accident report dated 7/5/13 at 6:50 p.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall from bed.... low position... onto mat... Description of incident: Resident noted sitting in floor (at) bedside in upright position. Side rails were up (times) 2 bed was in lowest position and floor mat was in place. Interventions: Assess for injury then assisted back into bed by staff (times) 2. No injuries noted...." There were no new interventions to prevent falls documented on the report or on the Resident Plan of Care. d. The Incident / Accident Report dated 7/8/13 at 3:50 p.m. documented, Location of incident: Resident bedroom... Type of incident: Fall... Description of incident: Sitting (with) bed alarm in place bed low position (with) safety mat... Interventions: Given prn (as needed) med. Keep door open..." The intervention to prevent falls was not documented on the Resident Plan of Care. e. On 7/26/13 at 11:46 a.m., the Director of Nursing was asked about the resident's falls and no new intervention on 7/5/13. She stated, "She has a low bed." 5. Resident #10 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 7/12/13 documented the resident was usually understood, sometimes understood others, was severely impaired in cognitive skill for daily decision making per staff assessment of mental status, was independent in bed mobility, required the limited physical assistance of one person for transfers, walking and locomotion, was unsteady and only able to stabilize with staff assistance when moving from a seated to a standing position, while walking, while turning around while walking, when moving on and off the toilet and during surface-to-surface transfers and had experienced 2 or more falls without injury since admission or prior assessment. a. The Resident Plan of Care dated 7/19/13 documented, "Falls... Problem Date: 4/4/13... At risk for fall related injury: Fall Risk factors present as determined by Fall Risk Screen, Fall Risk Scores: Date 3-29-2013 Score: 15 Related to: Disease process/condition... Confusion / Mental status change... (Goal) Resident will not sustain a fall related injury by utilizing fall precautions through next review date... (Approaches)... Observe for side effects of any drugs that can cause: (if noted, report to nurse) Gait disturbance Orthostatic hypotension Weakness Sedation Lightheadedness Dizziness Change in Mental Status... Provide environmental adaptations... Provide / monitor use of adaptive devices: wheelchair. Remind resident and reinforce safety awareness: Lock brakes on bed, chair etc before transferring. When rising from a lying position, sit on side of bed for a fe minutes before transferring / standing. Appropriate footwear...." b. The resident's Incident / Accident Report dated 7/1/13 documented, "Location of incident: Nursing Station... Type of incident: Fall on bottom... Description of incident: Resident (at) the Nurses Station confusion noted. Resident up per self from the wheelchair and fell to the floor on her bottom... Interventions: Encourage resident to wait for assistance..." The intervention to prevent falls was not documented on the Resident Plan of Care. c. The resident's Incident / Accident Report dated 7/8/13 at 8:45 a.m. documented, "Location of incident: Resident bedroom... Type of incident: Fall... Description of incident: Resident up to feet landing on her foot pedals on her bottom... Interventions: Resident encouraged not to get up on her own..." There were no new interventions to prevent falls documented on the report or on the Resident Plan of Care

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure Resident #1 received the necessary care and services to maintain the highest practicable physical well being. The facility failed to ensure a pain assessment was completed upon staff communication of resident displaying signs of pain for 1 of 1 case-mix residents (Resident #1) who experienced a fall with subsequent injury to head. The facility also failed to ensure neurological assessments were conducted one time per shift for 72 hours after a fall in which the resident sustained [REDACTED].#1) who experienced a fall with subsequent injury to head. The facility failure to assess staff reported signs of resident pain resulted in a delay in treatment and a pattern of actual harm for Resident #1 who exhibited signs of pain for 2 days after sustaining a fall which resulted in a Cervical Spine fracture (C5 and C6) and had the potential to cause more than minimal harm for 38 residents in the facility who were at risk for falls according to the Director of Nursing on 1/25/11 at 9:47 a.m. The findings are: 1. The facility's Incident/Accident (I/A) report policy and procedure documented, "Follow up report Q (every) shift for 72 hours." