Every finding on record at Dr Guy Gorman SR Care Home

Based on interview and record review the facility failed to implement required transfer and discharge procedures for two of two residents reviewed for discharge and one of two residents reviewed for transfers. Specifically, the facility failed to complete a discharge summary including a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of pre-discharge and post-discharge medications for Resident (R) 60 and R59; and failed to provide a written notice of transfer and bed hold policy to R7 or their representative or notify the ombudsman. Additionally, the Discharge Notice provided to R59 and R60 held inaccurate information about where to file an appeal and did not contain the required contents. This had the potential to compromise residents' appeal rights and the continuity of care during transfer and discharge. Cross Reference: F600 Free from Abuse Findings include: Resident 60: Review of R60's electronic medical record (EMR) under the Census tab revealed he was admitted to the facility on [DATE] and discharged on [DATE]. Review of R60's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] and located under the MDS tab of the EMR, revealed R60 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The MDS indicated R60 did not exhibit mood or behavioral symptoms. Review of R60's Nursing Progress Note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, Reception reported [R60] hit another resident . incident on camera per receptionist. Review of R60's Transfer/Discharge Notification, dated [DATE], signed by R60, and provided on paper by the Medical Records Technician (MRT), revealed, a planned date of discharge of [DATE] due to an incident that occurred on [DATE]. A corresponding note documented, This letter is to notify you of 30 days discharge notification . Our decision was based on the incident that had occurred on [DATE] which was serious and that [R60] was very much aware that physical behavior was not allowed or welcome in the facility . we are very concerned about the safety of other residents and especially those that cannot defend themselves . due to the safety of him and other residents the 30-day discharge planning needs to be initiated. Review of R60's Communication - with Resident note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, Entry from [DATE], met with resident and gave him the 30 day discharge notification regarding an incident that occurred [DATE] which resident was involved hitting another resident. Resident is mentally alert and is aware that physical behavior was not not [sic] permitted in the facility and that he aware [sic] and knows that any physical attack with injury to others will lead to discharge for the safety of the residents and staff. Resident quiet and did not say anything and just signed the discharge notice. [R60's family member] to made [sic] her aware of the discharge notice. Review of R60's Communication – With Family/NOK [next of kin]/POA [power of attorney] note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, Writer called [R60's family member] and informed her that resident is getting discharge Monday [DATE]. Per [family member] she received a call from case manager for her father and informed her that she found a facility for her father and that they want him there Monday and that she will make arrangements for transport for him for Monday. Review of R60's Information Note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, Case manager for resident E-Mail informing writer that resident will be picked up Sunday instead of Monday. Driver not able to pick up resident Monday [DATE] and that he will be here Sunday instead to pick up resident and inform resident of the change date. Review of R60's Nursing Progress Note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, 0905 [9:05 AM] approx. Transport driver arrival at DGGSCH to escort resident to [facility name withheld] . Review of R60's EMR under the Progress Notes tab revealed a Physician Orders note with an effective date of [DATE] and a note text date of [DATE] that documented, Transfer orders: Inability of current facility to manage patient's escalating behavior and due to physical altercation with another resident.Dx: Type 2 DM [diabetes], vascular dementia, depression, adjustment disorder, H/O CVA [history of stroke], hemiparesis (Lt [left] side), CAD [coronary artery disease], PAD [peripheral artery disease], LUTs [lower urinary tract symptoms].Allergies: Atorvastatin, IbuprofenVS [vital signs] & [and] Weight: routine [er [sic] facility protocolDiet: CCHO [controlled carbohydrate], Regular texture, regular consistencyActivity: As toleratedMedications: Resume all current medications ordersSee medication list. Discharge medications,Code Status: CPR/Full codeTransfer to accepting facility . Review of R60's [DATE] Discharge Summary note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, [AGE] years old resident discharged from the facility to [facility name withheld] . Sunday [DATE]. Reportedly the transport driver came at 09:05 AM and took resident to his new location . Resident discharged due to the incident which occurred [DATE] where resident hit another resident and cause [sic] injury to the resident. Case manager notified and she came over and met with resident and talk [sic] with resident. 30 days discharge notification was given to resident [DATE] [sic] and that his case manager found him a place where he was transfer to Sunday [DATE]. The discharge summary did not include a recapitulation of the resident's stay, a final summary of the resident's status, or reconciliation of pre-discharge and post-discharge medications. During an interview on [DATE] at 8:35 AM, Social Services (SS) 1 stated R60 was given a 30-day notice of intended discharge on [DATE] and was discharged from the facility to another nursing home on [DATE]. SS1 stated R60 was given 30-day notice due to hitting another resident and injuring the resident. SS1 stated even though R60 had not yet completed the 30-days of his notice, he was transferred to another facility as soon as the Case Manager found a location that would accept him because the bed was available. SS1 stated R60 did not request to discharge sooner than the 30-days but the Case Manager found a facility for him and the bed may not have been available if they waited any longer. SS1 stated she completed the Discharge Summary note in the EMR but did not complete any formal discharge summary or additional paperwork regarding the discharge or recapitulation of the resident's stay. SS1 stated the purpose of the 30-day notice was to allow time for a resident to appeal the decision if they desired. During an interview on [DATE] at 4:12 PM, the Director of Nursing (DON) stated upon a resident's discharge/transfer, the nursing staff sent the medication orders, diagnosis list, and other clinical information to the receiving facility and the physician wrote an order for discharge. There was no interdisciplinary team (IDT) discharge summary completed to include a recapitulation of the stay, summary of the resident's status, and medication reconciliation. The DON stated R60 was given 30-day notice of discharge due to hitting another resident and causing injury. She stated it was not an emergency situation where he had to be transferred out immediately, but it was a safety issue that had to be addressed quickly. The DON stated R60's Case Manager found placement for R60 within a few days of the notice being given, so he was discharged from the facility within only seven days rather than the required 30 days. The DON stated the resident ended up moving away from his family, culture, and community that he had always known to another nursing home that was not nearby. The DON stated the family did not have the full 30 days to get comfortable with the discharge or file an appeal if desired. The DON stated R60 did not exhibit any further behavioral symptoms after [DATE]. During an interview on [DATE] at 5:00 PM, the DON stated the facility did not have a policy outlining completion of a discharge summary. The DON confirmed R60 had no discharge summary. Resident 59: Review of R59's EMR under the Census tab revealed he was admitted to the facility on [DATE] and discharged on [DATE]. Review of R59's quarterly MDS, with an ARD of [DATE] and located under the MDS tab of the EMR, revealed R59 had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. The MDS indicated R59 exhibited physical and verbal behavioral symptoms one to three times a week. Review of R59's Nursing Progress Note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, 1400 [2:00 PM] approx. I heard a staff/CNA [Certified Nurse Aide] telling a resident [R59] not to do that again. [Another resident] reported to staff that [R60] hit [him] twice. Review of R59's Transfer/Discharge Notification, dated [DATE], signed by R59, and provided on paper by the MRT, revealed, a planned date of discharge of [DATE] due to Verbal/physical behavior which is an ongoing issue. A corresponding note documented, I am writing to inform you of our decision to discharge you . within the next 30 days . Our decisions were based off an ongoing behavior of physical and verbal behavior towards the other fellow male residents that can't defend for themselves. Review of R59's Communication - with Resident note, dated [DATE], revealed, Resident was informed of plan to discharge him due to an ongoing physical aggression towards those fellow residents who are not able to defend themselves. He was given 30 days discharge notice [DATE] but he refuses to accepted [sic] the letter that writer tried give to him saying that he is not going any place and that Chinle is his home community and that what everybody saying [sic] about his behavior are [sic] lies. Review of R59's Discharge Summary note, dated [DATE] and located under the Progress Notes tab of the EMR, revealed, Resident discharged from facility at [2:35 PM] with all belongings and medication. discharged r/t [related to] hitting another resident. Left via transport and accompanied by his son. Resident not happy about discharge and had some choice words with Social Services staff member. All discharge orders and paperwork faxed to receiving facility. Review of R59's EMR under the Progress Notes tab revealed a Physician Orders note with an effective date of [DATE] and a note text date of [DATE] that documented, Transfer Orders: Inability of current facility to manage patient's escalating behavioral issues. Dx: DM, BPH [enlarged prostate], major depressive disorder, degenerative disease of nervous system, hyperlipidemia, [vitamin] D deficiency, hypothyroidism, GERD (esophageal reflux], anemia, iron deficiency. Allergies: Ibuprofen, Naprosyn, corn, tomato VS & weight: routine per facility protocol. Diet: CCHO, Mechanical Soft Texture, Regular Consistency Activity: As tolerated Medications: Resume all current medication orders. Discharge with medications. Transfer to accepting facility. During an interview on [DATE] at 8:35 AM, SS1 stated R59 was given a 30-day notice of intended discharge due to hitting another resident and ongoing physical/verbal behaviors. SS1 stated she completed the Discharge Summary note in the EMR but did not complete any formal discharge summary or additional paperwork regarding the discharge or recapitulation of the resident's stay. During an interview on [DATE] at 4:12 PM, the DON stated upon a resident's discharge/transfer, the nursing staff sent the medication orders, diagnosis list, and other clinical information to the receiving facility and the physician wrote an order for discharge. The DON stated there was no interdisciplinary team (IDT) discharge summary completed including a recapitulation of the stay, summary of the resident's status, and medication reconciliation. During an interview on [DATE] at 5:00 PM, the DON stated the facility did not have a policy outlining completion of a discharge summary. The DON confirmed R59 had no discharge summary. Review of the facility's undated policy titled, Transfer/Discharge revealed, Before the discharge or transfer the facility must notify the resident and the family member or legal guardian of the transfer . The notice must be provided at least thirty (30) days prior to the transfer. The policy did not address the discharge summary. Resident 7: Review of R7's EMR under the Census tab revealed the facility admitted R7 on [DATE] and transferred to the hospital on [DATE] and [DATE]. Review of the Diagnosis tab revealed diagnoses included diabetes, dementia, hypothyroidism, and unspecified cardiovascular disease. Review of MDS tab of the eMR revealed the facility readmitted R7 on [DATE] and [DATE] from a short term hospital stay. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 4 out 15, indicating R7 was severely cognitively impaired, and was dependent on staff for activities of daily living and mobility. Requested to review copies of the transfer notices and bed hold policy provided to R7's or their responsible party for the [DATE] and [DATE] transfers. The facility provided two documents with a fax cover sheet titled Notice of Bed Hold Request. The forms documented a request by the facility's social worker (SW) sent to R7's insurance payor to hold the bed while R7 was in the hospital. The fax cover sheet indicated the forms were sent on [DATE] and [DATE] respectively. During an interview on [DATE] at 8:37 AM SW stated she did not complete transfer notices, provide a bed hold policy, or notify the ombudsman of transfers; the nurses on the floor completed those forms. Clarified with the DON on [DATE] at 8:41 AM the request was for the transfer/discharge notices, bed hold policy, and ombudsman notifications for R7's transfers. The DON stated she would review the chart and provide the requested information. During a follow-up interview with the DON on [DATE] at 2:23 PM, the DON was asked about the notices provided to R7 or their representative. The DON stated the nurses were supposed to use the Nursing Home Transfer or Discharge Notice form with the required contents of the notice and provide a copy to the resident and the ombudsman, as well as the bed hold policy. She was able to demonstrate another resident's medical record contained those forms. She stated after they provided the forms to the resident, she expected nursing to give a copy to the SW, who informs the insurance payor. She confirmed the notices were not provided to R7 or their representative for the [DATE] and [DATE] transfers. Contents of Notices: During the survey the DON concurrently reviewed a Nursing Home Transfer or Discharge Notice. The form included most of required contents. The section for Reason For Discharge or Transfer listed the acceptable specific regulatory reasons with a box to mark which reason applied and space to provide a brief explanation. A space to document the effective date of transfer or discharge. It did not include the specific location to which the resident was to be transferred or discharged . The form did explain the right to appeal, how to appeal, and the contact information to request an appeal through the Arizona Office of Administrative Hearings. Finally, the form included the name and contact information for the Ombudsman Program. The DON confirmed this was the form staff should use when transferring or discharging a resident. Review of the forms provided to R60 and R59 were not these forms. The Transfer/Discharge Notification for R60 documented the reason for discharge was Due to the incident that occurred on [DATE]. The effective date read [DATE]. The specific location section indicated their case manager was looking for another nursing home for R60. The Notice indicated the resident had the right to appeal, and inaccurately indicated could be filed with the US Department of Health & Human Services The Transfer/Discharge Notification for R59 documented the reason for discharge was Verbal/Physical behavior. The effective date read [DATE]. The specific location section indicated their case manager was looking for another nursing home for R59. The Notice indicated the resident had the right to appeal, and inaccurately indicated could be filed with the US Department of Health & Human Services

Based on interview and record review the facility failed to protect one of 19 sampled residents' right to be free from abuse when Resident (R) 60 hit R18. This caused R18 to have a bloody lip laceration which required sutures. Findings include: Review of facility reported incident 3025544 investigation report revealed that R60 and R18 had an altercation on 5/23/26 at approximately 04:00 PM in the hallway. R18 was propelling himself into Household 2 and lingered in the doorway when R60 encounters R18 in the doorway. R60 told R18 to get out of the way, and gestures with his hands. Registered Nurse (RN) 3 speaks to the residents and then walked away, leaving R60 and R18 still exchanging words. R18 then tossed a cup at R60 who reacted by grabbing R18's wheelchair and hit R18's face with his fist. R60 moved past R18. Certified Nursing Assistant (CNA) 6 approached R18 to see what happened and aided R18. The conclusion of the report read, [R60] clearly used physical violence towards another resident that resulted in a laceration to [R18's] right upper lip. Resident 18: Review of R18's admission Record revealed the facility admitted R18 on 8/19/25, diagnoses included type 2 diabetes, dementia, Parkinson's disease, and unsteadiness on feet. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. It coded that R18 displayed inattention and disorganized thinking continuously, hallucinations, and delusions. Observed R18 on 08/04/2026 at 1:49 PM, R18 was seated in a wheelchair in the living room area singing or quietly chanting. Other residents sitting near him watch R18 though do not intact with him. R18 did not engage in conversation when the surveyor introduced themselves. During an interview on 08/05/2026 at 1:44 PM, CNA6 described R18 as usually singing/chanting, and required a lot of redirection and supervision. While R18 was able to propel himself in the wheelchair, he tended to wander off in his own thoughts, he forgets. CNA6 confirmed R18 had been involved in Resident - Resident altercations in the past. In May CNA6 was taking care of R18 when he had an altercation with R60. CNA6 described, 'I saw [R18] and he was sitting there and holding his hand to his mouth. I saw the upper lip was bloody and I told the charge nurse. it happened in front of the camera. he was just in the way During an interview on 08/05/2026 at 3:39 PM Licensed Nurse (LN) 2 stated R18's dementia was getting worse, talking to people who are not there. The Activity Director (AD) stated during an interview on 08/06/2026 at 8:58 AM that they kept R18 away from some of the other male residents to prevent altercations during group activities. She was not sure what caused other residents to have a problem with R18, though did say R18 talks to himself more. Review of the care plan revealed a focus for a skin tear on R18's right upper lip as a result of physical altercation with another resident initiated on 5/23/26. Interventions included the sutures would remain intact and for nursing to observe until they dissolved. Resident 60: Review of Annual MDS assessment dated [DATE] revealed a BIMS score of 13, indicating R60's thinking and memory was cognitively intact. The admission Record revealed the facility admitted R60 on 4/17/24, diagnoses included type 2 diabetes, left sided weakness following a stroke, depression, adjustment disorder, and vascular dementia. Review of R60's care plan for ineffective impulse control initiated on 1/25/25. An intervention read, Monitor [R60] every 15 minutes for behavior related safety check. Assess needs and assist as needed. Review of facility investigation attachment documented their review of video footage of resident incident that took place on May 23, 2026, between R60 and R18 revealed R18 was signing in Navaho, sitting in his chair rocking back and forth slowly in the doorway to Household 2. Only one of two doors was open when R60 came into the video frame. R60 tells R18 to move out of the way so he can get through. R60 grabs R18's wheelchair handle to move him in rough manner. After moving R18's wheelchair the two continue to exchange words. RN3 steps into the video frame and says, hey hey hey guys, come on and then walks into a room. R18 tosses his cup of water at R60. R60 reacts balling up his first and striking R18 on the right side of his mouth. R18 moves his chair out of the way. As receptionist 2 approached the residents R60 walked through the doorway into the lobby. R18 is seen on the video wiping his mouth with a napkin which appeared to be bloody. During an interview on 08/07/26 at 8:35 AM Social Services stated R60 hit another resident. It was reported that R18 was sitting in doorway and R60 came and tried to get him to move, he got upset and hit R18. This prompted the facility to discharge R60. On 08/07/2026 at 2:09 PM during an interview the Director of Nursing (DON) concurrently reviewed the facility reported incident and facility investigation documents. The DON confirmed R18 sustained an injury of a bloody lip and was sent to the hospital for stiches when R60 hit him. The DON described she expected staff to separate residents if they have an altercation. R18's increasing confusion and auditory hallucinations increased his risk for abuse. Review of facility policy titled Abuse - Investigating and Reporting with revision date 4/18/24 read, Residents shall not be subject to abuse by any individual.

Based on interview, record review, and policy review, the facility failed to ensure allegations of resident-to-resident physical abuse were reported in accordance with facility policy and federal requirements to the Centers for Medicare and Medicaid Services (CMS) and law enforcement in accordance with section 1150B of the Act for reporting reasonable suspicion of a crime for one of three residents (Resident (R) 59) reviewed for abuse out of a total sample of 19 residents. On 02/16/26 and 02/18/26, staff documented allegations that R59 kicked another resident; however, the facility failed to report the incidents to CMS and law enforcement as required. This failure had the potential to delay investigation and implementation of protective measures, placing residents at risk for continued resident-to-resident physical abuse.Findings include: 1. a. Review of R59's electronic medical record (EMR) under the Census tab revealed he was admitted to the facility on [DATE] and discharged on 06/02/26. Review of R59's EMR under the Medical Diagnosis tab revealed R59 had diagnoses including depression, anxiety, and disappearance and death of a family member. Review of R59's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/26 and located under the MDS tab of the EMR, revealed R59 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. It was recorded that R59 exhibited physical and verbal behavioral symptoms one to three times a week. Review of R59's Care Plan, located under the Care Plan tab of the EMR and initiated on 08/24/23, revealed, [R59] has mood problems (verbal and physical aggression, refusal of care) r/t [related to] possible disease process: . hyperprolactinemia [a medical condition defined by high levels of the hormone prolactin in the blood] and . degenerative disease of nervous system [a condition that causes nerve cells in the brain or spinal cord to break down and die over time] . Review of R59's EMR under the Progress Notes tab revealed an eMAR - Administration Note, dated 02/16/26 and written by Registered Nurse (RN) 3, that documented, Notice [R59] kicked resident under table during the dinner. The resident who was kicked by R59 was not identified. Review of R59's EMR under the Progress Notes tab revealed an eMAR - Administration Note, dated 02/18/26 and written by RN2, that documented, Kitchen staff reported that [R59] was kicking his tablemate's legs. Apparently has been doing this for quite some time. [R55] was sitting sideways to be out of [R59's] kicking range, making in [sic] uncomfortable to eat. I approached [R55] and asked if he would like to be moved to be seated with [a different resident]. He agreed, so [R55] was moved that way. b. Review of R55's EMR under the Census tab revealed he was admitted to the facility on [DATE] and his diagnoses under the Medical diagnosis tab included hemiplegia and hemiparesis, aphasia, and malnutrition. Review of R55's quarterly MDS, with an ARD of 07/16/26 and located under the MDS tab of the EMR, revealed R55 had a BIMS score of five out of 15, which indicated the resident was severely cognitively impaired. It was recorded that R55 required partial to moderate assistance with mobility in a manual wheelchair. Review of R55's EMR under the Progress Notes tab revealed no documentation of an incident of being kicked by another resident on 02/18/26 or a skin assessment on that date to determine if there was any injury. Review of R55's EMR under the Assessments tab revealed a Skin Observation Tool, dated 02/19/26, that documented, Bruising to [bilateral] arms. The previous Skin Observation Tool, dated 02/05/26, did not document any bruising. During an observation on 08/05/26 at 8:29 AM in the Household 2 hallway, R55 was seated in a wheelchair and was not observed to move it independently. R55 was unable to be interviewed due to severely impaired cognition. During an interview on 08/06/26 at 5:01 PM, the Medical Records Technician (MRT) stated she was unable to find any incident reports or additional documentation regarding the above alleged resident-to-resident physical abuse incidents on 02/16/26 and 02/18/26. During a telephone interview on 08/07/26 at 9:28 AM, RN2 stated staff reported to her that R59 was kicking R55 in the dining room on 02/18/26, and she reported this to Social Services (SS) 1. RN2 could not recall whether this was a written report or verbal report. RN2 stated after the alleged resident-to-resident physical abuse incident on 02/18/26, R59 was moved to a different dining table. During an interview on 08/07/26 at 11:00 AM, SS1 stated she located a handwritten note dated 02/16/26 that outlined the alleged resident-to-resident physical abuse incident; however, there was no incident report submitted to CMS and no indication of reporting the allegation to law enforcement. SS1 stated the alleged incidents of resident-to-resident physical abuse were not reported because R59 told her he was just kicking a resident's wheelchair, not kicking a resident. SS1 stated she was unaware that the Progress Notes indicated R59 was kicking another resident on 02/16/26. SS1 stated she did not investigate further to determine whether a resident was actually kicked or whether his wheelchair was kicked. SS1 stated she was unaware that the Progress Notes indicated R59 was kicking R55 on 02/18/26. SS1 stated she did not have any documentation regarding alleged abuse on 02/18/26. During a telephone interview on 08/07/26 at 3:41 PM, the Medical Director stated he would expect any incident of resident-to-resident violence to be documented in the record and reported to the appropriate agencies. During an interview on 08/07/26 at 4:12 PM, the Director of Nursing (DON) stated when the alleged resident-to-resident physical abuse incidents occurred, an incident report should have been completed and each instance should have been reported to CMS within two hours and to law enforcement as well. The DON confirmed there were no incident reports for the alleged resident-to-resident physical abuse incidents on 02/16/26 and 02/18/26, and the incidents were not reported to CMS or to law enforcement. Review of the facility's policy titled, Abuse - Investigation and Reporting, dated 04/18/24, revealed, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse . are reported immediately to the Nursing administration, Chief Executive Officer (CEO), and CMS . The On-Duty Charge Nurse (CN) shall start and complete the Risk Incident (RI) report immediately and forward notification of incident to the Resident Family/Power of Attorney (POA), Social Services Coordinator (SSC), Nursing Administration, CEO, and CMS. If reportable bodily injury: CN shall report the RI to the Resident Family/POA, SSC, NursingAdministration, CEO, NN [Navajo Nation] Case manager, Arizona (AZ) Ombudsman, CMS, APS [Adult Protective Services], and/or law enforcement within 2 hrs [hours]. If NO Bodily injury: CN shall report the RI to the Resident Family/POA, SSC, Nursing Administration, CEO, NN Case manager, AZ Ombudsman, CMS, APS and/or law enforcement within 24 hrs.