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had severely impaired cognitive skills for daily decision making, required total assistance with all activities of daily living, rarely/never had the ability to understand others and had no speech - absence of spoken words. a. The facility's Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of property and Exploitation of Residents in Long Term Care Facilities from (Division of Medical Services (DMS) form-762) dated 1/10/11 documented, "On 1/8/11 at approx. (approximately) 6:10 p.m. after the evening meal, (Resident #1) was pushed to the South hall outside of the dining room area and positioned on the left side of the hall by (Certified Nursing Assistant (CNA) #1). (CNA #1) then takes another resident to her room and returns to get (Resident #1). (Resident #1) was still positioned on the left side of hall at a slight angle with w/c (wheelchair) pointing slightly to the center of the hallway. (Resident #1) was on the left side of the hall, another resident was positioned beside (Resident #1) in a w/c, with (CNA #3) behind that chair and an ambulatory resident standing beside (CNA #3). There was also (Licensed Practical Nurse (LPN) #3 and a med cart standing behind all the residents. (CNA #1) had returned to get (Resident #3) and attempted to step between (Resident #1's) w/c and the other resident's chair and tripped on the front wheel of (Resident #1's) w/c falling between the two chairs causing (Resident #1's) chair to flip backwards. (Resident #1) was seat belted in the chair, and did not come out of the chair. Resident was assessed by (LPN #3), who was standing in the hallway and witnessed the event. Resident and her chair were then set back upright by (CNA #3), (CNA #1) and (LPN #3). Resident did have a raised area on her posterior head and skin tear to her right elbow." b. Nurse's Notes dated 1/8/11 at 6:15 p.m. documented, "pt (patient) was sitting in w/c (wheelchair) on South Hall along with another resident that was sitting next to her. (CNA #1) tried to walk in between the w/c and tripped and fell , this residents w/c flipped backwards causing her to hit back of head on wall and causing skin tear to (R) (right) elbow. Resident assisted off floor and back in w/c. No neuro changes noted at this time. Minimal bleeding noted to elbow, bleeding controlled. 19:05 (7:05 p.m.) (Doctor) phoned at home no answer. Left message for him to call facility back. ...19:30 (7:30 p.m.) (Doctor) E.R. (emergency room ) doctor phoned. No new orders. Dr. (Doctor) advised to notify him of any neuro changes and observe pt. for neuro changes." As of 1/24/11 at 1:35 p.m., of the Nurse Notes show documentation of two neurological assessments for the evening shift on 1/8/11 and the day shift on 1/9/11. No further documentation was found in the Nurse Notes to indicate a neurological assessment was done on any shift from 1/8/11 on the evening or night shift, the day, evening or night shift on 1/9/11, or the day and evening shift through 1/11/11 at 1:32. Neurological assessments were conducted on 2 out of 9 shifts. c. Staff were interviewed regarding the resident ' s condition the day following the incident: 1) On 1/24/11 at 1:25 p.m., CNA #2 was asked if the resident experienced any pain while she gave her care anytime during her shift (7/3) on 1/9/11. She stated, "...she (Resident #1) looked like she was hurting. I would tell her it might hurt when I turned her. I'd be as gentle as I could. When I turned her she tensed up and hollered when I touched the back of her neck. ...before we got report that morning, respiratory asked me did I know the back of her head was hurting. We put the mask (for updraft) on and touched the back of her neck and she jumped." CNA #2 was asked if she reported the resident's pain to the nurse. She stated, "I told the nurse, (Licensed Practical Nurse (LPN)) #2)." The CNA was asked, " What did the nurse say to you? " She stated, "I will give her Tylenol or I've already given her Tylenol." CNA #2 was asked if the resident was transferred out of bed at anytime during her shift. She stated, "I don't remember, I can't remember if we got her up for lunch that day or not." a). On 1/25/11 at 9:25 a.m., LPN #2 was asked if CNA #2 had reported to her that (Resident #1) was in pain. LPN #2 stated, "I don't remember anyone reporting pain to me. If she had I would have given her Tylenol. I don't recall anything. We got her up in her w/c, it was snowing that day. I was talking to her (Resident #1) and I asked her if I could sleep with her if I got snowed in. She was turning her head to look at me, smiling. If she (CNA #2) told me, I did not hear her. But I'm going to give her Tylenol or something if they're in pain because I know how my joints feel. I remember telling them not to get her up because if she's up too long she would probably not want to eat because of being too tired...They (CNAs) have a bad habit of telling you things when we're in the middle of doing things, like when your passing meds." During the interview, LPN #2 commented that she did assess the resident "...but I didn't document it. That's my fault, I should've documented it." b). As of 1/24/11 at 1:35 p.m., the January 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2) On 1/24/11 at 3:29 p.m., CNA #3 was asked if the resident experienced any pain while she gave her care anytime during her shift (3/11) on 1/9/11. She stated, "...Yes, I reported it to the nurse. I believe the nurse was (LPN #2). We had to change her, we could tell by her facial expressions. She started shaking, you could just tell by facial expressions she was hurting." The CNA was asked what she had told the nurse. She stated, "I told her that (Resident #1) was in pain and that she actually needed a pain med." The CNA was asked, " What was the nurse doing when you told her about (Resident #1) hurting? " She stated, "We were in the dining room. She heard me. She was passing med. (medications)." The CNA was asked, " What did the nurse say when you told her the resident was hurting? " She stated, "Ok." 3) On 1/24/11 at 3:25 p.m., during a telephone interview, CNA #1 was asked if (Resident #1) experienced any pain while she gave her care anytime during her shift (3/11) on 1/9/11. She stated, "Yes, when we went to turn her and to change her, she acted like she was hurting." The CNA was asked, " What do you mean she acted like she was hurting? " She stated, "She made a whining noise. (CNA #3) told the nurse, (LPN #1)." The CNA was asked if the nurse did anything about the resident's pain. She stated, "I don't know." CNA #1 was asked if she knew where the pain was coming from. She stated, "When we turned her on her right side she seemed like she was hurting, I couldn't tell where." CNA #1 was asked if the resident's pain concerned her. She stated, "It scared me, it made me think it was more than just a bump on the head." 4) On 1/25/11 at 4:24 p.m., during a telephone interview, LPN #1, stated that on 1/8/11 when (Resident #1) fell , "I worked but wasn't her nurse. The next night on (1/9/11), I don't even think I was working." She was told according to her time card provided by the facility she worked on 1/9/11during the 3/11 shift. She was asked if she could remember CNA #3 reporting to her on 1/9/11 during that time that (Resident #1) was in pain. She stated, "No ma'am, not that I remember. I do remember I left early that night." The LPN's time card documented she clocked out at 9:07 p.m. She was asked what are the nurses required to do when following up with residents who have had I/A (incident and accident) reports. She stated, "...do neuro checks, v/s (vital signs) and document in the I/A book, reporting to the next shift what's going on with the resident, just things like that." The LPN was asked, "Did you do a pain assessment on (Resident #1)? " She stated, "I'm sure I did. If I didn't document in the nurse's notes, I normally document in the I/A book." The Nurses Notes and the I/A book were reviewed, LPN #1 had not documented the condition of the resident on 1/9/11. LPN #1 was asked why would CNA #3 say she reported the resident's pain to you while you were in the dining room passing medications. She stated, "...I don't know why. I don't remember." d. The nurse's notes dated 1/10/11 at 11:30 a.m. documented, "Res. (resident) moaned loudly when moving neck, called (Physician #1) and with (Physician's Nurse), nurse stated she would let (Physician #1) know we called and he would call back.... at 11:50 a.m., "(Physician ' s Nurse) called back and stated (Physician #1) ordered chest and cervical spine x-ray, will cont (continue) to monitor closely. ...at 1:00 p.m., Res. (resident) left nursing home to hospital via wheelchair with (employee), returned to facility at 1:20 p.m. via wheelchair by (employee)." The x-ray results dated 1/10/11 at 11:59 a.m. was faxed to the facility on [DATE] at 8:59 a.m., a lapse of time of approximately 21 hours later. The results documented, "Cervical Spine Series 5 views: ...Impression: Suspicion of perched facets and probable anterior subluxation of C5 over C6, likely resulting is significant central canal stenosis at this level. Strongly recommend correlation with a follow up CT of the cervical spine for further investigation." e. The nurse's notes dated 1/11/11 at 9:10 a.m. documented, "Spoke with (Physician #1) per phone concerning x-ray report of spine - T.O. ...to do CT of head and spine... at 10:10 a.m., resident transferred from bed to stretcher per 3 using mechanical lift - taken per stretcher to x-ray dept.(department) at hospital... at 10:50 a.m., resident returned per stretcher and is placed back in bed per 2 using mechanical lift - tol (tolerated) fair... at 1:00 p.m. resident was given tylenol ... at 0900 - repeated at 1:00 p.m. for grimacing and moaning as if in pain ...At 1:32 p.m. CT report faxed to (Physicia ' s #1) clinic..." The x-ray results dated 1/11/11 at 10:29 a.m. was faxed to the facility on [DATE] at 1:34 p.m. The results documented, "CT Cervical Spine without IV Contrast ...Impression: 1. Unstable fracture/subluxation deformity at C5-6 resulting is significant central canal and bilateral foraminal stenosis. Neurosurgical intervention will likely be required. 