Based on record review, interview, and policy review, the facility failed to thoroughly investigate allegations of resident-to-resident physical abuse for one of three residents (Resident (R) 59) reviewed for abuse out of a total sample of 19. Staff documented allegations on 02/16/26 and 02/18/26 that R59 kicked another resident; however, the facility failed to thoroughly investigate the allegations of abuse to determine whether physical abuse occurred. Specifically, the facility failed to complete an incident report, interview involved residents or potential witnesses, document investigative findings, or reach and document a conclusion regarding the allegations. This failure prevented the facility from determining whether abuse occurred and whether additional measures were necessary to protect residents from further resident-to-resident physical abuse.Findings include: 1. a. Review of R59's electronic medical record (EMR) under the Census tab revealed he was admitted to the facility on [DATE] and discharged on 06/02/26. Review of R59's EMR under the Medical Diagnosis tab revealed R59 had diagnoses including depression and anxiety. Review of R59's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/28/26 and located under the MDS tab of the EMR, revealed R59 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderately impaired cognition. The MDS indicated R59 exhibited physical and verbal behavioral symptoms one to three times a week. Review of R59's Care Plan, located under the Care Plan tab of the EMR and initiated on 08/24/23, revealed, [R59] has mood problems (verbal and physical aggression, refusal of care) r/t [related to] possible disease process: . hyperprolactinemia [a medical condition defined by high levels of the hormone prolactin in the blood] and . degenerative disease of nervous system [a condition that causes nerve cells in the brain or spinal cord to break down and die over time]. Review of R59's EMR under the Progress Notes tab of the EMR revealed an eMAR - Administration Note, dated 02/16/26 and written by Registered Nurse (RN) 3, that documented, Notice [R59] kicked resident under table during the dinner. The resident who was kicked by R59 was not identified. The documentation reflected an allegation of resident-to-resident physical contact that warranted investigation to determine whether abuse occurred. b. Review of R59's EMR under the Progress Notes tab of the EMR revealed an eMAR - Administration Note, dated 02/18/26 and written by RN2, that documented, Kitchen staff reported that [R59] was kicking his tablemate's legs. Apparently has been doing this for quite some time. [R55] was sitting sideways to be out of [R59's] kicking range, making in [sic] uncomfortable to eat. I approached [R55] and asked if he would like to be moved to be seated with [a different resident]. He agreed, so [R55] was moved that way. This documentation reflected an allegation that R59 made physical contact with another resident by kicking the resident's legs. Review of R55's EMR under the Census tab of the EMR revealed he was admitted to the facility on [DATE] and his diagnoses under the Medical diagnosis tab included hemiplegia and hemiparesis, aphasia, and malnutrition. Review of R55's quarterly MDS, with an ARD of 07/16/26 and located under the MDS tab of the EMR, revealed R55 had a BIMS score of five out of 15, which indicated severely impaired cognition. The MDS indicated R55 required partial to moderate assistance with mobility in a manual wheelchair. Review of R55's EMR under the Progress Notes tab of the EMR revealed no documentation of the incident on 02/18/26 or whether a skin assessment was completed on that date to determine if there was any injury. During an observation on 08/05/26 at 8:29 AM in the Household 2 hallway, R55 was seated in a wheelchair and was not observed to move it independently. R55 was unable to be interviewed due to severely impaired cognition. During an interview on 08/06/26 at 5:01 PM, the Medical Records Technician (MRT) stated she was unable to find any incident reports or additional documentation of investigation or analysis of the allegations of abuse on 02/16/26 and 02/18/26. The MRT acknowledged that the allegations were not thoroughly investigated; there was an absence of witness interviews with R55, dining staff, or other residents; and there was a lack of investigative findings or conclusions. During a telephone interview on 08/07/26 at 9:28 AM, RN2 stated staff reported to her that R59 was kicking R55 in the dining room on 02/18/26, and she reported this to Social Services (SS) 1. RN2 stated she did not investigate whether contact was made with R55, as SS1 would be the one to do the investigation. RN2 stated R59 was moved to a different dining table after the incident. During an interview on 08/07/26 at 11:00 AM, SS1 confirmed she was responsible for conducting investigations of abuse allegations. SS1 stated she would interview residents and staff, and the results would be forwarded to the Director of Nursing (DON). SS1 was asked if an investigation had been conducted for the abuse allegations on 02/16/26 and 02/18/26. SS1 stated she located a handwritten note dated 02/16/26 that outlined the incident; however, she had not documented in the resident's medical record, and there was no incident report completed. The note documented, It was reported to me that resident kicking resident's [wheelchair] and footrests. I went to his room and talk [sic] with resident about his behaviors and advised him that he should not be kicking resident's [wheelchair] or footrest but resident is in denial about that saying staff is just making up things for him because they don't like him. SS1 stated she did not investigate the allegation beyond speaking with R59 because he denied kicking another resident and stated he was only kicking a wheelchair or footrest. SS1 stated she was unaware the Progress Notes indicated R59 was actually kicking another resident. SS1 stated she did not investigate further to determine whether a resident was actually kicked. SS1 stated she did not have any documentation regarding the alleged abuse on 02/18/26. SS1 stated she did not interview potential witnesses in the dining room, including staff or other residents, or conduct any investigation into the incidents on 02/16/26 and 02/18/26. SS1 acknowledged that the allegations were not thoroughly investigated; there was an absence of witness interviews with R55, dining staff, or other residents; and there was a lack of investigative findings or conclusions. During a telephone interview on 08/07/26 at 3:41 PM, the Medical Director stated he would expect any incident of resident-to-resident violence to be investigated and documented in an incident report. During an interview on 08/07/26 at 4:12 PM, the Director of Nursing (DON) stated when the alleged resident-to-resident physical abuse incidents occurred, an incident report should have been completed and each instance investigated to determine if abuse occurred. The DON stated there were no incident reports for the alleged resident-to-resident abuse on 02/16/26 and 02/18/26 and the allegations of abuse were not thoroughly investigated or analyzed to determine whether abuse occurred. The DON acknowledged that the allegations were not thoroughly investigated; there was an absence of witness interviews with R55, dining staff, or other residents; and there was a lack of investigative findings or conclusions. Review of the facility's policy titled, Abuse - Investigation and Reporting, dated 04/18/24, revealed, The facility will investigate different types of incidents and identify the staff member responsible for the initial reporting, investigation of alleged violations, e.g., mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident policy [sic] . The alleged violations will be thoroughly investigated, and results of all investigationswill be reported within five (5) working days of the initial incident by the QAPI [Quality Assurance and Performance Improvement] Manager to CMS.

Based on record review, interview, and policy review, the facility failed to provide the necessary behavioral health services and interventions for one of two residents (Resident (R) 60) reviewed for mental and psychosocial concerns by failing to evaluate, care plan, monitor, and address newly identified behavioral symptoms and suspected contributing psychosocial factors, despite staff recognition of changes in the resident's behavior and condition. This failure had the potential to cause R60 to experience worsening behavioral symptoms, unidentified underlying causes of the behavioral changes, increased social isolation, diminished psychosocial well-being, and adverse health and safety outcomes associated with untreated changes in mental and behavioral status.Findings include: 1. Review of R60's electronic medical record (EMR) under the Census tab revealed he was admitted to the facility on [DATE] and discharged on 06/07/26. Review of R60's EMR under the Medical Diagnosis tab revealed R60 had diagnoses including vascular dementia, diabetes, adjustment disorder, depression, stroke, hemiplegia/hemiparesis, and problems in relationship with spouse or partner. Review of R60's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/26 and located under the MDS tab of the EMR, revealed a score of 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The MDS indicated R60 did not exhibit mood or behavioral symptoms. Review of R60's Care Plan initiated 11/07/23 and updated on 06/03/26 and located under the Care Plan tab of the EMR revealed, [R60] has ineffective impulse control AEB [as evidenced by] more easily upset, argumentative, and occasionally confronted with other resident. The approaches included: [R60] continues follow up with counselling services for individual psychotherapy session . [R60] must always receive professional assistance from staff using a two-person approach. Always inform [R60] about the care being provided and the assistance being offered. Communicate the type of support you expect from him during care, and make sure to introduce yourself and knock on the door before entering his room . Encourage [R60] to engage in brain exercise to help improve cognitive health by stimulating different parts of the brain. Provide an easy word search booklet if desired . Monitor [R60] every 15 minutes for behavior related safety check. Assess needs and assist as needed . Monitor [R60's] behavior every shift. Document observed behavior and attempted interventions, report as necessary . [and] Provide and encourage participation with activities daily, [R60] does attends [sic] and participates in activities of his choice. Review of R60's Behavior Note dated 02/25/26 and located under the Progress Notes tab of the EMR revealed, (Half-filled bottle of Gatorade w/odd smell observed on residents' dresser)- Writer rec'd. [received] report that [R60] has been acting differently very drowsy during the day, wearing a mask, avoiding the CNAs [Certified Nurse Aides], and utilizing his call-light less (to avoid staff interaction?). CNAs report he has been more drowsy with some difficulties to arouse, acting strange x 1 week now. As CNA was looking around in his room, she noticed a Gatorade bottle (opened) on his dresser and as she opened and smelled the drink, it had a very strange odor (not alcoholic but chemical smell). The CNA brought it to this Writer and it was observed, then forwarded to the DON [Director of Nursing]/ [Social Services (SS) 1]. Resident has been displaying some different behaviors as observed by several staff, including this Writer. When asked about he [sic] drink, he denied it was his, stating 'That's been there over a week, on my dresser, I don't know who put it there.' When asked why he didn't just put it in the trash, he stated, 'I told the housekeeping staff to trash it, but I guess they didn't do it all week.' When asked why he's been more drowsy lately that the staff have to physically shake him, Resident stated Well, I am not sleeping good at nights because of my bed, I told the Maintenance about the hard mattress, but they haven't done nothing about it. When asked why he is wearing a mask now (no prior mask use) and avoiding the staff, he just grinned and shrugged his shoulder. Resident has been refusing toileting more these several days when asked by the CNAs. Resident continued to deny that he smells anything strange in the Gatorade bottle, 'I don't smell anything' and that it was his bottle of Gatorade, 'It's not mine. I don't know who put it there last week.' Writer just advised resident, If there is anything strange or something that does not belong to you in here, notify the Staff, because nobody else should be here in your room, you have no roommate assigned. Resident then stated 'Ok, I'll do that.' Review of R60's Behavior Note dated 03/03/26 revealed, (2) similar episodes w/CNA reporting new findings - CNA when cleaning residents bedside reported that she found an empty bottle of mouth wash (containing Alcohol) and another bottle - still full (non-alcohol). Writer notified [SS1] that she may need to notify family and advise them to purchase non-alcohol mouthwash. ***FYI: (2) Two Incidents of finding drinks in his room w/ Pungent odor on 02/25/26 in Gatorade & 03/01/26 in OJ [orange juice]. Review of R60's Communication - with Family/NOK [Next of Kin]/POA [Power of Attorney] note dated 3/10/26 and located under the Progress Notes tab of the EMR revealed, A meeting was held with the resident's case manager . and 2 daughters . This writer (DON) and [SS1] were in attendance. The resident was not able to attend d/t receiving resident care during the meeting and the resident also had an appt [appointment] . during this time.Background: The residents [sic] odd behaviors during the times in which the Gatorade and OJ had pungent smells found by staff. Each time a report was written by staff, [SS1] and a nurse intervened and talked with the resident. The resident denied the drinks being his each time and accused a staff member of placing it in his room.At the time of the findings, staff were not able to comfort [sic] that alcohol was the content in which the drinks were mixed with but mouthwash containing alcohol was found by staff on one occasion [sic]. The resident was repeatedly reminded that alcohol or illicit items are not permitted within the facility and that it could result in being discharged from the facility or causing harm . daughter: Apologized for the mouthwash and stated that she had bought it for her father but didn't [sic] think he would use it for another purpose such as drinking. She stated she was in a rush and will only buy mouthwash that doesnt [sic] contain alcohol. [Daughter] states she will talk to her father, as the facility takes good care of him and he has no other place to go and she will talk to him about this and any behaviors. She also suggested that maybe he is lonely too and acting out d/t [due to] her family relocating to Colorado.Recommendations from DON:1. Continue to monitor his behaviors and for further incidents.2. If another incident should occur in which alcohol or illicit items are suspected, law enforcement will be contacted and upon findings, discharge may be imminent.3. SSC will continue to remind staff of the consequences of such behavior and intervene accordingly.4. Suggest family call their father more often if loneliness is a factor in this matter. Try to visit more often.5. SSC also suggested placement in a NH closer to family if the resident wishes and feels lonely.Recommendations by case manager:1. NH placement in CO will take several steps and requirements but is an option if resident wishes.2. For Mental Health Counseling appts- suggest having staff discuss topics such as alcohol abuse and loneliness.3. Referral to psychiatrist.Resident not in attendance due to an appt but family stated they would see the resident once he returns and talk to him about the meeting and the suspicion of mixing his drinks with an unknown substance.Staff will continue to complete incidents reports if and when an incident occurs and documentation will be kept. [SS1] CM, and family to be notified of such incidents when or if they should occur again. This writer will have SSC follow up with resident today 3/10/26. Review of R60's Infection Note dated 03/13/26 and located under the Progress Notes tab of the EMR revealed, Late Entry from dated 3/9/2026. Meeting was requested with resident and his family due to a concerns [sic] that care takers has [sic] noticed and were concern [sic] that resident lately has not been himself. Certain CNAs reported that resident lately had that he has been sleepy, not eating like he use [sic] to, and had been wearing mash [sic] which he never use [sic] to. Writer and nurse on duty went to see resident in his room and talk with resident about this report and kept saying I don't sleep good at night because of the mattress on my bed, it's too hard and very uncomfortable and that he reported to maintenance about it and he never came around to change the mattress. That bottle of drink on his dresser drawer was not his saying maybe the housekeeper staff put it there. Review of R60's EMR revealed the above recommendations were not incorporated into the Care Plan, there was no behavioral monitoring for similar occurrences, and the counseling notes did not address the incidents or alcohol abuse issues. During an interview on 08/07/26 at 8:35 AM, SS1 stated she was only aware of one occurrence where a housekeeper found a beverage with a smell of alcohol in R60's room and no one had reported to her it had happened more than once. SS1 stated R60 also began acting differently around that time, including being very lethargic and drowsy, slurring his speech, and using a mask when he did not use one before. SS1 stated R60 had denied the beverage was his and no further investigation was conducted. SS1 stated she did not add this behavior to the Care Plan, she only spoke to him and told him he should not be drinking alcohol. During a telephone interview on 08/07/26 at 11:33 AM, the psychiatrist stated she was aware of one instance of potential alcohol ingestion/intoxication that was reported to her; however, she was not aware this was alleged more than once. The psychiatrist stated she was not sure what the final determination was whether he had consumed alcohol or not and R60 denied consuming alcohol and stated the drink was not his. The psychiatrist stated she thought the facility was going to have a meeting with the family; however, she was unsure if this happened or what the outcome was. The psychiatrist stated there were no behavioral strategies implemented at the time of the alleged incident in February 2026. During an interview on 08/07/26 at 4:12 PM, the DON stated she was aware of the allegations of alcohol consumption and intoxication by R60 but stated there were no new behavioral interventions or monitoring put in place to address the behaviors. The DON stated the facility staff received training on behavior management through an online program; however, there were no additional resources available to provide the facility with specific intervention techniques for residents who exhibited behaviors. The DON stated the facility's psychiatrist did provide input during care planning at times and counseling services were provided to residents as needed. The DON stated the facility had limited resources to deal with behaviors and stated we do the best we can. We let our staff know basic techniques . it's the bare minimum but we do our best. The DON stated it would be nice to have more resources such as agencies that specialize in behavioral problems. Review of the facility's policy titled, Behavioral Assessment, Intervention, and Monitoring dated February 2026 revealed, The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition . The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately il necessary to protect the resident and others from harm . Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum:a. a description of the behavioral symptoms.