2. Avulsion fracture deformities of the C4 and C5 spinous process." f. The nurse's notes dated 1/11/11 documented, "...Approximately 2:00 p.m. EMT's (Emergency Medical Technician)'s at hospital were notified earlier by (Physician #1) to stabilize resident and bring her to ER - ...resident is taken per stretcher by EMT's from hospital to ER to be seen by (Physician #1). ...at 3:35 p.m., hospital ER reports that resident is to be transported by ambulance to (another hospital out of town) for the care of (Physician #2)." g. The hospital ER documentation dated 1/11/11 at 2:11 p.m. documented (Resident #1's) neck was first stabilized " ...Boarded and Collared..." on 1/11/11 at 2:14 p.m. h. The hospital history and physical (H/P) dated 1/11/11 documented, "..Assessment and Plan: At this point, I am going to make the patient NPO (nothing by mouth) and consider a swallow study. I am going to change the cervical collar to a Philly collar and consult the hospitalist to help with medical issues. ...I am very concerned that she would not be able to undergo surgical correction of this fracture. This would require possibly a 2 stage surgery and this point I am not sure she could survive any surgery at all. ...I informed the patient's son that also this is a very serious condition and with all of her other ailments this could end up causing death and she might not survive this." i. On 1/24/11 at 10:30 a.m., the Administrator provided an inserviced dated 1/12/11 which documented, "...Nurses: 1. If a resident falls make sure to assess them prior to staff getting them up. Please do assessment for pain and injury. 2. If there is indicators of head injury (hematoma, brusing, redness, or witnessed, etc.) we are to do neuro checks as follows: a. Q (every) 15 minutes x 4 then b. Q hour x 2 hours then 3. Q 2 hours x 24 hours Also there is a neurological assessment flow sheet that needs to be completed..." j. On 1/25/11 at 11:41 a.m., the Administrator and the Director of Nursing was asked how does the facility monitor the effectiveness of their inservices to ensure the staff is following through with their instructions. The Administrator indicated there had been no I/As since (Resident #1's) fall on 1/8/11 that involved a head injury or any resident hitting their head to conduct neuro assessments.

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure residents who required staff assistance and the use of a wheelchair for mobility were not placed in clusters that blocked safe passage down the corridor and failed to ensure a staff member did not attempt to step over and between the clustered wheelchairs for 1 (Resident #1) of 5 (Residents #1 - 5) case mix residents who required the assistance of staff and a wheelchair for mobility. The failed practice resulted in actual harm to Resident #1, who sustained a cervical spine fracture after her wheelchair was flipped over by a staff member, and had the potential to affect 10 residents who require a wheel chair and staff assistance for mobility according to a list provided by the Director of Nursing on 2/7/11 at 9:00 a.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] documented the resident had severely impaired cognitive skills for daily decision making, required total assistance with all activities of daily living, required total assistance of 2 or more staff members for bed mobility and transfers, was totally dependent on staff for mobility on and off the unit, used a wheel chair for mobility, rarely/never had the ability to understand others and had no speech - absence of spoken words. a. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, (and) Exploitation of Residents in Long Term Care Facilities form (Division of Medical Services (DMS) Form 762) dated 1/10/11 documented, "On 1/8/11 at approx. (approximately) 6:10 p.m. after the evening meal, (Resident #1) was pushed to the South hall outside of the dining room area and positioned on the left side of the hall by (Certified Nursing Assistant (CNA) #1). (CNA #1) then takes another resident to her room and returns to get (Resident #1). (Resident #1) was still positioned on the left side of hall at a slight angle with w/c (wheelchair) pointing slightly to the center of the hallway. (Resident #1) was on the left side of the hall, another resident was positioned beside (Resident #1) in a w/c, with (CNA #3) behind that chair and an ambulatory resident standing beside (CNA #3). There was also (Licensed Practical Nurse (LPN) #3) and a med (medication) cart standing behind all the residents. (CNA #1) had returned to get (Resident #3) and attempted to step between (Resident #1's) w/c and the other resident's chair and tripped on the front wheel of (Resident #1's) w/c falling between the two chairs causing (Resident #1's) chair to flip backwards. (Resident #1) was seat belted in the chair, and did not come out of the chair. Resident was assessed by (LPN #3), who was standing in the hallway and witnessed the event. Resident and her chair were then set back upright by (CNA #3), (CNA #1) and (LPN #3). Resident did have a raised area on her posterior head and skin tear to her right elbow." 