Based on observation, record review, and interviews, the facility failed to ensure that residents were evaluated for the need and safety for the use of bed rails prior to the installation/use of rails, failed to document alternatives to bed rails were attempted prior to the use of bed rails, failed to document reasons for failure of alternatives, and failed to advise residents and/or Resident Representatives (RR) of the risks and/or benefits of rail use with informed consent signed prior to the installation of bed rails for three of three residents (Resident (R) 14, R33, and R57) reviewed for bed rail use of 50 census residents. In addition, the facility had failed to evaluate the need and safety of bed rail use for all residents in the facility. This failure had the potential for all residents, or the RRs to be uninformed of the risks associated with bed rail use and could put the residents at risk for injury or entrapment due to all residents having bed rails.Findings include: 1. During an observation and interview on 07/21/25 at 11:27 AM, R14 was noted to have bilateral bed rails on his bed. R14 stated he used them, but Nobody talked to me about the risks. The physical therapist [name] talked to me about how to use it and how not to use it. Further discussion revealed R14 had not been advised of the potential risks for injury or entrapment. R14 also had a trapeze and floor to ceiling transfer pole. Review of R14's admission Record printed from the electronic medical record (EMR) Profile tab showed a facility admission date of 04/17/24 with medical diagnoses that included type II diabetes, dementia, cerebral infarction with subsequent hemiparesis and hemiplegia. Review of R14's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/25 showed a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15, indicative of being cognitively intact. Review of R14's EMR Assessment tab showed no evaluations for bed rail use. Review of R14's EMR Miscellaneous tab showed no assessments, evaluations, or informed consents for bed rails. Review of R14's care plan from the EMR Care Plan tab did not reveal a bed mobility plan that included bed rails. 2. During an observation and interview on 07/22/25 at 9:55 AM, R33 was noted to have bilateral bed rails on his bed. R33 stated he used them. When asked if anyone had explained any risks (with examples), R33 stated, No. Review of R33's admission Record printed from the EMR Profile tab showed a facility admission date of 11/05/24 with medical diagnoses that included chronic obstructive pulmonary disease (COPD), visual loss, osteoarthritis, gastroesophageal reflux disease (GERD), and hypertensive heart disease. Review of R33's quarterly MDS with an ARD of 05/21/25 revealed a BIMS score of 14 out of a possible 15, indicative of being cognitively intact. Review of R33's EMR Assessment and Miscellaneous tabs revealed no assessments, evaluations, or informed consents for bed rails. Review of R33's care plan from the EMR Care Plan tab did not reveal a bed mobility plan that included bed rails. 3. During the first portion of the survey, R57's bed was observed to have bilateral bed rails. R57 was observed sleeping in bed with bilateral bed rails on 07/22/25 at 9:43 AM and 07/23/25 at 9:15 AM. Review of R57's admission MDS with an ARD of 04/23/25 showed a BIMS score of 11 out of a possible 15, indicative of moderate cognitive impairment. Review of R57's EMR Assessment and Miscellaneous tabs revealed no assessments, evaluations, or informed consents for bed rails. Review of R57's care plan from the EMR Care Plan tab did not reveal a bed mobility plan that included bed rails. During an interview on 07/23/25 at 11:52 AM regarding evaluations for bed rails, the Interim Director of Nursing (IDON) stated We don't have side rails. When explained they had assist bars and upper quarter rails which were considered side rails. The IDON responded The only place it will be indicated is in the care plan. At 3:00 PM, when requesting a policy for bed rails, the IDON stated We don't have it and confirmed all residents had hand bars. Upon request, IDON provided a list of residents with bed rails, all but one current resident was listed as having a right and left rail. Observation of that one bed on 07/21/25 at 9:40 AM, revealed the bed was noted to have bilateral bed rails with an air mattress. During a follow up observation on 07/25/25 at 2:29 PM, Licensed Practical Nurse (LPN) 6 confirmed that that bed did have bilateral bed rails.Observation of Household 1 on 7/24/25 at about 4 PM showed bedrails on all resident beds. During an interview on 07/25/25 at 10:35 AM, the Maintenance Director stated he did not remove bed rails between residents and that Every bed has some type of hand rail. During an interview on 07/25/25 at 2:39 PM regarding bed rail evaluations and informed consent, the Director of Nursing (DON) stated she had identified the issue and was working on a risk/benefit and consent form. The DON stated, All residents need to be updated with consent forms yearly or when there are changes. The families and residents need to be educated regarding the risk/benefits and alternatives, we need to get orders [physician], get consents, and then use should be care planned.

Based on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information.Findings includeReview of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2, 2025 ([DATE] to March 30) indicated the facility failed to submit required data for the quarter.During Entrance Conference on 7/21/25 at about 8:37 AM Administrator was informed that PBJ Report for Q2 2025 was not submitted. Administrator stated that a new Chief Operations Officer (COO) started in May and is responsible for submitting PBJ reports.During an interview on 7/22/25 at 10:33 AM Interim Director of Nursing (IDON) stated that Payroll specialist used to complete PBJ submissions and she left about four months ago with new COO starting on 5/5/25. IDONs stated that no one trained new COO regarding submitting PBJ reports.Review of Centers for Medicare and Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual version 2.6, dated June 2022, documented Section 6106 of the Affordable Care Act requires facilities to electronically submit direct care staffing information based on payroll and other auditable data .(p) Mandatory submission of staffing information based on payroll data in a uniform format .(5) submission schedule. The facility must submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.

Based on interview and record review, the facility failed to ensure 4 of 5 currently employed sampled Certified Nursing Assistant (CNA)(3, 21, 26, and 6) reviewed for training completed the required 12 hours of annual in-service education based on their hire dates. The facility also failed to ensure CNA26 and CNA6 received annual abuse, dementia, and infection control training. This placed residents at risk for receiving care from unskilled staff and increased risk for abuse, neglect and diminished quality of care.Findings includeReview of facility all staff list documented CNA3 was hired in March 2014.Review of facility training records for CNA3 documented 7.82 hours of annual training was completed; less than the required 12 hours.Review of facility all staff list documented CNA21 was hired in May 2017.Review of facility training records for CNA3 documented 8.57 hours of annual training was completed; less than the required 12 hours.Review of facility all staff list documented CNA26 was hired in April 2022.Review of facility training records for CNA3 documented 0.17 hours of annual training was completed; less than the required 12 hours and did not include abuse, dementia care, and infection control training.Review of facility all staff list documented CNA6 was hired in January 2008. Review of facility training records for CNA3 documented 0 hours of annual training was completed; less than the required 12 hours and did not include abuse, dementia care, and infection control training. The last training module completed was on 5/11/23.During a phone interview on 7/25/25 at 11:42 AM Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse (IADON/QA QI ICN) (who was on leave and available via text or phone) stated that she oversaw the facility's staff training which was conducted and tracked through Relias system. During a concurrent record review and interview on 7/25/25 at 1:18 PM CNA26 stated that Relias is how staff completes training topics. CNA26 reviewed her Relias training record which showed 0.17 hours completed and confirmed the training record was accurate and did not include completing training on abuse, dementia or infection control. CNA26 stated that she is unable to complete Relias computer-based training at home because she does not have good internet service at home so she has to complete training while at work, often there is no time to complete these trainings at work so she focuses on doing the trainings that don't take a lot of time. CNA26 stated that otherwise, she would have to come to the facility on her days off, she does not live close by, it would waste gas, and it would be unpaid time.During an interview on 7/25/25 at about 2:10 PM IDON stated that the expectation was for CNAs to complete the required 12 hours of training annually and this has been an ongoing challenge to achieve. IDON stated that she is aware some staff do not have good internet service at home and staff can come into the facility on their days off, and complete four hours of training and the facility will pay them. IDON stated that staff will be reminded of this at the next staff meeting.Review of Facility Assessment, reviewed 3/26/25, documented Staff education and trainings are provided by the RELIAS online training program. Annual training modules are assigned based on Centers for Medicare and Medicaid Services (CMS) requirements for inservice trainings. The topics for CNAs included annual abuse, infection, and dementia care.

Based on interview and record review, the facility failed to notify a Resident's Representative Party (RP) when the resident experienced a change in condition for two of seven residents (Resident (R) 3 and R4) reviewed for changes out of a total sample of 18 residents. The failure to notify an RP for family member of a change in condition and/or transfer could lead to an inability to support their family member during a time of illness. This failure had the potential to affect any of the fifty-current residents that might have a change in condition and/or a transfer to another facility for evaluation.Findings include:R3 1.During an interview on 07/21/25 at 12:44 PM, RP3 stated, About six months ago I was at the hospital and looked over and he [R3] was over in the ER [emergency room]. I asked staff what was wrong with him, he wasn't feeling well for a few days, so they decided to bring him in here [ER]. I was not called. I called [name] at the facility, she said it was constipation. He was there until after 9:00 PM, they gave him IV [intravenous] fluids and an antibiotic … I get called for injuries and infections, but if [R3] visits the emergency room they don't call me about that. Review of R3's electronic medical record (EMR) Progress Notes tab revealed: Effective Date: 12/06/2024 09:03 Type: Nursing Progress Note Text: (QUIET/LESS ACTIVE/EYES CLOSED)- Resident this morning with continued change in condition. Less active then [sic] usual, not attempting AROM [active range of motion], more quieter, not very vocal, eyes remain closed, not looking around. CNA [Certified Nurse Aide] on Night Shift reports No urine output all night. PO [oral] intake of food and fluids has been good. Reported Lg. [large] BM [bowel movement] x 1. Resident to be sent to [hospital identified] [NAME] [ER Department] for further evaluation d/t [due to] change in disposition. Transfer Sheet and Bed Hold Policy provided to resident prior to transfer. … Effective Date: 12/06/2024 14:37 Type: COMMUNICATION - with Family… Note Text: Family member [RP3 identified] had called this afternoon d/t notice [R3] at the Hospital, Writer updated her on his change in disposition, but eating/drinking well and VSS [Vital signs stable]. Sent to clinic for evaluation. Advised [RP3] that we will notify her following MD [Medical Doctor] evaluation. During an interview on 07/24/25 at 4:23 PM, the Interim Director of Nursing (IDON) read the notes and stated the Charge Nurse was responsible for calling the RP. The IDON stated the facility did not have a policy regarding notification of change. The IDON confirmed it was not done. R4 Review of R4's record documented the facility admitted the resident on 2/7/23 with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), diabetes, and dementia. R4's Minimum Data Set (MDS-assessment tool), dated 4/20/25, documented R4's brief interview for mental status was 2. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 0 to 7 is an indication of severe cognitive impairment), and was dependent on staff for eating, toileting, dressing, personal hygiene, mobility and transfers and did not walk and used a wheelchair. Review of R4’s current care plan, printed on 7/21/25, documented a self-care deficit related to limited mobility, weakness and frailty, vision deficient, and wheelchair use with resident required total assistance from staff for personal hygiene and used a mechanical lifter by 2 persons during transfer. Review of R4’s Profile in electronic health record documented her FM1 was substitute decision, emergency contact #1 and financial representative and FM1’s mobile phone was shown. No other family members were shown. Review of R4’s progress notes documented: *7/3/25. FOOT 3 OR MORE VIEWS. Exam Date: JUN 27, 2025@13:37. Reason for study: Right plantar swelling/injury? COMPARISON: No prior studies available. Impression: Posterior calcaneal (heel) minimally displaced fracture.*7/5/25 by Registered Nurse (RN)2. P1 referred resident to Podiatry. 92F(emale) Nursing Home resident w localized right foot plantar tenderness/swelling-x-ray shows posterior calcaneal minimally displaced fracture. Patient presents to podiatry clinic for follow up diabetic foot check and toenail debridement. Patient has also been referred for complaint of tenderness and pain to RIGHT heel 2/2 minimally displaced calcaneal fracture… Recommended cushining (sic) padding to right heel with foam/sponge heel off loading pressure relief ankle and foot orthosis, foot care orders for [nursing home] staff, examine feet QAM and QPM (every morning and every evening), make sure there are not external pressures to patient's feet that may lead to pressure ulcerations, Between podiatry visits, trim patient's toenails, ted hose to bilateral lower legs if patient has no h/o CHF (history of congestive heart failure), patient should have heel protectors to feet at all times.*7/6/25 by Licensed Practical Nurse (LPN)7 “Writer email CMS regarding Closed Fracture to right foot and tried contacting [FM1 at phone number shown on resident profile] (phone not working).” During interview on 7/21/25 at 2:11 PM called FM1 at phone number shown on resident profile, FM1 stated that they were not informed of resident’s foot fracture. FM1 stated that no one at the facility called about it and it was not mentioned during visit to the facility last Friday. During an interview on 7/22/25 at 2:37 PM LPN7 stated that she returned from vacation and came across notes about resident right heel fracture and called it in on 7/6/25 because she saw that no one had called it in yet. LPN7 stated that R4 is total care and not sure how resident fractured her foot. LPN7 stated, “I called FM1 but there was no phone service, it’s the only number we have and we couldn’t leave a message.” During an interview on 7/24/25 at 1:07 PM with the Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that when staff should notify resident representatives of changes in resident conditions such as fracture foot. If staff is unable to reach the family or representative, staff should hand it off to the next shift. During an interview on 7/24/25 at 2:34 PM LPN7 stated that she did not tell the next shift to call FM1 because FM1’s phone was not working. Review of email communications with IDON, dated 7/24/25 at 3:09 PM, documented facility policy for notification for change in condition is made by the charge nurse on duty, which is charted in progress notes. Facility did not have a policy for Notification of Change in Condition.

Based on interview and record review, the facility failed to report allegations of abuse to the Centers for Medicare and Medicaid Services within the required time frame for 1 of 2 sampled residents (R)(4) reviewed for abuse. This failure placed residents at risk for abuse.Findings includeFacility policy, Abuse-Investigation and Reporting, revised date 4/18/24, documented .facility practices (b) to prohibit abuse, neglect.3. Residents shall not be subject to abuse by any individual.4. Identification: The facility will identify events such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse.7. Reporting/Response: Charge Nurse shall report incident immediately to Physician, family, and nursing administration. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the Nursing administration, Chief Executive Officer (CEO), and CMS. The protocol for alleged instances of abuse included: The On-duty Charge Nurse (CN) shall start and complete the Risk Incident (RI) report immediately and forward notification of incident to the Resident Family/Power of Attorney (POA), Social Services Coordinator (SSC), Nursing Administration, CEO and CMS. If reportable bodily injury, CN shall report the RI to the Resident Family/POA, SSC, Nursing Administration, CEO, NN [Navajo Nation] Case Manager, Arizona (AZ) Ombudsman, CMS, APS [Adult Protective Services] and/or law enforcement within 2 hrs [hours]. If NO Bodily injury: CN shall report the RI to the Resident Family/POA, SSC, Nursing Administration, CEO, NN Case Manager, AZ Ombudsman, CMS, APS and/or law enforcement within 24 hrs.Review of R4's record indicated the facility admitted the resident on 2/7/23 with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), diabetes, and dementia. R4's Minimum Data Set (MDS-assessment tool), dated 4/20/25, documented R4's brief interview for mental status was 2. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 0 to 7 is an indication of severe cognitive impairment), and was dependent on staff for eating, toileting, dressing, personal hygiene, mobility and transfers and did not walk and used a wheelchair. Review of R4's current care plan, printed on 7/21/25, documented a self-care deficit related to limited mobility, weakness and frailty, vision deficient, and wheelchair use with resident required total assistance from staff for personal hygiene and used a mechanical lifter by 2 persons during transfer.Review of R4's progress notes documented: *6/24/25 by Nursing: Resident started crying beginning of shift stopping intermittently for about one to two hours then, repeating episodes, through the night. Offered Tylenol 650 mg 2045 and 0400 however repeatedly, resident spitting out offer.*6/26/25 by Provider(P)1: Comfortably sleeping. Nursing staff: light bruising to rt (right) plantar (sole or bottom) foot and has left 5th toenail avulsion (tear). Assessment/Plan:Rt foot swelling lat(eral) (outside) plantar aspect-possibly injured during hoyer lift transfer?Pt does not ambulate or get up. Rt foot xray order placed 6/24/2025. *7/3/25. FOOT 3 OR MORE VIEWS. Exam Date: JUN 27, 2025@13:37. Reason for study: Right plantar swelling/injury? COMPARISON: No prior studies available. Impression: Posterior calcaneal (heel) minimally displaced fracture.*7/5/25 by Registered Nurse (RN)2. P1 referred resident to Podiatry. 92F(emale) Nursing Home resident w localized right foot plantar tenderness/swelling-x-ray shows posterior calcaneal minimally displaced fracture. Patient presents to podiatry clinic for follow up diabetic foot check and toenail debridement. Patient has also been referred for complaint of tenderness and pain to RIGHT heel 2/2 minimally displaced calcaneal fracture.decreased osseous mineralization. Fracture deformity about the posterior calcaneous of unknown chronicity. Mild polyarticular arthritic changes. Arteriosclerotic vasculary disease. No significant soft tissue swelling. Further explained that given patient's age and health profile, and since patient does not ambulate, the fracture is not indicated for surgical intervention. Recommended cushining (sic) padding to right heel with foam/sponge heel off loading pressure relief ankle and foot orthosis, foot care orders for [nursing home] staff, examine feet QAM and QPM (every morning and every evening), make sure there are not external pressures to patient's feet that may lead to pressure ulcerations, Between podiatry visits, trim patient's toenails, ted hose to bilateral lower legs if patient has no h/o CHF (history of congestive heart failure), patient should have heel protectors to feet at all times.*7/6/25 by Licensed Practical Nurse (LPN)7 Writer email CMS regarding Closed Fracture to right foot and tried contacting [family member, phone number] (phone not working).During an interview on 7/21/25 at 12:51 PM Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse (IADON/QA QI ICN) (who was on leave and available via text or phone) stated that R4 had a closed ankle fracture based on xray results on 6/27/25 but staff did not report it to her; therefore, she did not report it to CMS. Review of the facility's abuse investigations for 2025 did not document an investigation was completed or reported for R4.During an interview on 7/22/25 at 1:59 PM P1 stated that she was doing R4's routine two-month exam and noticed that resident's right heel was a bit more swollen and when she manipulated resident's foot, resident opened her eyes. Usually, the resident has her eyes closed and this was different. The resident's foot was a little swollen and was not discolored. They had mentioned that she had to be lifted with hoyer, maybe there was a little [NAME] with the hoyer. When asked who told her this, P1 stated that she did not recall. P1 stated that she ordered an x-ray of right foot and when she received fracture right calcaneus results, she referred resident to Podiatry who recommended padding to heel and nothing much because resident was not walking.During an interview on 7/22/25 at 2:37 PM LPN7 stated that she returned from vacation and came across notes about resident right heel fracture and called it in on 7/6/25 because she saw that no one had called it in yet. LPN7 stated that R4 is total care and not sure how resident fractured her foot. LPN7 stated that she called resident's family and messaged the interim Director of Nursing and IADON/QA QI ICN, and also sent an email to CMS. During an interview on 7/24/25 at 1:07 PM with the Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that when staff discover something like a fracture, it should be reported, but no one submitted a report. The bruising occurred a week before and the night nurse saw it, but didn't report it. When we got the xray results, we saw the resident had a fracture in her foot and LPN7 put her on alert charting. IDON stated that she did not receive any message from LPN7 reporting fracture. IDON confirmed there was a delay in reporting to CMS.

Based on observation, interview and record review, facility failed to have documented evidence of thorough investigation, including preventing further potential abuse while the investigation of the alleged violation was in progress, of alleged abuse for 1 of 2 sampled residents (R) (R4) reviewed for abuse. Without thorough investigations, the facility could not prevent or prohibit further abuse. These failures placed residents at risk for abuse.Findings includeFacility policy, Abuse-Investigation and Reporting, revised date 4/18/24, documented .facility practices (b) to prohibit abuse, neglect.3. Residents shall not be subject to abuse by any individual.5. Investigation. The facility will investigate different types of incidents and identify the staff member responsible for.investigation of alleged violations, e.g. mistreatment, neglect, abuse, injuries of unknown source.6. Protection. How the facility will protect its residents from harm during the investigation: .b. The alleged violations will be thoroughly investigated.All alleged violators (employees) shall be placed on administrative leave by the immediate supervisor(s).Review of R4's record indicated the facility admitted the resident on 2/7/23 with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), diabetes, and dementia. R4's Minimum Data Set (MDS-assessment tool), dated 4/20/25, documented R4's brief interview for mental status was 2. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 0 to 7 is an indication of severe cognitive impairment), and was dependent on staff for eating, toileting, dressing, personal hygiene, mobility and transfers and did not walk and used a wheelchair. Review of R4's current care plan, printed on 7/21/25, documented a self-care deficit related to limited mobility, weakness and frailty, vision deficient, and wheelchair use with resident required total assistance from staff for personal hygiene and used a mechanical lifter by 2 persons during transfer.Review of R4's progress notes documented: *6/24/25 by Nursing: Resident started crying beginning of shift stopping intermittently for about one to two hours then, repeating episodes, through the night. Offered Tylenol 650 mg 2045 and 0400 however repeatedly, resident spitting out offer.*6/26/25 by Provider(P)1: Comfortably sleeping. Nursing staff: light bruising to rt (right) plantar (sole or bottom) foot and has left 5th toenail avulsion (tear). Assessment/Plan:Rt foot swelling lat(eral) (outside) plantar aspect-possibly injured during hoyer lift transfer?Pt does not ambulate or get up. Rt foot xray order placed 6/24/2025. *7/3/25. FOOT 3 OR MORE VIEWS. Exam Date: JUN 27, 2025@13:37. Reason for study: Right plantar swelling/injury? COMPARISON: No prior studies available. Impression: Posterior calcaneal (heel) minimally displaced fracture.*7/5/25 by Registered Nurse (RN)2. P1 referred resident to Podiatry. 92F(emale) Nursing Home resident w localized right foot plantar tenderness/swelling-x-ray shows posterior calcaneal minimally displaced fracture. Patient presents to podiatry clinic for follow up diabetic foot check and toenail debridement. Patient has also been referred for complaint of tenderness and pain to RIGHT heel 2/2 minimally displaced calcaneal fracture.decreased osseous mineralization. Fracture deformity about the posterior calcaneous of unknown chronicity. Mild polyarticular arthritic changes. Arteriosclerotic vasculary disease. No significant soft tissue swelling. Further explained that given patient's age and health profile, and since patient does not ambulate, the fracture is not indicated for surgical intervention. Recommended cushining (sic) padding to right heel with foam/sponge heel off loading pressure relief ankle and foot orthosis, foot care orders for [nursing home] staff, examine feet QAM and QPM (every morning and every evening), make sure there are not external pressures to patient's feet that may lead to pressure ulcerations, Between podiatry visits, trim patient's toenails, ted hose to bilateral lower legs if patient has no h/o CHF (history of congestive heart failure), patient should have heel protectors to feet at all times.Observation on 7/21/25 at 11:59 AM showed R4 sitting in high back wheelchair with eyes closed. Staff sat next to resident and offered several spoonsful and placed cups to resident's lips, but resident only opened her mouth a few times and did not consume much. Staff called the resident's name, patted the resident on her back or shook her shoulder but the resident did not respond or open her eyes.During an interview on 7/21/25 at 12:51 PM Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse (IADON/QA QI ICN) stated that R4 who was completely dependent on staff for care and did not have a fall had a closed ankle fracture based on xray results on 6/27/25. A facility investigation for an injury of unknown origin and possible abuse or neglect should have been completed for resident but it was not. Observation on 7/22/25 at 10:10AM showed Certified Nursing Assistant (CNA) 26 and 21 change resident's briefs and then used mechanical lift to transfer resident to high back wheelchair. Resident had eyes closed and saw only a few words during cares. Resident required total care from staff. Review of the facility's abuse investigations for 2025 did not show an investigation was completed for R4.During an interview on 7/22/25 at 1:59 PM P1 stated that she was doing R4's routine two-month exam and noticed that resident's right heel was a bit more swollen and when she manipulated resident's foot, resident opened her eyes. Usually, the resident has her eyes closed and this was different. The resident's foot was a little swollen and was not discolored. They had mentioned that she had to be lifted with hoyer, maybe there was a little [NAME] with the hoyer. When asked who told her this, P1 stated that she did not recall. P1 stated that she ordered an x-ray of right foot and when she received fracture right calcaneus results, she referred resident to Podiatry who recommended padding to heel and nothing much because resident was not walking.During an interview on 7/24/25 at 1:07 PM with Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that when staff discover something like a fracture, it should be investigated, especially for R4 who was dependent on staff for her cares and there was no report that resident had a fall.

Based on interview and record review, the facility failed to ensure required documentation for discharge was present in the medical record for 1 of 2 sampled residents (Resident 51), when there was no physician documented reason for discharge.This placed the resident at risk of being discharged from the facility without a physician's assessment to ensure all treatment options were explored which may have allowed resident to remain in the facility.Findings includeFacility policy Transfer/Discharge, undated, documented It is the policy of the [name of facility] Nursing Home to transfer or discharge a resident once the resident has been admitted to the facility on ly within the Federal Rules and Regulations. To protect all residents form being removed from the facility without the necessary requirements having been met.The facility may not transfer or discharge the resident unless:1. The transfer or discharge is necessary to meet the resident's welfare and the resident's and the resident's welfare cannot be met in the facility;.3. The safety of individuals in the facility is endangered.4. The health of individuals in the facility would otherwise be endangered.8. To demonstrate situations 1 and 2 above, the residents; physician must provide the documentation.9. In the situation 4 above, the documentation must be provided by any physician.10. Reason for transfer/discharge; Review of Resident 51's records documented that resident was admitted to the facility on [DATE], readmitted on [DATE] and discharged on 6/13/25. R51's diagnoses included dementia, psychotic disturbance, mood disturbance, anxiety, acute kidney failure and diabetes. R51's Minimum Data Set (MDS-assessment tool), dated 6/13/25, documented R51's brief interview for mental status was 9. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 8 to 12 is an indication of moderate cognitive impairment). Review of R51's Transfer/Discharge Notification, dated 6/13/25, documented resident was being transferred/discharged to another nursing facility due to ongoing verbal and physical aggressive behavior towards caretakers with care. Nursing home can no longer able to tolerate her behavior and the effective date was per case manager request to discharge [name of resident] to [name of another nursing facility].Review of progress notes, dated 6/12/25, by Interim Director of Nursing (IDON) documented Upon arrival this morning writer was informed of incident 6/11/2025 by resident toward staff member. Physical and verbal aggression with actual contact to (sic) staff member. [Name of Case Manager] Case Manager was contacted, [Name of Social Services Coordinator, SSC] SSC was also informed to get the expedite the transfer process to get resident to the proper care she needs. Facility has depleted resources to attempt continuity of care, but with her continued manipulative behavior, now with physical aggression she needs to be transferred as soon as possible due to safety measures of all involved, including the resident, as she has been inflicting self-harm and accusing staff. Documents were gathered and forwarded to [Case Manager]. She called back at 1650 to inform writer that resident has been accepted to [Name of another nursing facility]. Review of provider orders showed order from Provider (P)2, dated 6/12/25, to Discharge and Transfer to [name of nursing facility] with medications and treatment plans.' The order did not document the reason for discharge or transfer.Review of progress notes did not show evidence that a physician documented the reason for discharge or transfer.During an interview on 7/24/25 at 10:59 AM IDON stated that R51 was discharged to another nursing home because the resident's needs could not be met in the facility and the safety of individuals, resident, other residents, visitors and staff, and the resident was endangered due to the behavior status of the resident. IDON stated that the last straw was R51 attacked nurse twice in one day, resident had physical aggression towards staff, this was not the best appropriate place for her, resident needed a place where her behavioral needs could be met. The resident was alert, oriented and knew what she was doing, she was manipulative and targeted the nurse. The resident was a danger to herself, she scratched both arms, made false accusations that we were hurting her, we could not manage that level of behavior. We tried several things such as 2 persons, redirection, encouraged her to take her medications, reminders and consequences of behaviors. IDON confirmed there was no documentation in the medical record by a physician that a transfer or discharge was necessary or documentation of the basis for the transfer or discharge.

Based on interview and record review, the facility failed to transmit required Minimum Data Set (MDS-assessment tool) resident assessment data to the Centers for Medicare & Medicaid Services (federal agency that provides health coverage) within the required timeframe for 2 of 6 sampled residents (R) (R53 and R57) reviewed for timeliness in transmitting discharge Minimum Data Set (MDS-an assessment tool). This placed residents at risk for unmet care needs and a diminished quality of life.Findings include Review of Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Version 1.19.1, dated October 2024, documented discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD) (A2300), and it must be submitted/transmitted within 14 days of the MDS completion date (Z0500+14 days) to the database as required. Resident 53 Review of Resident 53’s (R53) record documented the resident was admitted on [DATE] and discharged on 4/11/25. Review of the facility's electronic health record system Point Click Care showed that a discharge MDS with an ARD of 4/11/25 was not submitted and accepted until 5/8/27; therefore, the transmittal was not completed within the required 14 days. During a concurrent interview and record review on 7/24/25 at 3:12 PM MDS Nurse stated that the RAI manual for MDS completion was used as the facility policy and reference source. MDS Nurse stated that they would complete the discharge MDS within 14 days from the ARD. Joint record review of Resident 53's MDS look up assessment showed the discharge MDS dated [DATE] was submitted on 5/8/27; more than the required 14 days from the ARD date. MDS Nurse stated that it was submitted late because staff kept saying they weren't sure if the resident was coming back or not. MDS RN stated, “I told them we needed to complete the MDS or we will be late.” During an interview on 7/24/25 at 1:07 PM with the Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that they expected the MDS to be completed and transmitted in a timely manner. Resident 57 Review of R57's admission Record, printed from the electronic medical record (EMR) Profile tab showed a facility admission date of 04/10/25, readmission on [DATE], with medical diagnoses that included type II diabetes, nutritional deficiency, and hypertension. Review of R57's EMR Progress Notes tab revealed: Effective Date: 05/05/2025 15:03 Type: COMMUNICATION - with Family/NOK [Next of Kin]/POA [Power of Attorney] Note Text : NOTIFICATION TO FAMILY MEMBER-Son [name] notified by Writer to inform him that his Father [name] will be Transported to an Out of Facility Hospital for further care (possible Pacemaker). Son advises He will call the [name] Hospital to follow-up on his Fathers' medical evaluation and transport Per facility Driver The Doctor was saying [R57's name] would probably be sent to Phoenix. Writer called [hospital name]-[NAME] [emergency room Department] and confirmed that [R57's name] will be sent to [name] Medical Center in Phoenix, AZ. Per [NAME] Receptionist, Family (NOK) which at the [facility name] lists [R57's] Daughter and Spouse have been notified. Review of R57's EMR MDS tab showed a DCRA with an Assessment Reference Date (discharge date ) of 05/05/25, but the EMR History tab for the MDS showed it was not submitted until 05/29/25. During an interview on 07/23/25 at 4:02 PM regarding MDS submission policy, the Interim Director of Nursing (IDON) stated they follow the RAI (Resident Assessment Instrument) manual. During an interview on 07/24/2025 at 1:35 PM regarding the DCRA submission on 05/29/25, the MDS Coordinator (MDSC) stated, The MDS sections did not meet the times for each area completion. They were late so I submitted it (DCRA) late. Review of the October 2024 RAI Manual, page 2-39, revealed: 10. OBRA Discharge Assessment–Return Anticipated .-Must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days…-Must be completed . within 14 days after the discharge date . (i.e., discharge date . + 14 calendar days).

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one of three sampled residents (Resident (R) 37) for pressure ulcers. The failure to accurately code/assess the resident's condition had the potential to affect the care planning for the resident to receive all required services.Findings include: During the initial attempt for an interview on 07/21/25 at 3:33 PM, R37 was found non-interviewable, but had triggered for review of a facility acquired pressure ulcer. Review of R37's admission Record printed from the electronic medical record (EMR) Profile tab showed a facility admission date of 07/26/21 with medical diagnoses that included dementia, type II diabetes, protein calorie malnutrition, age related physical debility, and hemiplegia/hemiparesis following cerebrovascular disease with history of transient ischemic attacks and cerebral infarction (stroke). Review of R37's quarterly MDS with an Assessment Reference Date (ARD) of 06/14/25 showed a Brief Interview for Mental Status (BIMS) score of three out of a possible 15, indicative of severe cognitive impairment. Review of R37's MDS skin assessments for unhealed pressure ulcers showed on the following assessment reference dates:-03/13/24 Quarterly - none-06/13/24 Quarterly - none-09/13/24 Quarterly - one stage one-12/02/24 Annual - none-03/14/25 Quarterly - none-06/14/25 Quarterly - one stage two Review of R37's EMR Assessments tab, Progress Notes tab, and Miscellaneous tab did not show any documentation regarding pressure ulcers. During an interview on 07/23/25 at 3:00 PM, the Interim Director of Nursing (IDON) stated, I don't remember him [R37] ever having a pressure ulcer. During a follow-up interview on 07/23/25 at 4:02 PM regarding an MDS accuracy policy, the IDON stated they follow the RAI (Resident Assessment Instrument) manual. During an interview on 07/24/25 at 3:40 PM, the MDS Coordinator (MDSC) stated she coded the pressure ulcer on the 06/14/25 assessment from this EMR Progress Note because she couldn't find any notes that it was healed: Effective Date: 03/04/2025 19:38 Type: Skin/Wound Note Text: RT. BUTTOCK OPEN WOUND- Measuring 1.5 cm. x 1.9 cm. x 0. Superficial. Wound edges intact. No undermining. No surrounding redness. Scant amt. of bleeding with cleansing. LT. BUTTOCK OPEN WOUND- Measuring 1.0 cm. x 1.6 cm. x 0. Superficial. Wound edges intact. No undermining. No surrounding redness. Scant amt. of bleeding with cleansing.-At 4:06 PM, the MDSC showed a progress note, dated 04/25/25, stating the buttocks were healed, and stated, I coded it because I looked back to the March 14th through June 25th for the assessment. Review of the October 2024 Resident Assessment Instrument (RAI) manual with MDSC, page M-5, revealed: Coding Instructions Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days. Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back period. Then skip to M1030, Number of Venous and Arterial Ulcers. Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. The MDSC stated the MDS was coded incorrectly for a pressure ulcer.

Based on interview and record review, the facility failed to ensure resident's plan of care were revised when diet texture was changed, glasses were no longer available, transfer needs changed, and foot fracture was sustained for 1 of 18 sampled residents (R) (R4) whose care plans were reviewed. This failure increased the risk for unmet care needs.Findings includeReview of R4's record indicated the facility admitted the resident on 2/7/23 with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), diabetes, and dementia. R4's Minimum Data Set (MDS-assessment tool), dated 4/20/25, documented R4's brief interview for mental status was 2. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 0 to 7 is an indication of severe cognitive impairment), and was dependent on staff for eating, toileting, dressing, personal hygiene, mobility and transfers and did not walk and used a wheelchair.Review of R4's July Medication Administration Record documented resident's diet was CCHO (consistency carbohydrate) diet pureed texture, nectar consistency.Review of R4's current care plan, printed on 7/21/25, documented a self-care deficit related to limited mobility, weakness and frailty, vision deficient, and wheelchair use with resident required total assistance from staff for personal hygiene and 1. Utilized a stand-up lifter and must be assisted by two staff members (Date initiated 4/20/21) 2. Assist [name of resident4] by two (2) person during transfer using mechanical lifter for safety (Date initiated 8/26/22)3. Remind/assist [name of resident4] to wear glasses when up. Ensure [name of resident4] is wearing glasses which are clean free from scratches and in good repair. Report any damage to nurse/family. (Date Initiated: 4/20/21)4. Please offer [name of resident4] all Liquids w/straw as [name of resident4] states she does better drinking through the straw. (Date Initiated: 4/20/21)5. Provide [name of resident4] Diet as ordered (CCHO diet, pureed texture, nectar consistency) (Date initiated 1/25/20)6. There was no care plan for resident's right heel fracture per x-ray exam on 6/27/25Progress notes documented on 7/5/25 by Registered Nurse (RN)2. Provider 1 referred resident to Podiatry. 92F(emale) Nursing Home resident w localized right foot plantar tenderness/swelling-x-ray shows posterior calcaneal minimally displaced fracture. Patient presents to podiatry clinic for follow up diabetic foot check and toenail debridement. Patient has also been referred for complaint of tenderness and pain to RIGHT heel 2/2 minimally displaced calcaneal fracture.decreased osseous mineralization. Fracture deformity about the posterior calcaneous of unknown chronicity. Mild polyarticular arthritic changes. Arteriosclerotic vasculary disease. No significant soft tissue swelling. Further explained that given patient's age and health profile, and since patient does not ambulate, the fracture is not indicated for surgical intervention. Recommended cushining (sic) padding to right heel with foam/sponge heel off loading pressure relief ankle and foot orthosis, foot care orders for [nursing home] staff, examine feet QAM and QPM (every morning and every evening), make sure there are not external pressures to patient's feet that may lead to pressure ulcerations, Between podiatry visits, trim patient's toenails, ted hose to bilateral lower legs if patient has no h/o CHF (history of congestive heart failure), patient should have heel protectors to feet at all times.Observation on 7/21/25 at 11:59 AM showed R4 sitting in high back wheelchair with eyes closed. Staff sat next to resident and offered cup to resident's lips, but resident only opened her mouth a few times and did not consume much. R4 diet was pureed texture and there was no straw on meal tray. Resident was not wearing glasses. During a phone interview on 7/21/25 at 2:11 PM Family Member (FM)1 stated that resident used to have glasses but hadn't been wearing them.Observation on 7/22/25 at 10:10AM showed Certified Nursing Assistant (CNA) 26 and 21 change resident's briefs and then transfer resident with mechanical lift to high back wheelchair. Resident was not wearing glasses. During multiple observations from 7/21/25 to 7/25/25 R4 was not observed wearing glasses.During an interview on 7/22/25 at about 10:13AM Certified Nursing Assistant (CNA) 26 stated that she knows R4 well, having taken care of her during the past 3 years. CNA26 stated that resident is transferred via mechanical lift and not the stand-up lifter or sit to stand as resident does not stand. CNA26 also stated that she has never seen R4 wear glasses and has not seen glasses in her room.During an interview on 7/23/25 at 8:57 AM CNA21 stated that resident is transferred using mechanical hoyer lift with two people. During an interview on 7/24/25 at 1:07 PM with the Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that care plans should reflect care that is needed.Record review of email communications, dated 7/24/25 at 2:33 PM, Interim Director of Nursing (IDON) documented The interim care plans are done by the nurses. Any updates are usually done by RegisteredNurse Assessment Coordinator (RNAC).During a phone interview on 7/25/25 at 9:40 AM RNAC confirmed that she updates resident's care plans by noting any changes such as fall incidents, MDS changes such as significant changes or quarterly changes, hospital readmission, she contacts staff by phone and email, participates in weekly meetings and Quality Assessment Performance Improvement meetings, contacts CNAs and asks how they are doing with daily change. RNAC also stated that if a resident has an incident such as a fall or fracture, the doctor's orders are incorporated into care plan. RNAC stated that yesterday a careplan was held for R4 which family member (FM)1 attended. RNAC stated that there were no recommendations or revisions to resident's care plan. RNAC stated that resident uses the stand-up lifter when informed observation and staff interview showed resident used the mechanical hoyer lift and not the stand-up lifter, RNAC stated that she will ask the lead CNA about this. RNAC stated that the lead CNA did not attend yesterday's care plan meeting. RNAC stated that she was aware that R4 had a foot fracture last month which included physician orders and treatment for use of heel protectors, cushioning, pain management, ice as tolerated, and assessment. When asked if a care plan for foot fracture was developed, RNAC stated no but that should have been done. RNAC stated I missed that. When asked about use of glasses and straw, RNAC stated that she will check with staff and update the care plan.During an interview on 7/25/25 at 10:01 AM Lead CNA stated that R4 can't suck liquids from a straw because R4 is on nectar thick liquids so instead staff bring the cup to resident's mouth.Facility policy Comprehensive Assessment and Care Planning, dated 1/2024, documented As appropriate, our facility will revise the resident's care plan to assure its continued accuracy. The Care Plan will be reviewed as often as changes occur in the resident's condition and will be revised to maintain accuracy. Each resident's comprehensive assessment and care plan will be reviewed at least every three (3) months by all members of the IDT, who will then meet to discuss any change in services required.

Based on interview and record review it was determined the facility failed to ensure a registered nurse worked eight consecutive hours for 1 of 203 days reviewed for staffing. This placed residents at risk for lack of nursing assessments.Findings includeA review of the facility's Licensed Nurses Schedule for week of 5/19/25 showed there were no RN on duty on 5/18/25. Review of Interim Director of Nursing (IDON) Custom Time Card Report for 5/18/25 showed hours worked from 8:30 AM to 1:00 PM (4.5 hours) and then 6:30 PM to 9:15 PM (2.75 hours). The facility census was less than 60.During a concurrent review and interview on 7/24/25 at 10:59 AM IDON confirmed the facility did not have an RN for eight consecutive hours on 5/18/25.