1.) Nurse's Notes dated 1/8/11 at 6:15 p.m. documented, "pt (patient) was sitting in w/c (wheelchair) on South Hall along with another resident that was sitting next to her. (CNA #1) tried to walk in between the w/c and tripped and fell , this residents w/c flipped backwards causing her to hit back of head on wall and causing skin tear to (R) (right) elbow ... " 2.) Nurse's Notes dated 1/10/11 at 11:30 a.m. documented, "Res. (resident) moaned loudly when moving neck, called (Physician #1) and with (Physician's Nurse), nurse stated she would let (Physician #1) know we called and he would call back.... at 11:50 a.m., "(Physician ' s Nurse) called back and stated (Physician #1) ordered chest and cervical spine x-ray, will cont (continue) to monitor closely... at 1:00 p.m., Res. (resident) left nursing home to hospital via wheelchair with (employee), returned to facility at 1:20 p.m. via wheelchair by (employee)." 3.) The Radiology Report dated 1/10/11 at 11:59 a.m. documented the x-ray results as, "Cervical Spine Series 5 views: ...Impression: Suspicion of perched facets and probable anterior subluxation of C5 (fifth cervical vertebra) over C6 (sixth cervical vertebra), likely resulting is significant central canal stenosis at this level. Strongly recommend correlation with a follow up CT (computed tomography scan) of the cervical spine for further investigation." 4.) Nurse's Notes dated 1/11/11 at 9:10 a.m. documented, "Spoke with (Physician #1) per phone concerning x-ray report of spine - T.O. (telephone order)... to do CT of head and spine... At 1:32 p.m., CT report faxed to (Physician #1 ' s) clinic..." 5.) The Radiology Report dated 1/11/11 at 10:29 a.m. documented, "CT Cervical Spine without IV (intravenous) Contrast ...Impression: 1. Unstable fracture/subluxation deformity at C5-6 resulting in significant central canal and bilateral foraminal stenosis. Neurosurgical intervention will likely be required. 2. Avulsion fracture deformities of the C4 and C5 spinous process." 6.) Nurse's Notes dated 1/11/11 documented, "...Approximately 2:00 p.m. EMT's (Emergency Medical Technicians)'s at hospital were notified earlier by (Physician #1) to stabilize resident and bring her to ER (emergency room ) - ...resident is taken per stretcher by EMT's from hospital to ER to be seen by (Physician #1). ...at 3:35 p.m., hospital ER reports that resident is to be transported by ambulance to (another hospital out of town) for the care of (Physician #2)." 7.) The hospital ER documentation dated 1/11/11 at 2:11 p.m. documented, "(Resident #1's) neck was first stabilized ... Boarded and Collared... 1/11/11 at 2:14 p.m. 8.) The hospital History and Physical (H/P) dated 1/11/11 documented, "..Assessment and Plan: At this point, I am going to make the patient NPO (nothing by mouth) and consider a swallow study. I am going to change the cervical collar to a Philly collar and consult the hospitalist to help with medical issues. ...I am very concerned that she would not be able to undergo surgical correction of this fracture. This would require possibly a 2 stage surgery and this point I am not sure she could survive any surgery at all. ...I informed the patient's son that also this is a very serious condition and with all of her other ailments this could end up causing death and she might not survive this." b. On 1/24/11 at 12:20 p.m., CNA #1 was asked about the incident involving (Resident #1) on 1/8/11. The CNA stated, "I came out of the dining room and pushed (non case mix female Resident #1) down the hall. She (the other female resident) normally will push herself when I put her out in the hall. I went back in the dining room and pushed (Resident #1) into the hall. As I was pushing (Resident #1) out, CNA #3 was pushing (non case mix female Resident #2) behind me. I put (Resident #1) on the left side of the hallway because I had to move (non case mix female Resident #1) ahead down the hall to get her out of the way." CNA #1 indicated she couldn't get by because (non case mix female Resident #2) was placed in the middle of the hall next to Resident #1. CNA #1 also stated at this same time, an ambulatory (non case mix female Resident #3) resident was standing in the hallway on the other side of (non case mix female Resident #2). CNA #1 indicated LPN #3 was behind all of them in the hallway with her medication cart. According to CNA #1, at this time, the hallway became congested and a total of 3 employees (CNA #1, CNA #2 and LPN #3) and 4 residents (Resident #1 and non case mix female Residents #1, #2, and #3) were all congested outside the D/R, in the South hallway. CNA #1 stated, "I went to go between the 2 wheelchairs and I tripped on (non case