Based on interview and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs for 1 of 5 sampled resident (R) (R7) reviewed for unnecessary medication use. R7 received anti-hypertensive medications that did not meet physician's ordered blood pressure parameters. This failure placed residents at risk for adverse side effects such as hypotension, dizziness, and falls. Findings includeReview of R7's records documented resident was admitted on [DATE] with diagnoses including congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently), hypertension, dementia, diabetes, and cerebral infarction (stroke, blood supply to part of the brain is blocked, causing parts of the brain to be damaged or die, can cause weakness in one side of the body and swallowing difficulties).Review of R7's care plan documented [Name of R7] has hypertension and takes medicines with goal for resident's blood pressure to be within normal limits.Review of R7's physician orders and July 2025 Medication Administration Record documented *Hydralazine 25 mg, give 50 mg by mouth three times a day for hypertension. Hold for SBP (systolic blood pressure, top number of blood pressure) less than 130.During the month of July, resident's SBP was less than 100 but Hydralazine was documented as given five times on 7/5/25 (BP 124/49), 7/6/25 (BP 123/52), 7/7/25 (BP 128/69), 7/12/25 (BP 107/65), 7/20/25 (BP 125/67).During a concurrent interview and record review on 7/24/25 at 1:07 PM with Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that R7's blood pressure medications should have been held if blood pressure was too low and nurses need to be following physician's orders.Facility policy Medication Administration, dated 1/2024, documented Medications are administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility failed to ensure records were complete and accurate for 1 of 5 sampled residents (R)(R7) reviewed for unnecessary medication use. This placed residents at risk for incomplete clinical records.Findings includeReview of R7's records documented resident was admitted on [DATE] with diagnoses including congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently), hypertension, dementia, diabetes, and cerebral infarction (stroke, blood supply to part of the brain is blocked, causing parts of the brain to be damaged or die, can cause weakness in one side of the body and swallowing difficulties).Review of R7's care plan documented [Name of R7] has hypertension and takes medicines with goal for resident's blood pressure to be within normal limits.Review of R7's physician orders and July 2025 Medication Administration Record documented *Hydralazine 25 mg, give 50 mg by mouth three times a day for hypertension. Hold for SBP (systolic blood pressure, top number of blood pressure) less than 130.During the month of July, resident's SBP was less than 100 but Hydralazine was documented as given five times on 7/5/25 (BP 124/49), 7/6/25 (BP 123/52), 7/7/25 (BP 128/69), 7/12/25 (BP 107/65), 7/20/25 (BP 125/67).During a concurrent interview and record review on 7/23/25 at 1:36 PM Licensed Practical Nurse (LPN)2 stated that although R4's Medication Administration Record shows she gave Hydralazine on 7/20/25 when BP was 125/67 (SBP was less than 130), she knows that is a mistake because she recalls resident's SBP was low all day Sunday so she held the resident's BP medications. LPN6 stated that she might have clicked the wrong thing in the electronic health record Point Click Care. When asked about 7/7/25 BP reading of 128/69, LPN6 stated she also did not administer Hydralazine on this day since it shows resident's SBP was less than 130. LPN6 stated that she is aware the record shows she gave the Hydralazine, but it was a mistake. LPN6 stated that she understands that it is important that the medical record documentation is accurate and also that if resident is given Hydralazine when SBP is not greater than 130, then the resident's BP could drop too low.During a concurrent interview and record review on 7/24/25 at 1:07 PM with the Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that R7's blood pressure medications should have been held if blood pressure was too low and nurses need to be following physician's orders, and it is important that the medical record reflect accurate and complete documentation. During an interview on 7/25/25 at about 2:10 PM IDON stated that the expectation is medical record documentation is accurate and reflect what was done. Upon request for medical record policy for documentation accuracy, facility provided Content of Medical Record. This policy did not outline the need for medical record documentation to be accurate.

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required participants for 2 of 4 quarters reviewed for participation. This failed practice placed residents at risk for quality and infection control deficiencies, adverse events, and diminished quality of life.Findings includeFacility's 2025 Quality Assessment Performance Improvement (QAPI) Committee, undated, documented meetings were at a minimum once every quarter with members listed: Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse (IADON QA QI ICN), Interim Director of Nursing (IDON), Medical Director, Consult Pharmacist, Board of Directors, Supervisors for Housekeeping/dietary, Maintenance, Social Services, Lead Certified Nursing Assistant (CNA), MDS (Minimum Data Set) Coordinator, Activity Supervisor and Nurses, CNAs and all staff are welcome to attend. The facility's list of QAPI/QAA participants met the minimal regulatory requirements that the Medical Director/Designee, Director of Nursing Services (DON), Administrator/Owner/Board Member/Other Leader, Infection Prevention & Control Officer (IP), At least two additional members participated and QAA met at least quarterly. Review of facility's 2024 and 2025 QAPI binder showed that 3/26/25 meeting did not have the required meeting participants when the Medical Director and Administrator/Board member did not attend. In addition, the Medical Director did not attend the 10/2/24 meeting. During text communications on 7/25/25 at 9:05 AM IADON/QA QI ICN (who was on leave and available via text or phone) stated that if the Medical Director was not on the sign-in sheet, he most likely was not able to attend. During an interview on 7/25/25 at 10:25 AM IDON stated that the Medical Director stated that he has no proof that he attended the 3/26/25 meeting.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases when staff did not change gloves during 1 of 2 sampled resident (R) (4) personal care observation when going from dirty tasks to clean tasks. This placed residents at risk for the spread of infection and its associated discomfort and decline in physical condition.Findings includeReview of R4's record indicated the facility admitted the resident on 2/7/23 with diagnoses including heart failure (heart disorder which causes the heart to not pump the blood efficiently), diabetes, and dementia. R4's Minimum Data Set (MDS-assessment tool), dated 4/20/25, documented R4's brief interview for mental status was 2. (BIMS, a scoring system used to determine the resident's cognitive status about attention, orientation, and ability to register and recall information. A BIMS score of 0 to 7 is an indication of severe cognitive impairment), and was dependent on staff for eating, toileting, dressing, personal hygiene, mobility and transfers and did not walk and used a wheelchair. Review of R4's current care plan, printed on 7/21/25, documented a self-care deficit related to limited mobility, weakness and frailty, vision deficient, and wheelchair use with resident required total assistance from staff for personal hygiene. Observation on 7/22/25 at 10:10AM showed Certified Nursing Assistant (CNA) 26 and 21 change resident's briefs. CNA26 unfastened resident's briefs with gloved hands, then wiped resident private area several times. With same gloved hands, CNA26 picked up clean new brief and placed under resident and then repositioned resident on her side and fastened briefs.During an interview on 7/22/25 at about 10:13AM Certified Nursing Assistant (CNA) 26 stated that R4's briefs was wet. When asked about changing gloves during brief change, CNA26 stated that she used one pair of gloves. When asked how she kept new brief clean when she touched brief with same gloves she used to clean resident's soiled briefs. CNA26 stated that I guess the glove was dirty when she touched the clean brief with the gloves she had just used. CNA26 stated that it's not like she keeps briefs in her pocket and she needs to attend to the resident.During text communications on 7/25/25 at 9:07 AM Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse (IADON/QA QI ICN) (who was on leave and available via text or phone) documented the expectation is staff to know when to change gloves after a dirty procedure and before doing a clean procedure or act. Staff should not be using one pair of gloves when changing soiled briefs. During an interview on 7/24/25 at 1:07 PM with Interim Director of Nursing (IDON) and Director of Nursing, IDON stated that staff should be changing gloves between dirty and clean tasks.Facility policy Handwashing/ Hand Hygiene, dated 1/2024, documented change gloves and perform hand hygiene during patient care, if.c moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs

Based on observations, interviews, review of records, and policy, the facility failed to ensure that 3 of 6 residents reviewed for accidents (Residents (R) 207, R106, and R156) did not sustain preventable falls with major injuries. Specifically, 1) The facility failed to conduct neuro checks after an unwitnessed fall, ensure neuro checks conducted were consistent with their policy, implement fall interventions, and provide adequate supervision for R106. R106 had 16 falls during his four-month stay, including three falls where the facility recommended 1:1 monitoring which was not implemented. After the series of falls where 1:1 monitoring was recommended but not implemented, R106 had four additional unwitnessed falls. After the last unwitnessed fall, the assigned LPN failed to conduct neuro checks as required by facility policy and professional standards of practice. The facility's failure caused harm to R106 who had repeated falls in the facility with the last fall resulting in transfer to the Emergency Department, where R106 was diagnosed with a subdural hematoma (serious condition usually caused from a head injury when blood collects between the brain and its outermost covering), requiring hospitalization , ventilator support, and ultimately died . 2) The facility failed to implement an intervention of an anti-rollback device which the IDT recommended for the prevention of falls for R156. R156 had 15 falls during their stay in the facility, half of which involved R156 not locking her wheelchair breaks, and all of which involved R156's non-compliance with following facility education to request assistance with transfers and ambulation. The facility's failure caused harm to R156 who had repeated falls in the facility and resulted in transfer to the Emergency Department where R156 was diagnosed with a subdural hematoma, requiring hospitalization . 3) The facility failed to ensure one resident (R207), with assessed ADL dependence and severe cognitive impairment received mobility services/assistance to propel her wheelchair to ensure she did not sustain a preventable fall with major injury, hospitalization , and death. Cross reference to F600 Findings include * For Resident 106: Review of Resident 106's (R106) record documented the resident was admitted on [DATE] with diagnosis including dementia, diabetes, frequent falls, orthostatic hypotension (sudden drop in blood pressure when you stand up from a sitting or lying position) and stroke. R106's Minimum Data Set (MDS-assessment tool), dated [DATE], documented resident's brief interview for mental status was 12 of 15, indicating moderate cognitive impairment and required supervision or touch assistance when transferring from chair to bed or walking 50 feet while using a walker. Resident was transferred to the hospital on [DATE]. 1. Neuro checks Review of facility's Falls and Fall Risk Managing policy, dated ,d+[DATE], documented under section Steps (Post Fall) 30 minutes 3. neurological checks: Required for all falls with head injury or unwitnessed falls. a. Neurological checks include assessing: i. Glasgow Coma Scale [a tool used to measure a person's level of consciousness and how responsive they are], ii. LOC (level of consciousness), iii. Orientation, iv. Movement in Extremities, v. Pupil size and reaction and vi. Speech and Responses. b. For 72 hours at a frequency of: i. q (every) 15 min(utes)x1 hour, ii. q30 min(utes) x 1 hour, iii. q1 hourx4 hours, iv. q4 hoursx24 hours, then v. qshift x72 hours, 4. Monitor vital signs, 5. Monitor for signs/symptoms of delayed injury (i.e., bruising, bleeding, fracture). 1 hour: 2. Complete the following documentation: a. Post Fall Screening Sheet .e. Neurological Checklist with a head injury and unwitnessed fall (UDA)(user defined assessment) Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and had unwitnessed fall on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] and witnessed fall on [DATE] and [DATE]. Please monitor his vital signs, neuro checks, pain, skin condition, ROM (range of motion) and delayed injuries. Follow the facility protocol for monitoring s/p (status post, after) fall condition with start date [DATE]. PROGRESS NOTES Review of R106's progress notes, dated [DATE] at 8:46 PM, Licensed Practical Nurse (LPN)6 documented Informed by another resident (R), R106 was sitting on floor in the Great Room. No wheelchair in area and attempting to get up but not calling out. Resident's wheelchair was found in room [resident's room] by bathroom door and bed linen in room was ruffled up. Resident was attempting to get up during assessment. No injury noted, no bump on head, no bleeding. Resident questioned if he was hurting or if he bumped his head. Denied both and wanted to get up. Resident asked if he needed to go to the hospital - denied. Resident was then assisted to w/c. Continuing on VS [vital signs] from recent fall earlier. Phone cont(inue) busy. Review of R106's progress notes, dated [DATE] at 10:57 PM LPN6 documented During shift report, CNA (Certified Nursing Aide) reported Resident (R106) having multiple episodes of emesis (vomiting). Near beginning of shift CNA reported Resident vomited; VS [vital signs] taken, BSL @ (blood sugar level at) 223. Elevated BP, confused and aggressive. Review of R106's progress notes, dated [DATE] at 2:58 AM LPN6 documented Resident reported with bout of emesis this shift approx(imately) 2000 (8PM). VS taken and CNA reported elevated BP (blood pressure). Resident monitored by CNA, attempting to get up OOB (out of bed), bed alarm sounding d/t (due to) continued restlessness. During bed checks, Resident sleeping w/ (with) legs hanging off the side of the bed, ,d+[DATE] dressed and partly exposed. Assisted CNA with getting Resident back into bed and changed. Encouraged Resident to rest and he calmed down. Called to room when emesis reported. VS cont(inue) w/ elevated BP, skin cool to the touch, staff reported Resident did not look right/normal. Called ER (emergency room ) and spoke w/ Nurse [Name of nurse], we would send Resident in via facility van. Returned to Resident and was informed Resident was now unable to stand, more lethargic, VS unchanged and cont(inue) cool to touch. Called ER, then EMS for transport. Resident left facility at 2340 (11:40 PM) FALL INVESTIGATION Review of facility incident witness report form, dated [DATE] at 8:30 PM, documented by LPN6 showed checkmark in box for Other and a checkmark was not shown in box for Fall for type of incident. The details section documented Alerted to (R106) was sitting on floor in Great Rm (room) but another resident. No calling out observed. When notified by staff, Resident wanted assist to get off of floor. During the assessment of Resident, CNAs attempted to get Resident up but were told to wait since Resident had to be assessed. Resident told staff I slipped when asked. But no w/c (wheelchair) nearby. WC found in [another resident room] with alarm sounded and muted. Resident assisted off of floor to w/c x3 staff. While being assess Resident denied hitting head, denied pain, denied wanting to go to the hospital. Just wanted to get up. Resident on AC (alert charting) for recent fall, no new protocol continued. Resident cont(inued) with ongoing behavior prior to fall. Had resident sit in w/c-later assisted to room. Review of facility incident witness report form, dated [DATE] at 8:15 PM, documented by LPN2 showed checkmark in box for Fall as type of incident with details At approx(imately) 2015 (8:15 PM) I was completing treatments in (nursing unit). I had gathered my supplies and was entering [another resident's room] when I heard [name being called], I leaned back out of the room and resident [room number of resident] was pointing into the living room area. As I looked in that direction, I observed [R106] lying on the floor near the [unit] kitchenette. [Name of LPN6] was nearby and I asked her Did you guys put [R106] on the floor? He's on the floor. [LPN6] walked over and observed resident then called to the night CNAs The following documents were not provided by facility for [DATE] fall, which were required per facility policy after an unwitnessed fall, including: 1. Post Fall Screening form which is a checklist to determine why resident fell such as what type of footwear resident was wearing, if environment was clear or cluttered, was resident confused or dizzy, was resident wearing glasses or hearing aide, if there were skin tears, lacerations or any injuries, immediate blood pressure, oxygen saturation level, heart rate, temperature, pain level, level of consciousness. 2. Interdisciplinary Post-Fall Assessment form which describes fall, outlines the number of falls in the last 30, 90 and 180 days, if there were recent medication changes, pattern of current falls such as time of day, six month review of falls and if there were any patterns or trends related to falls, probable cause of falls, root cause analysis of falls, recommendations from the review by IDT (Interdisciplinary Team), and care plan revisions. 3. Neurological check form that documented initial assessment of resident's pupil size and reaction to light, movement of extremities, vital signs, and level of consciousness. 4. Post Fall-Nurse Neurological Check Guidelines that documented assessment of resident's pupil's reaction to light, able to follow finger, verbal responses, pain level and level of consciousness every 15 minutes for 1 hour, every 30 minutes x4, every hour x4, every four hours x4 and every shift x3. 5. 72-hour intentional rounding after fall that assessed and documented pain, positioning, peri-needs and possessions such as call light within reach, glasses, water and environmental conditions every hour. INTERVIEWS During an interview on [DATE] at 7:36 AM LPN2 stated that when residents have an unwitnessed fall she completes neuro checks and completes fall packet which includes neuro checks every 15 minutes x4, then every 30 minutes x4 and so forth as outlined on form. LPN2 stated that she checks on the resident's level of consciousness, if the resident is alert, lethargic, nonresponsive, the resident's pupils reaction to light, size, extremity strength, weakness, and take their vitals. LPN6 stated when R106 fell on [DATE] she had worked the day shift and her shift ended at 7:30 PM but was doing a last minute treatment on R106's unit when she heard a resident calling her name who directed her that R106 was on the floor. LPN2 stated that she asked LPN6 if she put R106 on the floor and LPN6 said no and then LPN6 called the CNAs over to help. LPN2 stated that R106's fall was unwitnessed because R106 was found on the floor and staff did not put R106 on the floor. During an interview on [DATE] at 2:48 PM Assistant Director of Nursing (ADON) who was also the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) stated that R106 had multiple falls in the facility and confirmed during resident's four month stay in the facility, resident had 16 falls, which were both witnessed and unwitnessed. ADON/QAPI/IP confirmed that when resident have an unwitnessed fall, nursing is directed to complete fall packet which includes post fall screening form, neurological check form, post fall nurse neurological check guidelines and 72 hour intentional rounding form. ADON/QAPI/IP further stated that licensed nurses should complete neuro check form for the specific time period as outlined on the form such as every 15 minutes x4, then every 30 minutes x4 to check for concussion or effects of head injuries. ADON/QAPI/IP stated that R106 had a witnessed fall on [DATE] and an unwitnessed fall on [DATE] and she should have received a fall packet including fall sheet and neuro checks for the [DATE] fall but didn't. ADON/QAPI/IP stated that when she did not receive the fall packet at the end of the day on [DATE], she asked LPN6 for the fall packet and LPN6 responded that she didn't complete the fall packet including neuro checks. ADON/QAPI/IP stated that she reviewed the video footage for R106's [DATE] fall and saw that R106 tripped and fell near the kitchenette, and LPN6 was not observed to complete a neuro assessment or vital signs after the fall but should have. The next day in the evening, R106 vomited and wasn't himself so he was sent to the emergency room . ADON/QAPI/IP stated that LPN6 no longer works at the facility. When asked about if the frequency and duration for neuro checks on the post fall nurse neurological check guidelines form should match the facility's fall policy, ADON/QAPI/IP stated yes. Joint review of two documents comparing frequency, duration, and content was conducted and ADON/QAPI/IP confirmed that the form did not direct nurses to assess for movement of extremities, pupil size, and instead of monitoring for neuro checks every 4 hours for 24 hours, the form only directed staff to monitor for every 4 hours four times (shortened duration of monitoring by 8 hours). ADON/QAPI/IP stated that due to the format of the form, staff were not monitoring neuro checks per facility policy which was based on policy reference source of Glascow coma scale and medpass and that shouldn't have happened. ADON/QAPI/IP also stated that it was important to do neuro checks for the frequency and duration because of latent effects, residents can have a change in level of consciousness later and R106 didn't have nausea/vomiting for almost 24 hours after his fall. During an interview on [DATE] at 9:34 AM Medical Doctor (MD)1 confirmed he was R106's physician, resident had multiple falls, and it was important to do neuro checks for ,d+[DATE] hours after falls because of latent injuries and possible concussion. MD1 further stated that it was important to watch for neuro changes so action can be taken as soon as possible. MD1 confirmed that resident's vomiting and change in mental status the day after a fall could be contributed to a head injury from the fall. MD1 also confirmed that resident was transferred to the emergency room , was air lifted to nearby hospital as family wanted everything done, resident was full code, and resident was found to have a subdural hematoma that required ventilator support, surgery, intensive care services and subsequently died . During an interview on [DATE] at 9:21 AM Director of Nursing (DON) stated that staff are expected to complete neuro checks and continue assessments for 72 hours after an unwitnessed fall because there could be delayed effects, and this was not done for R106 during his last fall in the facility. Review of Emergency Department (ED) note, dated [DATE], showed R106 was well known to the ED and had a history of frequent falls. His last visit to this ED was due to a fall on [DATE] with an atraumatic head CT (noninvasive imaging involving x-rays and computer showing no trauma). He was seen in ED for lethargy and vomiting 3 times tonight at the nursing home. The nursing home think the resident had a fall the night before ([DATE]), nothing was witnessed. The ED records showed resident was lethargic, closed his eyes quickly after opening, left eye lid droops, good gag, moved all four extremities equally and purposefully, doesn't stay awake long enough to test anything else such as finger-nose, and usually resident known to joke around but today resident is so lethargic it is hard to evaluate his mental state. A CT of the head was completed due to resident's altered mental status and was compared to [DATE] previous exam. The CT of the head showed there was a left subdural hematoma with maximal diameter of 1.7 cm with a shift to the midline from left to the right. Resident had a history of frequent falls who presented today some 30 hours after a presumed fall at the nursing home with progressive lethargy and vomiting. Resident's diagnosis and prognosis was communicated to family members who understood resident's condition was poor and outcome is uncertain and confirmed resident was full code and that they want everything done. The plan was to intubate (flexible tube placed through the mouth and down into the windpipe to help keep the airway open), do all critical care necessary to keep resident alive and family understood resident would be on life support. Subsequently, resident was intubated, placed on a ventilator (a machine that helps a person breathe when they are unable to do so on their own by pushing air into the lungs through a tube), a cervical collar was applied, multiple intravenous lines and monitoring devices were initiated and resident was transferred to another hospital for intensive care services via air transport on [DATE] at 9:37 AM. Review of R106's progress notes, dated [DATE], documented resident died and family members picked up resident's personal belongings at the facility. 2. Inadequate fall management Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and monitor (R106)'s location frequently and assess his needs. Assist with toileting, transferring and walking as need. (R106) requires every 15 minutes safety check with start date [DATE]. Review of facility's fall incident reports documented resident had 16 falls during four-month stay. Falls on [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE], [DATE], [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE], [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE](unwitnessed), [DATE] (unwitnessed), [DATE], [DATE] (unwitnessed). Twelve of the 16 falls were unwitnessed. Review of facility's fall incident reports documented: *[DATE] (unwitnessed fall) *[DATE] (unwitnessed fall) *[DATE] *[DATE] *[DATE] (unwitnessed fall) *[DATE] at 7:31 AM with unwitnessed fall. Wheelchair rolled while resident was attempting to transfer, breaks were unlocked, resident confused, impulsive, no safety awareness and sustained bruises from fall, bumped his head slightly. The interdisciplinary team recommendations included 1:1 supervision (1 staff member dedicated to supervising R106, ratio of 1 staff to 1 resident). 1:1 supervision recommended and not implemented. 1:1 supervision was not added to resident's care plan. Wheelchair rolled while resident attempting to transfer, wheelchair breaks were unlocked. *[DATE] *[DATE] at 5:10 AM with unwitnessed fall. Resident was found in the living room and sustained abrasions to his head and both knees. Resident stated, I hit my head. The wheelchair alarm was delayed. Resident transported to the emergency room . The interdisciplinary team recommendations included 1:1 monitoring. 1:1 monitoring recommended and not implemented. 1:1 monitoring was not added to resident's care plan. *[DATE] (unwitnessed fall) *[DATE] at 3:55 PM with unwitnessed fall. Resident wandered into another room. Anti-roll back wheelchair was recommended (device attached to wheelchair that locks wheels automatically when resident begins to stand). Anti-roll back wheelchair was not added to resident's care plan. *[DATE] (unwitnessed fall) *[DATE] at 9:00 PM with unwitnessed fall in hallway, in great room. Resident stated, I was trying to go to the bathroom, got up from wheelchair while in great room to go to the bathroom and fell in the hallway. The interdisciplinary team recommendations included 1:1 monitoring (not available at facility at this time) and constant redirection. 1:1 monitoring was recommended and not implemented. 1:1 monitoring was not added to resident's care plan. Anti-roll back wheelchair was recommended. Anti-roll back wheelchair was not added to resident's care plan. *[DATE] (unwitnessed fall): wheelchair breaks unlocked. Resident getting up from wheelchair without assistance. Attempting to transfer to bed and fell . *[DATE](unwitnessed fall): resident hit his head, sent to ED. *[DATE] (unwitnessed fall) *[DATE] *[DATE] at 8:30 PM with unwitnessed fall. Neuro checks should have been initiated but was not. During interview on [DATE] at 2:48 PM ADON/QAPI/IP stated that she conducted fall investigations which included reviewing documents in fall packet such as incident witness report forms, post fall screening form, neurological check form, post fall nurse neurological check guidelines and video footage and she completed the Interdisciplinary Post-Fall Assessment form with the input from the interdisciplinary team which included unit charge nurses, Director of Nursing, social workers, MDS nurse, Housekeeping, Maintenance, and sometimes activities and the lead CNA. When asked what were some of the root cause analysis of the falls and interventions to prevent recurrent falls ADON/QAPI/IP mentioned several actions and stated that resident was a high fall risk, would sundown in the evenings, and resident was sometimes confused, reorientation didn't always work, he had orthostatic hypotension, impulsive behaviors of getting up all the time, and he sometimes turned off the wheelchair and bed alarms so we couldn't rely on them. When asked about the level of supervision, ADON/QAPI/IP stated that they had every 15-minute safety checks, but we didn't have 1:1 even though it was something that we recommended but we don't have that level of funding for staff to sit with him. When staff had free time, they sat and kept an eye on him, but we were short on staff and didn't have the adequate staff he needed, on nights we sometimes had only two CNAs and the nurse was passing medications. ADON/QAPI/IP stated that the only intervention that would keep R106 safe would be 1:1 supervision but the facility could not provide that level of supervision because the facility did not have the staff. ADON/QAPI/IP acknowledged the facility was responsible for keeping R106 safe and the facility did not provide adequate supervision to R106. During an interview on [DATE] at 8:10 AM Restorative Nursing Assistant (RNA) stated that she did not recall providing or seeing R106 with an anti-roll back wheelchair. RNA stated that R106 received therapy services. During an interview on [DATE] at 2:05 PM Physical Therapist (PT) stated that he did not recall what type of wheelchair R106 had and if R106's wheelchair included an anti-roll back device. PT stated that it should be documented in therapy/restorative notes as part of services provided but sometimes wheelchairs are switched even without a referral. Review of therapy notes provided by facility upon request for all of R106's physical therapy and restorative notes, including assessment on [DATE] and [DATE], did not show documented evidence that R106 received or used a wheelchair with anti-roll back devices. During an interview on [DATE] at 8:14 AM Certified Nursing Assistant (CNA)10 and CNA11 were interviewed. CNA11 stated that she recalled R106 whose room was right near charting station and resident was constantly trying to stand up and move, resident would propel wheelchair and would lift feet and place over wheelchair leg rest and was very challenging. CNA11 stated that she did not recall R106 having anti-roll back devices on his wheelchair. During an interview on [DATE] at 9:21 AM DON stated that facility was short staffed and unit aides used to provide 1:1 monitoring but unit aides were lost when the covid waivers went away. DON confirmed R106 was inadequately supervised because he really needed 1:1 monitoring which the facility could not provide. DON further stated that they were trying to get R106 to a memory care facility, but it was not covered under resident's insurance. During an interview on [DATE] at 4:16 PM MDS nurse stated that she and Registered Nurse (RN)4 who help develop care plans attended IDT meetings to discuss R106's falls and actions to reduce falls and any recommendations made at meeting should be reflected in R106's care plan. MDS nurse further stated that if an action is not in the care plan, it is a break in the intended process. Please refer to F600. 40844 * For Resident 156: Review of Admission MDS assessment dated [DATE] revealed the facility admitted R156 on [DATE] with diagnoses of non-Hodgkin lymphoma, adult failure to thrive, pain in right knee, unsteadiness on feet, repeated falls, mechanical ptosis (a condition in which the upper eyelid droops, sags or falls over the eye) of bilateral eyelids, paralytic ptosis of right eyelid, and need for assistance with personal care. R156's cognitive function was assessed to be intact scoring 13 out 15 on a Brief Interview for Mental Status. The assessment indicated R156 exhibited rejections of care 1 to 3 days during the 7 previous days. The initial nursing assessment dated [DATE] indicated R156 required staff assistance with transfers and a ADLs. The note read, Resident is very unsteady gait/poor balance and needs assistance x 1. Very High Risks for fall. Under observations it read, needs full assistance with transfers and ambulation - not safe to ambulate by self. The facility developed a care plan focus upon admission for R158's risk for falls with a goal of being free from injury. Interventions included to provide assistance with transfers and ambulation, anticipating R158's needs, keeping the call bell within reach, providing a safe environment, the use of chair and bed sensors, follow facility fall protocol, ensure appropriate footwear, and keeping the environment free of clutter. Review of the April fall log provided by the facility revealed R158 had three falls in April on, [DATE], [DATE], and [DATE]. All three were unwitnessed falls. Review the facility's investigation into the falls provided by the facility revealed the root cause of the falls included R156 self-transferring, not asking for assistance, and failing to lock the brakes of the wheelchair. The IDT documented two recommendations on the Post-Fall assessment dated [DATE]: Encourage using call light for assistance - refuses @ times. And Antiroll back wheelchair. An anti-roll back device is a braking mechanism that automatically locks rear wheelchair wheels when a patient stands. Additional review of the facility fall logs for May, June, July, August revealed R158 had 5 additional falls in May ([DATE], [DATE], [DATE], [DATE], and [DATE]); 3 falls in June ([DATE], [DATE], and [DATE]); 2 falls in July ([DATE], and [DATE]); and 2 falls in August ([DATE] and [DATE]). Additional review of the facility fall investigations revealed 6 of the 12 falls between May and August ([DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]) identified not locking wheelchair breaks as a root cause. The IDT identified a component of non-compliance to their efforts to educate R158 to ask for assistance before getting up, and/or to lock her wheelchair breaks for all 15 falls. Additional review of the care plan for falls revealed frequent updates related to educational interventions for safety, fall events, and monitoring, however the care plan lacked the recommended intervention of using anti-rollback device on the wheelchair. The facility reported the [DATE] fall to CMS as a fall with major injury. The report indicated neuro checks were initiated with findings that right eye was not reactive to light, though R156 has problems with that eye. R156 was sent to the local hospital for evaluation after R156 complained of left arm pain. Hospital records included a CT of the head completed on [DATE] which read, Acute subdural hematoma over the right anterior frontal lobe. During an interview with the Assistant Director of Nursing (ADON) who was also the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) on [DATE] at 09:57 AM, R156's falls and fall investigations were reviewed. ADON/QAPI/IP described R156 as aware of where she is, who she is. She was identified as a fall risk. We had no issues the first couple of days. Then we would get notifications she having difficulty going to bed, impulsive getting up on her own. We oriented to her environment and the call light . we would find her getting up and rummaging through her drawers, and staff heard the shower on, [she was showering independently]. At first, with those reorientations or reminders she was receptive and after a while she would become aggressive and lash out. ADON/QAPI/IP confirmed the IDT identified R156 as being resistant to requesting assistance, and frequently did not lock her wheelchair breaks before self-transferring. When asked the IDT recommendation on [DATE] for an anti-roll back device, ADON/QAPI/IP confirmed it was a recommendation. She stated, We talked about it, we had some available, we just didn't go back to revisit it. When asked why a recommendation by the IDT would not be implemented ADON/QAPI/IP replied, I don't know, probably busy. She described the IDT as including all department heads, and confirmed when a recommendation was made, it was not assigned to anyone specific to follow through on it. She stated if a device was issued it would be on the care plan. She stated she would review and provide additional documentation if a device was issued. Additional documentation was not provided prior to the survey exit. During an interview on [DATE] at 04:35 PM, Restorative Nurse's Aide (RNA) confirmed the facility had several anti-rollback devices for wheelchairs. She described they had a nurse who ordered them. It is for a resident that gets up and . she demonstrated on a wheelchair in the rehab gym how the device engaged the wheels and prevented the wheelchair from rolling back. RNA was not aware of a system for knowing who has one on their chair or not. She stated, nobody is charting it. When asked if she recalled R156, she confirmed she was familiar with the resident. She stated R156 did not have an anti-rollback device on her chair and showed the surveyor R156's chair. Observed the wheelchair shown, stored in the rehab gym, had R156's name on it. It did not have an anti-rollback device on it. Review of progress note type: Discharge Summary dated [DATE] revealed R156 was still in the hospital, and the family reported R156 would be starting rehab. Review of facility policy titled Falls and Fall Risk Managing dated - read under the policy statement, Based on previous evaluations and current data, the staff shall identify interventions related to the resident's specific risks and causes to try to reduce falls, reduce injuries, and minimize complications related to falls and identify residents at risk for falls. 41020 * For Resident 207: R207 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (a condition that causes a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life, with no specific diagnosis) and wedge compression fracture (a type of vertebral fracture that occurs when the front of the vertebra collapses, giving the bone a wedge shape) of unspecified lumbar vertebra (lower back), initial encounter for closed fracture. A limited physical mobility and self-care deficit care plan initiated on [DATE] had a goal which indicated the resident required assistance with ADLs (Activities of Daily Living). Interventions included PT/OT (Physical Therapy/Occupational Therapy) evaluation and treatment as ordered. According to the ADL (Activities of Daily Living) Index Report (meaures a person's ability to perfor[TRUNCATED]