mix Resident #2 ' s) wheelchair pedal and (Resident #1's) w/c fell backwards with me. It happened so fast..." The CNA was asked if she had any orientation before starting work. She stated, "Yes, 3 days." She indicated she was oriented on the floor with another CNA and stated she had no classroom orientation, no videos regarding environmental hazards and safety... nothing on cluttered hallways. CNA #1 indicated the reason the facility did not go over keeping the hallways clear and clutter free was based on her experience and that she had worked in another facility. She was asked, since the accident on 1/8/11, what she had been told to ensure this did not happen again. She stated, "...if we have a resident in the hallway, make sure they're on one side of the hall, make sure there's not a hall cluster." CNA #1 was asked, " Why were you told that? " CNA #1 stated, "So we can prevent accidents." The CNA was asked did if she realized there was not enough space between the 2 wheelchairs for her to pass through. She stated, "No, because I thought there was enough space to pass." The CNA was asked, " Would the accident have happened if the hall had been clear? " She stated, "No, probably not." She was asked if LPN #3, who was present in the hallway when the accident occurred, had instructed the CNA ' s at any time to clear the corridor because it was becoming too crowded. She stated, "No." She was asked what could have prevented the accident with (Resident #1) and stated, "I could've waited until (CNA #3) pushed (non case mix Resident #3) up the hall or gone around her wheelchair." c. On 1/24/11 at 3:29 p.m., CNA #3 was asked about the incident with (Resident #1). The CNA stated, "...after supper, we were pushing residents out of the dining room into the South Hall... (CNA #1) pushed a resident forward to make room for us to go through. (CNA #1) came back to get (Resident #1), who was stopped (in the hall) and (CNA#1) tripped on another resident's chair. (CNA #1) started falling, it happened so fast. All I saw was (Resident #1's) wheelchair flipping backwards and she hit the wall. (CNA #1) got her foot in (non case mix Resident #2's) (foot) pedal and (CNA #1) fell , pushing over (Resident #1) in her w/c with her." CNA #3 was asked, " Was the hall congested at that time? " She stated, "I would say yes, because they were all coming out of the dining room at the same time." She was asked if there had not been congestion in the hallway, if the accident would still have occurred. She stated, "Probably not." CNA #3 was asked if she had been instructed before the accident on 1/8/11 on what to do about keeping the environment safe, free of clutter and congestion in hallways. She indicated no. CNA #3 indicated she was instructed after the accident that, "we're only supposed to push one resident at a time, not to be training the residents (putting the resident in a train down the hall)." She was asked why they were told that. She stated, "For the safety of the residents and ourselves." d. On 1/24/11 at 11:25 a.m., the Administrator was asked to provide documentation that indicated the facility had inserviced staff on environmental safety and hazards such as hall congestion, keeping the hall clear and free from clutter prior to the incident on 1/8/11. She stated, "I'm not sure if it been written down. We have talked about it. They (staff) know to keep the hallway clear, everything off to the side." At 11:30 a.m., the Administrator provided a memo she stated was posted on 1/4/11 which documented, "Linen carts are not to be in hallways during meal times..." e. On 1/24/11 at 10:30 a.m., the Administrator provided an inservice dated 1/12/11 which documented, "...congestion in hallway a. make sure that everything is on one side of hallway at all times. b. Linen carts are to be off hallway when not in use. c. Only park resident on one side of hallway..." f. On 1/25/11 at 11:41 a.m., the Administrator and Director of Nursing (DON) were asked how the facility monitored the effectiveness of their inservices to ensure the staff were following through with their instructions. The Administrator stated, "We QA'd (discussed with Quality Assessment and Assurance Committee) it, we been doing checks on the hall." When asked, " Who is responsible for monitoring the halls " , the Administrator stated, "(Assistant Director of Nursing (ADON))." She was asked how often the facility was monitoring and stated, "...We do it at various times during the day and randomly. We look at the cameras. We can roll back the camera at any time." The Administrator was asked if they had documentation to support the monitoring. She stated, "Yes." The Administrator was asked to provide the documentation. g. On 1/25/11 at 12:22 p.m. the facility provided the following monitoring to prevent further incidents documented on the Quality Assurance Monitor form. The form documented, 1/13/11 and 1/17/11 monitoring on the North, South and East hall with action taken.