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect (R106) and failed to protect residents' right to be free from physical abuse by another resident for (R)(R2 and R27) for 7 sampled residents reviewed for abuse as evidenced by: 1. Failed to ensure resident-centered care and treatment was provided in accordance with professional standards of practice to 1 of 6 sampled residents (R) (R106) reviewed for accidents. Licensed Practical Nurse (LPN) 6 failed to conducted neuro checks to assess for neurological changes and ensure timely interventions after R106's unwitnessed fall, 2. Failed to provide adequate supervision for 1 of 6 sampled residents (R106) reviewed for accidents to prevent recurrent falls when one to one staffing was recommended but not provided, 3. Failed to provide sufficient certified nursing aides (CNA)s on R106's unit for 7 of 16 days when R106 fell . 4. Failed to ensure 1 of 6 sampled staff (LPN6) reviewed completed required annual training including Fall prevention and management during the past two years. The cumulative effect of these failures contributed to environment of neglect. The failure to implement 1:1 monitoring as assessed and identified to ensure resident's safety given repeated falls, failure to ensure staff completed training on fall prevention and management, failure to conduct neuro checks after unwitnessed fall and failure to ensure sufficient nurse staffing to ensure resident safety resulted in harm to R106 who required hospitalization , ventilator care, surgery and subsequently died after final fall in the facility. In addition, the facility failed to: 5. Ensure R27 was free from physical abuse when R106 hit him in the face and pulled his arm. 6. Ensure R2 was free from physical abuse when R21 hit her in the face. These failures placed R27 and R2 at risk for pain and a diminished quality of life. Findings include Review of facility policy Abuse-Investigation and Reporting, revised [DATE], documented Neglect/Mistreatment was defined as failure to give appropriate care, ignore or disregard Residents shall not be subject to abuse by any individual which includes .other residents. The policy outlined that abuse included physical abuse such as hitting/slapping grabbing . Review of Resident 106's (R106) record documented the resident was admitted on [DATE] with diagnosis including dementia, diabetes, frequent falls, orthostatic hypotension (sudden drop in blood pressure when you stand up from a sitting or lying position) and stroke. R106's Minimum Data Set (MDS-assessment tool), dated [DATE], documented resident's brief interview for mental status was 12 of 15, indicating moderate cognitive impairment and required supervision or touch assistance when transferring from chair to bed or walking 50 feet while using a walker. Resident was transferred to the hospital on [DATE]. Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and had unwitnessed fall on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] and witnessed fall on [DATE] and [DATE]. Please monitor his vital signs, neuro checks, pain, skin condition, ROM (range of motion) and delayed injuries. Follow the facility protocol for monitoring s/p (status post, after) fall condition with start date [DATE]. Review of facility's fall incident reports documented resident had 16 falls during four-month stay. Falls on [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE], [DATE], [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE], [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE] (unwitnessed), [DATE](unwitnessed), [DATE] (unwitnessed), [DATE], [DATE] (unwitnessed). Twelve of the 16 falls were unwitnessed. 1. Neuro checks (Please also refer to F689) Review of facility's Falls and Fall Risk Managing policy, dated ,d+[DATE], documented under section Steps (Post Fall) 30 minutes 3. neurological checks: Required for all falls with head injury or unwitnessed falls. a. Neurological checks include assessing: i. Glasgow Coma Scale [a tool used to measure a person's level of consciousness and how responsive they are], ii. LOC (level of consciousness), iii. Orientation, iv. Movement in Extremities, v. Pupil size and reaction and vi. Speech and Responses. b. For 72 hours at a frequency of: i. q (every) 15 min(utes)x1 hour, ii. q30 min(utes) x 1 hour, iii. q1 hourx4 hours, iv. q4 hoursx24 hours, then v. qshift x72 hours, 4. Monitor vital signs, 5. Monitor for signs/symptoms of delayed injury (i.e., bruising, bleeding, fracture). 1 hour: 2. Complete the following documentation: a. Post Fall Screening Sheet .e. Neurological Checklist with a head injury and unwitnessed fall (UDA)(user defined assessment) PROGRESS NOTES Review of R106's progress notes, dated [DATE] at 8:46 PM, Licensed Practical Nurse (LPN)6 documented Informed by another resident (R), R106 was sitting on floor in the Great Room. No wheelchair in area and attempting to get up but not calling out. Resident's wheelchair was found in room [ROOM NUMBER] by bathroom door and bed linen in room was ruffled up. Resident was attempting to get up during assessment. No injury noted, no bump on head, no bleeding. Resident questioned if he was hurting or if he bumped his head. Denied both and wanted to get up. Resident asked if he needed to go to the hospital - denied. Resident was then assisted to w/c. Continuing on VS [vital signs] from recent fall earlier. Phone cont(inue) busy. Review of R106's progress notes, dated [DATE] at 10:57 PM LPN6 documented During shift report, CNA (Certified Nursing Aide) reported Resident (R106) having multiple episodes of emesis (vomiting). Near beginning of shift CNA reported Resident vomited; VS [vital signs] taken, BSL @ (blood sugar level at) 223. Elevated BP, confused and aggressive. Review of R106's progress notes, dated [DATE] at 2:58 AM LPN6 documented Resident reported with bout of emesis this shift approx(imately) 2000 (8PM). VS taken and CNA reported elevated BP (blood pressure). Resident monitored by CNA, attempting to get up OOB (out of bed), bed alarm sounding d/t (due to) continued restlessness. During bed checks, Resident sleeping w/ (with) legs hanging off the side of the bed, ,d+[DATE] dressed and partly exposed. Assisted CNA with getting Resident back into bed and changed. Encouraged Resident to rest and he calmed down.Called to room when emesis reported. VS cont(inue) w/ elevated BP, skin cool to the touch, staff reported Resident did not look right/normal. Called ER (emergency room ) and spoke w/ Nurse [Name of nurse], we would send Resident in via facility van. Returned to Resident and was informed Resident was now unable to stand, more lethargic, VS unchanged and cont(inue) cool to touch. Called ER, then EMS for transport. Resident left facility at 2340 (11:40 PM) FALL INVESTIGATION Review of facility incident witness report form, dated [DATE] at 8:30 PM, documented by LPN6 showed checkmark in box for Other and a checkmark was not shown in box for Fall for type of incident. The details section documented Alerted to (R106) was sitting on floor in Great Rm (room) but another resident. No calling out observed. When notified by staff, Resident wanted assist to get off of floor. During the assessment of Resident, CNAs attempted to get Resident up but were told to wait since Resident had to be assessed. Resident told staff I slipped when asked. But no w/c (wheelchair) nearby. WC found in Rm 1213 with alarm sounded and muted. Resident assisted off of floor to w/c x3 staff. While being assess Resident denied hitting head, denied pain, denied wanting to go to the hospital. Just wanted to get up. Resident on AC (alert charting) for recent fall, no new protocol continued. Resident cont(inued) with ongoing behavior prior to fall. Had resident sit in w/c-later assisted to room. Review of facility incident witness report form, dated [DATE] at 8:15 PM, documented by LPN2 showed checkmark in box for Fall as type of incident with details At approx(imately) 2015 (8:15 PM) I was completing treatments in (nursing unit). I had gathered my supplies and was entering Rm 1207 when I heard [name being called], I leaned back out of the room and resident [room number of resident] was pointing into the living room area. As I looked in that direction, I observed [R106] lying on the floor near the [unit] kitchenette. [Name of LPN6] was nearby and I asked her Did you guys put [R106] on the floor? He's on the floor. [LPN6] walked over and observed resident then called to the night CNAs The following documents were not provided by facility for [DATE] fall, which were required per facility policy after an unwitnessed fall, including: 1. Post Fall Screening form which is a checklist to determine why resident fell such as what type of footwear resident was wearing, if environment was clear or cluttered, was resident confused or dizzy, was resident wearing glasses or hearing aide, if there were skin tears, lacerations or any injuries, immediate blood pressure, oxygen saturation level, heart rate, temperature, pain level, level of consciousness. 2. Interdisciplinary Post-Fall Assessment form which describes fall, outlines the number of falls in the last 30, 90 and 180 days, if there were recent medication changes, pattern of current falls such as time of day, six month review of falls and if there were any patterns or trends related to falls, probable cause of falls, root cause analysis of falls, recommendations from the review by IDT (Interdisciplinary Team), and care plan revisions. 3. Neurological check form that documented initial assessment of resident's pupil size and reaction to light, movement of extremities, vital signs, and level of consciousness. 4. Post Fall-Nurse Neurological Check Guidelines that documented assessment of resident's pupil's reaction to light, able to follow finger, verbal responses, pain level and level of consciousness every 15 minutes for 1 hour, every 30 minutes x4, every hour x4, every four hours x4 and every shift x3. 5. 72-hour intentional rounding after fall that assessed and documented pain, positioning, peri-needs and possessions such as call light within reach, glasses, water and environmental conditions every hour. INTERVIEWS During an interview on [DATE] at 7:36 AM LPN2 stated that when residents have an unwitnessed fall she completes neuro checks and completes fall packet which includes neuro checks every 15 minutes x4, then every 30 minutes x4 and so forth as outlined on form. LPN2 stated that she checks on the resident's level of consciousness, if the resident is alert, lethargic, nonresponsive, the resident's pupils reaction to light, size, extremity strength, weakness, and take their vitals. LPN6 stated when R106 fell on [DATE] she had worked the day shift and her shift ended at 7:30 PM but was doing a last minute treatment on R106's unit when she heard a resident calling her name who directed her that R106 was on the floor. LPN2 stated that she asked LPN6 if she put R106 on the floor and LPN6 said no and then LPN6 called the CNAs over to help. LPN2 stated that R106's fall was unwitnessed because R106 was found on the floor and staff did not put R106 on the floor. During an interview on [DATE] at 2:48 PM Assistant Director of Nursing (ADON) who was also the facility's Quality Assurance and Performance Improvement and Infection Preventionist (ADON/QAPI/IP) stated that R106 had multiple falls in the facility and confirmed during resident's four month stay in the facility, resident had 16 falls, which were both witnessed and unwitnessed. ADON/QAPI/IP confirmed that when resident have an unwitnessed fall, nursing is directed to complete fall packet which includes post fall screening form, neurological check form, post fall nurse neurological check guidelines and 72 hour intentional rounding form. ADON/QAPI/IP further stated that licensed nurses should complete neuro check form for the specific time period as outlined on the form such as every 15 minutes x4, then every 30 minutes x4 to check for concussion or effects of head injuries. ADON/QAPI/IP stated that R106 had a witnessed fall on [DATE] and an unwitnessed fall on [DATE] and she should have received a fall packet including fall sheet and neuro checks for the [DATE] fall but didn't. ADON/QAPI/IP stated that when she did not receive the fall packet at the end of the day on [DATE], she asked LPN6 for the fall packet and LPN6 responded that she didn't complete the fall packet including neuro checks. ADON/QAPI/IP stated that she reviewed the video footage for R106's [DATE] fall and saw that R106 tripped and fell near the kitchenette, and LPN6 was not observed to complete a neuro assessment or vital signs after the fall but should have. The next day in the evening, R106 vomited and wasn't himself so he was sent to the emergency room . ADON/QAPI/IP stated that LPN6 no longer works at the facility. ADON/QAPI/IP stated that it was important to do neuro checks for the frequency and duration because of latent effects, residents can have a change in level of consciousness later and R106 didn't have nausea/vomiting for almost 24 hours after his fall. During an interview on [DATE] at 9:34 AM Medical Doctor (MD)1 confirmed he was R106's physician, resident had multiple falls and it was important to do neuro checks for ,d+[DATE] hours after falls because of latent injuries and possible concussion. MD1 further stated that it was important to watch for neuro changes that so actions can be taken as soon as possible. MD1 confirmed that resident's vomiting and change in mental status the day after a fall could be contributed to a head injury from the fall. MD1 also confirmed that after resident was transferred to the emergency room , he was air lifted to nearby hospital as family wanted everything done, resident was full code, and resident was found to have a subdural hematoma that required ventilator support, surgery, intensive care services and subsequently died . During an interview on [DATE] at 9:21 AM Director of Nursing (DON) stated that staff are expected to complete neuro checks and continue assessments for 72 hours after an unwitnessed fall because there could be delayed effects, and this was not done for R106 during his last fall in the facility. 2. 1:1 supervision (Please also refer to F689) Review of R106's care plan documented resident was at risk for falls related to history of recurrent falls, wandering, confusion and gait (walking) imbalance with goal that resident would not sustain serious injury related to fall. Actions to achieve goal included follow facility fall protocol to prevent fall and monitoring protocol with start date [DATE] and monitor (R106)'s location frequently and assess his needs. Assist with toileting, transferring and walking as need. (R106) requires every 15 minutes safety check with start date [DATE]. Review of fall incident reports documented: *Fall on [DATE] at 7:31 AM was unwitnessed. Wheelchair rolled while resident was attempting to transfer, breaks were unlocked, resident confused, impulsive, no safety awareness and sustained bruises from fall. The interdisciplinary team recommendations included 1:1 supervision (1 staff member dedicated to supervising R106, ratio of 1 staff to 1 resident). 1:1 supervision was not added to resident's care plan. *Fall on [DATE] at 5:10 AM was unwitnessed. Resident was found in the living room and sustained abrasions to his head and both knees. Resident stated, I hit my head. The wheelchair alarm was delayed. Resident transported to the emergency room . The interdisciplinary team recommendations included 1:1 monitoring. 1:1 monitoring was not added to resident's care plan. *Fall on [DATE] at 9:00 PM was unwitnessed in hallway, in great room. Resident stated, I was trying to go to the bathroom, got up from wheelchair while in great room to go to the bathroom and fell in the hallway. The interdisciplinary team recommendations included 1:1 monitoring (not available at facility at this time) and constant redirection. 1:1 monitoring was not added to resident's care plan. During interview on [DATE] at 2:48 PM ADON/QAPI/IP stated that she conducted fall investigations which included reviewing documents in fall packet such as incident witness report forms, post fall screening form, neurological check form, post fall nurse neurological check guidelines and video footage and she completed the Interdisciplinary Post-Fall Assessment form with the input from the interdisciplinary team which included unit charge nurses, Director of Nursing, social workers, MDS nurse, Housekeeping, Maintenance, and sometimes activities and the lead CNA. When asked what were some of the root cause analysis of the falls and interventions to prevent recurrent falls ADON/QAPI/IP mentioned several actions and stated that resident was a high fall risk, would sundown in the evenings, and resident was sometimes confused, reorientation didn't always work, he had orthostatic hypotension, impulsive behaviors of getting up all the time, and he sometimes turned off the wheelchair and bed alarms so we couldn't rely on them. When asked about the level of supervision, ADON/QAPI/IP stated that they had every 15-minute safety checks, but we didn't have 1:1 even though it was something that we recommended but we don't have that level of funding for staff to sit with him. When staff had free time, they sat and kept an eye on him, but we were short on staff and didn't have the adequate staff he needed, on nights we sometimes had only two CNAs and the nurse was passing medications. ADON/QAPI/IP stated that the only intervention that would keep R106 safe would be 1:1 supervision but the facility could not provide that level of supervision because the facility did not have the staff. ADON/QAPI/IP acknowledged the facility was responsible for keeping R106 safe and the facility did not provide adequate supervision to R106. During an interview on [DATE] at 9:21 AM DON stated that facility was short staffed and unit aides used to provide 1:1 monitoring but unit aides were lost when the covid waivers went away. DON confirmed R106 was inadequately supervised because he really needed 1:1 monitoring which the facility could not provide. DON further stated that they were trying to get R106 to a memory care facility, but it was not covered under resident's insurance. 2. Staffing (Please also refer to F725) Review of Facility Assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) received from facility on [DATE], dated [DATE], documented eight CNAs were needed on the weekdays and six CNAs were needed on the weekends/holidays. Under another section of Facility Assessment titled Staff Type/Plan, the following was documented for Direct care staff: 1:,d+[DATE] resident ratio Days and 1:,d+[DATE] resident ratio Nights. Facility Assessment also documented there were 27 residents on B wing (where R106 resided) in January to [DATE]. During a concurrent interview and joint review of Facility Assessment on [DATE] at 2:32 PM ADON/QAPI/IP stated that the facility assessment was based on resident acuity. When asked to explain the Facility Assessment and how many CNAs were needed during the weekdays and weekends for each shift, ADON/QAPI/IP stated that it is three CNAs per each unit (male household and female household) on day shift and the same on night every day. ADON/QAPI/IP also stated that the facility was so short staffed with licensed nurses and CNAs that they could not account for someone like R106 who needed 1:1 supervision. Review of C.N.A Weekly Group Schedule for [DATE] to [DATE], documented less than required 3 CNAs worked on R106's unit seven times during the specific date and times when R106 fell . During a concurrent interview and joint review of CNA schedule and CNA punch timecards, Payroll Specialist (PS) confirmed two CNAs worked on the specific dates and shifts below. *On [DATE] at 5:50 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 6:00 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 7:31 AM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 6:05 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 5:10 AM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 6:00 PM R106 fell and two CNAs worked, less than required 3 CNA worked. *On [DATE] at 9:00 PM R106 fell and two CNAs worked, less than required 3 CNA worked. During an interview on [DATE] at 9:21 AM DON stated that facility was short staffed and unit aides used to provide 1:1 monitoring but unit aides were lost when the covid waivers went away. DON confirmed R106 was inadequately supervised because he really needed 1:1 monitoring which the facility could not provide. DON further stated that they were trying to get R106 to a memory care facility, but it was not covered under resident's insurance. 4. Annual trainings (Please also refer to F726) During a concurrent interview and record review on [DATE] at 10:35 AM ADON/QAPI/IP stated that she oversaw nursing staff training which was completed and documented through Relias system. ADON/QAPI/IP further stated that the facility did not have a policy for staff competency but stated all nursing staff including licensed nurses were required to minimally complete 22 modules each year which included module Preventing Falls: An Interdisciplinary Approach. ADON/QAPI/IP provided copy of LPN6's official transcript which showed during 2022, a half hour training titled About Falls was completed. Preventing Falls training or any training regarding Falls was not completed in 2023 and 2024. In addition, 10 of the 22 required training was not completed in 2022, 21 of the 22 required training was not completed in 2023 and 22 of the 22 required training was not completed in 2024. ADON/QAPI/IP confirmed LPN6 did not complete required annual training during 2022, 2023 and 2024 which was expected for all nursing staff. ADON/QAPI/IP stated that LPN6 was notorious for not completing training and LPN6 was informed verbally and in writing to complete training, but trainings were not completed. During an interview on [DATE] at 9:21 AM DON stated that the expectation is staff complete required training annually and when it is overdue it should be completed as soon as possible but it was so difficult because facility was so crunched and short with staffing. RESIDENT to RESIDENT ABUSE Review of R27's progress notes dated [DATE] at 10:35 PM documented R27 was hit in the face by [R106]. R27 was noted to have minimal amount of redness to the right side of his face. Review of facility's alleged abuse investigation, dated [DATE] documented that Licensed Nurse Aide (LNA)2 observed on [DATE] at 7:20 PM that R106 hit R27 on the right side of R27's head/face. R27 was parked in front of R106, R27 turned around to see what was happening and R106 grabbed R27's right arm and was aggressive towards him/shaking R27. R27 was trying to pull his arm back as he was sitting away from R106. LNA2 stated that she yelled stop, don't do that, let him go and ran over to have R106 let go. The two residents were separated. Protective measures to ensure that further abuse, neglect does not occur included .(R106) to be monitored frequently, not able to provide 1:1 monitoring at this time IDT (interdisciplinary team) recommended the following changes in facility procedures of a plan of care frequent monitoring of (R106)---as staffing allows. During a concurrent interview and record review on [DATE] at 3:45 PM ADON/QAPI/IP reviewed facility's investigation that included video footage and ADON/QAPI/IP confirmed that R27 was abused when R106 hit R27's face and grabbed R27's arm. 41020 -R21 was readmitted to the facility on [DATE] with diagnoses which included unspecified dementia (a clinical syndrome that occurs when a person has dementia but it can't be diagnosed as a specific type), unspecified severity, with other behavioral disturbance (a pattern of disruptive behaviors that can cause problems in social, home, and school settings) and delirium (a mental state that causes a person to be confused, disoriented, and have reduced awareness of their surroundings) due to known physiological condition. Review of the annual Minimum Data Set (MDS) (Comprehensive) assessment dated [DATE] revealed the resident scored 12 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. An Incident Note dated [DATE] at 3:12 PM revealed the resident was the recipient of physical aggression from another resident (R206). -R206 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and delirium due to known physiological condition. The admission MDS assessment dated [DATE] revealed the resident scored 9 on the BIMS assessment, indicating moderately impaired cognition. An Incident Note dated [DATE] at 3:59 PM revealed R206 initiated physical aggression with another resident (R21). Review of the facility's investigation report dated [DATE], revealed the charge nurse heard some verbal commotion as she was at the Household 1 nursing station. The commotion was coming from down the hallway. Just as the nurse looked that direction, she witnessed both residents parked parallel to one another and verbally exchanging words. Then, R206 swung her arm out and hit R21 on the right arm. From the opposite direction, another staff witnessed R206 also hit R21's right cheek. The two staff members who observed the altercation immediately intervened and ran over to separate the two residents. An interview was conducted on [DATE] at 2:15 PM with a Certified Nursing Assistant (CNA14). She stated that R206 would go into R21's bathroom and sometimes they would have altercations about it. She stated that they moved R206 to another room, but R206 would tend to stay around R21's room. She stated that staff would separate the residents and that R206 was on 15-minute checks for the longest time because of her behavior. During an interview conducted on [DATE] at 2:41 PM with a Licensed Practical Nurse (LPN2). She stated that R21 was always doing things to the other residents, and that R206 went into everybody's room. She stated that at that time, they just kept them separated. She stated they would take R206 back to her room, but she just couldn't comprehend that. R21 was educated to come to staff, but they couldn't always keep an eye on them. She stated that she saw R206 raise her fist and hit R21 on the right arm. Another staff (CNA15) saw R206 hit R21 in the right cheek. She stated that she thought R21 might have had a little bit of redness, she couldn't really remember. She stated that R206 was not hit. On ,d+[DATE] at 1:13 PM an interview was conducted with the Director of Nursing. She stated that supervision was one of the hardest challenges, and day shift was really, really busy. She stated that she was trying to emphasize that the charge nurse goes rounding with the CNA's so they that things are getting done. She stated that she tries to educate the charge nurses because it was hard to say that supervision was being done. She stated that it was unfortunate that the blanket waiver for unit aides was lifted, so they don't have them anymore. She stated that they were really helpful and prevented a lot of incidents. She stated that the intervention was to keep the residents apart as much as possible, and to have the social worker to educate them on not behaving like that. She stated that they still slipped through, and that staffing-related issues were one of the biggest challenges right now. A request was made for the Resident Supervision and Dementia Care policies. The Assistant Director of Nursing indicated that they did not currently have policies on resident supervision and dementia care.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure seven residents (Resident (R) 99, R98, R24, R3, R39, and R36) received care and treatment in accordance with professional standards of practice. 1. The facility failed to perform Accuchecks (finger stick blood sugar checks) per the physician's orders for eight days while continuing to administer scheduled insulin to R99; 2. and failed to notify R98's Physician to obtain an order for Accuchecks after the resident was admitted to the facility with an order for insulin. 3. The facility failed to perform neuro checks after R39, R24, and R36 had sustained unwitnessed falls. 4. Additionally, the facility failed to ensure skin assessments and wound measurements were completed per the facility's policy for R3. An Immediate Jeopardy (IJ) was identified on 09/15/23 and was determined to exist starting on 08/08/23, in CFR 483.25 F684: Quality of Care. The Director of Nursing (DON) was notified on 09/15/23 at 12:25 PM of the failure to provide care and services in diabetic management for R98 and R99. The events and potential risk of serious harm and/or death constituted the IJ for R98 and R99 which constituted Substandard Quality of Care at CFR 483.25. The facility was notified that the Immediate Jeopardy was removed after on-site verification of the plan to remove the immediacy was implemented, on 09/15/23 at 5:45 PM. The deficient practice remained at an E (Pattern with no actual harm with potential for more than minimal harm) scope and severity following the removal of the Immediate Jeopardy. Findings include: 1. Resident 99: Review of the facility's policy titled, Glucose Management, dated 07/2019 revealed, .Glucose management requires the license nurse to administer medications according to the established schedule, unless clinically contraindicated by high or low Blood Glucose Level (BGL). The facility will maintain a medication administration record (EMAR) to document all interventions and order in the Electronic Health Record (EHR), and Point Click Care (PCC) .A licensed nurse (Registered Nurse, Licensed Practical Nurse) or Medical Assistant (MA) will obtain a blood sample 30 minutes before meals (Breakfast, Lunch, Dinner) for most accurate BGL .to safely administer insulin to adult residents .To optimize glycemic control .To ensure appropriate documentation of insulin administration and BGL monitoring . Review of R99's undated Transfer and Discharge form provided by the DON revealed R99 was admitted to the facility on [DATE] with diagnoses which included diabetes. Review of R99's handwritten Admission Orders from the hospital dated 08/16/23, provided by facility revealed, Accuchecks AC BID [before meals two times daily.] Review of R99's updated handwritten Physician Order dated 08/23/23, provided by the provided by the facility revealed, Check fasting blood sugar daily, send results to [Physician 20] in 2 weeks. Review of R99's admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 08/30/23 revealed R99 had a Brief Interview for Mental Status (BIMS) score of ten out of 15 which indicated she was moderately cognitively impaired. Continued review of the MDS revealed R99 had been administered insulin for seven out of seven days during the observation period. Review of R99's August 2023 and September 2023 Medication Administration Record (MAR) located in the Orders tab of the EMR, revealed the facility had performed the accuchecks three times daily when the accuchecks were only ordered one time per day from 08/23/23 to 09/07/23 then discontinued the Physician Order after the two weeks. There was no documentation in the Nursing Progress Notes that Physician 20 was notified of the Accucheck levels during the two-week period. Continued review of the MAR revealed from 09/07/23 to 09/15/23 (eight days,) R99 was administered her regular scheduled insulin two times daily; however, no Accuchecks were performed daily and no sliding scale insulin (as needed insulin when BGL are performed) was administered to monitor and intervene for any unsafe blood sugar levels. During an interview on 09/15/23 at 11:01 AM, [NAME] Clerk (WC) 43 was asked if she had transcribed the physician order on 08/23/23, when Physician 1 had assessed the resident. WC43 stated, Yes, I created it. I got it from Physician 1, she wrote it. WC43 was asked how she decided the order meant to perform Accuchecks for only two weeks and then discontinue. WC43 stated, I entered the order incorrectly. The nurses are to check the orders though. During an interview on 09/15/23 at 11:27 AM, Licensed Nursing Assistant (LNA) 77 was asked if he performed the accuchecks on R99. LNA77 stated, I have not been doing them since 09/07/23 as it [the order] was only for two weeks. I had been doing them prior to this. During an interview on 09/15/23 at 10:35 AM, R99 was interviewed via an interpreter. R99 was asked if she was administered insulin. She stated, Yes. R99 was asked if the nurses perform her Accuchecks and how often they do them. She stated Yes, three times a day. R99 was asked, since you were admitted , did you have any high or low blood sugars, that you were aware of. R99 stated, No. During an interview on 09/15/23 at 11:30 AM, the Quality Assurance and Program Improvement Nurse (QAPIN) was asked if the physician order on 08/23/24 supersedes the admission orders on 08/17/23. The QAPIN37 stated, Yes. The QAPIN read the 08/23/23 order and confirmed that the order read to check Accuchecks daily and notify the physician in two weeks, not to discontinue the order. QAPIN was asked what the potential negative outcome would be since R99 has not had Accuchecks performed in the last eight days. QAPIN37 stated, It would be bad. She could have been hypo/hyper [low/high] glycemic without us knowing about it, as she is still getting insulin. During an interview on 09/15/23 at 12:14 PM, the DON was asked what the process was for when a physician order was received and if the order was unclear or needed clarification. The DON stated, All of our orders go to the [NAME] Clerk. When the nurses see that the [NAME] Clerk has entered the order, they are ok with it, and sign off. The DON was asked if the nurses would call (the physician) and get clarification if an order was confusing. The DON stated, They do not. Most likely the nurses would do whatever is on the orders and not question them. The DON was asked why they did not call and get clarification. She stated, I don't know why they (the nurses) are not questioning them. The DON was asked if her expectation was for the nurses to recognize dangerous situations and notify the physician. The DON stated, It's never been questioned, most likely they just follow orders. Licensed Practical Nurse (LPN) 15 just noted the order and didn't question it. 2. Resident 98: Review of R98's undated Transfer/Discharge Report provided by the facility revealed R98 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic neuropathy. Review of R98's admission MDS with an ARD of 08/21/23 located in the electronic medical record (EMR) under the MDS tab revealed the facility assessed R98 to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of R98's Clinical Physician's Orders dated 09/13/23 located in the EMR under the Orders tab revealed R98 was ordered Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 8 unit subcutaneously at bedtime related to type 2 diabetes mellitus. Further review of the Clinical Physician's Orders revealed no documented evidence of an order for R98's blood sugars to be checked. Review of R98's hospital Assessment/Plan dated 07/27/23, located in the EMR under the Misc tab revealed R98's Hemoglobin A1c (a simple blood test that measures your average blood sugar levels over the past three months) was 6.8 in June 2023 and was well controlled. R98 received Glargine 10 units at bedtime and had sliding scaled insulin administered in the hospital, prior to her nursing home admission. The hospital record revealed R98's blood sugar was checked once a day in the hospital. Review of R98's nursing Progress Notes from 08/08/23 - 09/13/23 in the EMR under the Progress Notes tab revealed no documented evidence related to checking R98's blood sugars. Review of R98's MAR from 08/08/23 - 09/13/23 in the EMR under the Orders tab revealed no documented evidence related to checking R98's blood sugars. R98 was administered insulin once daily at bedtime as ordered by the physician. Review of R98's MAR dated 09/15/23 revealed R98's BS was checked on this date, and it was 152. This was the first BS check documented on the MAR. Review of R98's Treatment Administration Record (TAR) from 08/08/23 - 09/13/23 in the EMR under the Orders tab revealed no documentation related to checking R98's blood sugars. Review of R98's Nutrition/Dietary Note dated 08/20/23 included no reference to blood sugars or diabetes mellitus. Review of the R98's Annual Physical Examination Note dated 08/23/23 in the EMR under the Progress Notes tab revealed, Dr. [name] here at [facility name] this morning. Resident seen by her provider for an admission PE [physical examination]. Progress notes pending at this time. The documentation from the physician was not available until 09/14/23, after the surveyor requested it. Review of the R98's 60/30 Day Eval Notes dated 09/13/23 in the EMR under the Progress Notes tab revealed, Dr. [name]e here at [facility name] this morning. Resident seen by her provider for a 30-day evaluation. Progress notes pending at this time. The documentation from the physician was not available until 09/14/23, after the surveyor requested it. Review of the R98's physician's Progress Note dated 09/13/23 provided by the facility on 09/15/23 revealed, DM2 [diabetes mellitus type 2]: -A1c 6.8 June '23 -current regimen: Lantus 8u [units] q [at] HS [hour of sleep] --well controlled, no symptomatic lows since admission, continue current regimen --Will start FSBS [fasting blood sugars] pre-breakfast daily and as needed. Review of the R98's Care Plan dated 08/08/23 in the EMR under the Care Plan tab revealed the problem of: I, [R98] has [sic] diabetes mellitus type 2 and I use long-acting insulin at bedtime. The goal was, I, [R98], will have no complications related to diabetes through the review date. Interventions in pertinent part were: -Administer [R98] diabetes medication (Insulin Glargine 8 unit at bedtime) as ordered by doctor. Monitor/document for side effects and effectiveness. -[R98] Dietary consult for nutritional regimen and ongoing monitoring. -Monitor [R98] document/report PRN any s/sx [signs/symptoms] of hyperglycemia [high blood sugar] . -Monitor [R98] document/report PRN any s/sx of hypoglycemia [low blood sugar] . -I, [R98], has [sic] potential risk for hypoglycemia episode r/t [related to] disease process (Type 2 DM), use of medicines insulins (glargine) and diet (diabetic/CCHO). -I, [R98], will be free from any s/sx of hypoglycemia through the review dates . -If [R98]'s glucose meter reading =70 mg/dl, Treat hypoglycemia per protocol w/o [without] any delay: Follow 15-15 rule for hypoglycemic management. (1) For BS = 70, give one of the carbohydrates (15 gm)-gel tube, boost breeze 100 ml, suplena 60 ml, 1 tbsp of sugar, honey or corn syrup and recheck after 15 minutes. (2) If the BS is = 70, have another serving and notify the provider for further management instructions. (3) If the BS is > 70, notify the provider for further management instructions. Notify the provider within 30 minutes of first BS = 70. Although the Care Plan directed staff to notify the physician and take specific action for blood sugars of 70, the staff did not have and order to check blood sugar, did not check R98's blood sugars, and would not have known what the blood sugar levels were. During an interview of 09/11/23 at 10:25 AM, R98 stated she received insulin in the evening every day. R98 stated the staff had not checked her blood sugar. R98 stated her blood sugar had been checked every morning when she was in the hospital and at home prior to her admission to the facility. R98 stated her blood sugar typically, runs around a 100 something. During a follow up interview on 09/15/23 at 10:10 AM, R98 verified her blood sugar was checked daily prior to admission to the facility. R98 stated she could not tell when her blood sugar was high. R98 stated there was an instance of high blood sugar recently when it was above 300. R98 stated she did not have low blood sugar. During an interview on 09/13/23 at 3:56 PM, Registered Nurse (RN)76 stated R98 did not get insulin, then reviewed the physician's orders and stated, yes R98 received glargine insulin in the evening. RN76 verified there was no order for BS checks and stated R98's BS had not been checked. During a subsequent interview on 09/14/23 at 1:02 PM, RN76 sated the physician had been informed about a lack of BS checks for R98. RN76 stated R98's primary diagnosis was diabetes mellitus and BS were usually checked and should be checked for residents on insulin. RN76 stated she did not administer insulin to R98 on her shift (day shift). During an interview on 09/15/23 at 9:26 AM, the Minimum Data Set Coordinator (MDSC) stated R98 had received insulin daily since admission. The MDSC stated residents on insulin were supposed to have blood sugar checked usually twice a day, or at least once a day. The MDSC stated it was important to check blood sugars due to the possibility of hypoglycemia. The MDSC stated she was the nurse who had admitted R98 and questioned the lack of BS checks. The MDSC stated she asked the night shift nurse (LPN and traveling nurse) about it and was told if the doctor did not order it, then there was no need to follow up. The MDSC asked the LPN on night shift if she would follow up. During a follow up interview on 09/15/23 at 11:38 AM, the MDSC stated she asked the evening shift LPN about the lack of BS checks when R98 was admitted on [DATE] even though she was a more qualified nurse, being an RN vs LPN. The MDSC stated if R98 was hyperglycemic or hypoglycemic, she would not know if the BS wasn't checked. The MDSC stated high or low BS could affect the brain and result in injury or the resident becoming brain dead. The MDSC stated there were no standing orders to check BS for residents who were prescribed insulin. The MDSC stated, residents with insulin should have regular BS checks, in the morning or night or even, if stable, at least once a week. The MDSC verified she did not call the physician to verify the orders although she stated she should have. The MDSC stated there was another resident on insulin who also did not have BS checks. The MDSC stated she could have contacted the DON; however, she did not. The MDSC stated she did not feel comfortable administering insulin without checking BS herself and would check BS even if there wasn't an order to do so. During an interview on 09/15/23 at 11:17 AM, the WC stated on 09/13/23 she contacted R98's physician about checking BS for R98. The WC stated the physician stated he would review R98's record and orders came on 09/14/23 to check R98's BS. During an interview on 09/15/23 at 12:13 PM, the DON stated if an order was unclear, it should be referred to the WC. The DON stated the nurses did not question physician's orders. The DON stated she did not know why the nurses did not question physician's orders. The DON stated she would expect nurses to identify a dangerous situation. The DON stated she had never had a nurse come to her about a questionable order. The DON verified she was not notified that there was no BS check order for R98. The DON stated R98's physician was asked about checking BS for R98 (during the survey) and initially said her hemoglobin A1c (lab measuring diabetic control) was stable and that BS checks were not needed. The facility presented an acceptable plan of removal on 09/15/23 at 2:30 PM which included: ~ The resident who was identified to be affected will have an order for accuchecks by her PCP [primary care physician]. ~ All residents who receive Insulin per physician orders have the potential to be affected. There is (1) resident identified today 09/15/23. ~ Notifications sent to Medical Director, I.H.S. [Indian Health Service] Provider Physician 20, and charge nurses. ~ Notification will be sent to Physician 20 to clarify the order for the resident (R99). Accucheck order written by Physician 20 on 08/26/23. ~ A nurses' meeting will be held to provide in-house training to all nurses before the nurse is allowed to work the floor on 09/15/23. A sign-in sheet will be provided for nurses who attend the training. Nurses who are not able to complete the training in person will be able to call in via telephone for the training. Transcription of orders policy reviewed with nursing admin and charge nurses. ~ Nurse duties and responsibilities with Physician orders. The topics in training will include .Critical thinking skills to identify potentially dangerous and adverse effects of medication or treatment orders .Notification to physician to clarify questionable orders .Documentation of notification must be made. ~ Interim DON will retrieve a clear order for accuchecks for R99 that will accompany her scheduled insulin administration from Physician 20 today, 09/15/23. ~ All charge nurses will be responsible for transcribing incoming physician orders into the MAR [Medication Treatment Record] once they are received. ~ The transcribing nurse will have another nurse double check the physician's order to make sure the order is accurate. ~ If the order is noted to be questionable or inaccurate, the nurse will contact the prescribing physician for clarification before the order is transcribed and carried out by the nurse. ~ DON will audit all orders transcribed by the charge nurses on a weekly basis to make sure orders are accurate. The IJ immediacy was removed on 09/15/23 at 5:45 PM. 3. Neuro Checks after unwitnessed falls: Review of the facility's undated Falls and Fall Risk Managing policy and provided by the facility revealed, Based on previous evaluations and current data, the staff shall identify interventions related to the resident's specific risks and causes to try to reduce falls, reduce injuries, and minimize complications related to falls and identify residents at risk for falls . Neurological checks: Required for all falls with head injury or unwitnessed falls. A. Neurological checks include assessing: i. Glasgow Coma Scale ii. LOC [level of consciousness] iii. Orientation iv. Movement in extremities v. pupil size and reaction and vi. Speech and responses b. For 72 hours at a frequency of: i. q 15 mins [minutes] x[for] 1 hour ii. q 30 mins x 1 hour iii. q 1 hour x 4 hours iv. q 4 hours x 24 hours, then v. q shift x 72 hours . Resident 24: Review of R24's undated Transfer/Discharge Report provided by the facility revealed R24 was (re)admitted to the facility on [DATE] with diagnoses including dementia and age-related physical debility. Review of R24's quarterly MDS with an ARD of 08/02/23, located in the resident's EMR under the MDS tab revealed the facility assessed R24 to have a BIMS score of zero out of 15 which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed R24 required extensive assistance with most activities of daily living (ADLS) such as transfers, bed mobility, and locomotion on and off the unit. R24 had not experienced any falls since the prior MDS assessment. Review of R24's Care Plan dated 05/09/23, located in the EMR under the Care Plan tab revealed the problem of, High risk for falls r/t [related to] gait/balance problems, vision/hearing problems and intermittent confusion episodes. The goal was for R24 to, be free of falls through the review date. Interventions in pertinent part included, Follow facility fall protocol to prevent [R24's] fall and injury. Review of R24's Nursing Progress Note dated 04/10/23 at 8:18 AM, located in the EMR under the Progress Notes tab revealed R24 experienced a fall on 04/09/23 as follows: Resident found at bedside prior to 2300 [11:00 PM] rounds. No injury, sitting talking to herself, did not hear an alarm. CNA [certified nurse aide] was answering call light for another roommate. After assessment and body/skin check, Resident was lifted off the floor and placed on the bed. Bed in low position w/o [without] blue mats on floor. No skin issues, bone deformity nor abrasions, nor bruises observed. Head w/o bruises, no tenderness, no bleeding seen. Fall protocol paperwork initiated. Resident did state to CNAs, that she wanted to sit up. Her O2 [oxygen] NC [nasal canula] was still attached on w/ [with] SaO2 [oxygen saturations] above 90%. Review of R24's Neurological Check Form dated 04/09/23, at 11:00 PM provided by the facility revealed neurological checks were completed on this date at this time. Review of R24's Neurological Check Form dated 04/12/23, provided by the facility revealed neurological checks were completed on this date at 5:12 PM. No additional neuro checks were provided by the facility. During an interview on 09/13/23 at 3:36 PM, RN 76 stated neuro checks should be completed if a resident had an unwitnessed fall or if they hit their head. RN76 stated there was a flow sheet that should be filled out at specific intervals for a specific time frame. During a follow up interview on 09/14/23 at 12:58 PM, RN76 stated it was important to complete all the neurological checks within the 72-hour time frame because things could change. RN76 also stated a resident's eyes could become fixed, the resident could start vomiting, etc. after a prior check that was normal. RN76 stated neurological checks were important to rule out a head injury. During an interview on 09/14/23 at 11:36 AM, the DON stated, following the initial assessment, there was only one neurological check completed on 04/12/23 for R24 after her fall on 04/09/23. During a follow up interview on 09/15/23 at 1:10 PM, the DON stated the nurses should complete all the specified neurological checks to evaluate if changes occurred. The DON stated the purpose was to evaluate the resident for a head injury and she expected all the nurses to complete the neuro checks. Resident 39: Review of R39's undated Admission Record located in the resident's EMR under the Profile tab reveled the resident was admitted to the facility on [DATE], with diagnoses which included spinal stenosis, presence of right artificial knee joint, and dementia. Review of R39's Progress Notes located in the resident's EMR under the Progress Notes tab revealed R39 had an unwitnessed fall on 07/17/23. Review of the R39's fall investigation provided by the facility, revealed a Nuerological [sic] Check Form dated 07/17/23 at 3:50 PM. The form included the initial neurological check, no other neurological checks were included in the investigation. During an interview on 09/14/23 at 2:38 PM, LPN90 was asked what she could recall about R39's fall. LPN90 stated, I remember he was laying on the floor beside his bed. [I] Assessed him and placed him back in bed with the help of other staff. LPN90 was asked if neurological checks were performed. LPN90 replied, I filled out the form for the initial check and then the rest of the checks are placed in the EMR. LPN90 was asked where those checks could be found. LPN90 reviewed the EMR and could not locate them. LPN90 stated. He did go to the hospital, but neurological checks should have been started back up when he returned from the hospital. Neurological checks should be done on all unwitnessed falls. The checks should include 15 minutes checks and 30 minutes then q shift for 72 hours. During an interview on 09/14/23 at 3:17 PM, the DON was asked what the expectation was when there was an unwitnessed fall. The DON stated, I expect staff to do and complete neuro [neurological] checks. There should be 15-minute checks for the first hour then go to 30 minute and so on until 72 hours have been completed. They should be available in the EMR. 40844 Resident 36: Review of the facility demographic sheet revealed R36 was admitted on [DATE]; diagnoses included dementia, cognitive impairment, and abnormalities of gait. On 09/13/23 at 1:06 PM LN65 described the facility process when a resident has an unwitnessed fall. She stated, We go by this, and concurrently reviewed a blank post-fall packet. The packet included forms titled Post Fall Screening and Neurological Check Form. She stated they complete an initial assessment of the resident, check for injuries and if ok to get up, We get them up and finish our assessment . start them on alert charting. She described alert charting was a 72-hour monitoring. She confirmed a neuro check was done during their initial assessment, and subsequent checks were part of monitoring for changes. When asked how frequently they assessed a neuro check she stated, Usually they [the nurses] do them q [every] shift. When asked if she was aware of the timing and frequency their fall policy directed, every 15 minutes for the first hour, every 30 minutes for the 2nd hour, every hour for four hours, every 4 hours for 24 hours, and then every shift, she confirmed she was not aware of that. She stated, We don't do that. She stated after the initial neuro check included in the fall packet, subsequent checks would be documented on the Assessments tab in the e-HR. During the interview with LN65, a concurrent record review of R36's e-HR revealed there was one to three neuro assessments for each of R36's unwitnessed falls on 09/07/23, 08/20/23, 07/16/23, 07/14/23, 07/10/23, 07/09/23, and 07/09/23. The record lacked neuro assessments completed at the frequency outlined by the policy and standard nursing care. During an interview on 09/13/23 at 4:12 PM the Quality Assurance Nurse, RN37 confirmed the post-fall packets did not include more than one neuro assessment form. She stated, Our system doesn't include that, if you go under assessments there is a new neuro form. She added that she and the DON had discussed this and were planning on adding to the form for the additional neuro checks. 32513 5. Skin Assessments: Review of the facility's policy titled, Skin Wound System Documentation, dated 03/29/22 revealed, .During shift of admission the skin risk assessment will be done and documented in Skin Wound-Total Body Skin Assessment .The head-to-toe exam of the resident's skin will be done within the first 24 hours and documented in the Nursing Admission Screening/History under Assessment .Any existing wounds, bruising, skin tears, bruising, lesions that are present, will be recorded and documented as On admission skin condition .Each resident will have a skin monitoring completed each shift .Each resident will have a weekly assessment/measurement of skin condition/wounds and will be recorded accordingly .In the event of a skin/wound problem, present on admission, or develops during stay .A skin/wound event will be entered in the Risk Management (RM) area of Point Click Care (PCC-electronic medical record EMR) to document the initial discovery or the condition on admission. This will allow the treatment to be linked to the specific skin/wound . Review of R3's undated Transfer and Discharge form provided by the DON, revealed R3 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease and diabetes. Review of R3's Nursing Progress notes dated 04/08/23, located in the Progress Notes tab of the EMR revealed CNA reported bruise behind left leg and discoloration lower inner leg with skin intact but pain upon touch. [NAME] hose socks [compression stockings] were not wearing [sic] properly which was bunch up [sic]. Resident bilateral legs have edema +1 pitting .Skin intact and wrap with kerlix for protection . Alert charting was initiated (every shift charting for change in condition) however, no skin assessment or measurement of the bruise was documented on the Skin/Wound Assessment form in the Assessments tab of the EMR. Review of R3's Nursing Progress notes dated 04/12/23, located in the Progress Notes tab of the EMR revealed CNA reports the bruise again to the nurse after a shower. The wound was then measured for the first time at 9.0 cm [centimeters] x 6.0 cm and was tender to the touch. The resident was transferred to the emergency room for further evaluation. Review of R3's Skin/Wound Assessment form dated 04/12/23, located in the Assessments tab of the EMR did not show documentation that initial wound measurements were documented on the form, per the facility policy. Review of R3's Progress Notes dated 04/12/23, located in the Progress Notes tab of the EMR revealed on 04/12/23, R3 returned from the emergency room with documentation to show a hematoma (a solid swelling of clotted blood within the tissues) and to return to the emergency room if the area became infected. The Progress Note further showed that R3 was referred to the surgery clinic within one week. An x-ray of the tibia/fibula [bones in the lower leg] was performed at the emergency room to rule out trauma. This was negative. Review of the R3's Progress Notes dated 04/13/23, located in the Progress Notes tab of the EMR, dated 04/13/23 revealed, the facility had called the surgery clinic and documented that the physician looked over the documentation and said it wasn't a priority and scheduled her for 08/14/23 (four months later.). Review of the R3's Nursing Progress notes dated 04/16/23, located in the Progress Notes tab of the EMR, dated 04/16/23, revealed that R3 continued to have increased pain, swelling, redness, and drainage to the leg. R3 was transferred back to the local emergency room and then was transferred via ambulance to a medical center and admitted for left leg cellulitis (a common and potentially serious bacterial skin infection). Review of the R3's TAR located in the Orders tab of the EMR and Skin/Wound Assessment located in the Assessments tab of the EMR did not show, between 04/12/23 and 04/16/23 documentation of that wound measurements had been completed. The TAR only showed vital signs were documented. Review of the R3's Progress Notes dated 04/26/23, located in the Progress Notes tab of the EMR revealed, on 04/26/23 (10 days later), R3 was readmitted to the facility after having had surgery on the left lower extremity. Review of the R3's admission nursing assessment dated [DATE], located in the Assessments tab of the EMR showed documentation of the wound, however, did not show an assessment of the wound including wound measurements. The only documentation included that the left lower extremity had a dressing on it. Review of the R3's May 2023 TAR located in the Orders tab of the EMR, and the Skin/Wound Assessments located in the Assessments tab of the EMR revealed, only on two occasions (05/16/23 and 05/24/23) was the wound was documented on the Skin/Wound Assessment form out of five weeks. The wound measurements were only documented on the 05/16/23 Skin/Wound Assessment form which showed the wound measured, 13.0 cm x 6.0 cm. Review of the R3's June 2023 TAR located in the Orders tab of the EMR, and the Skin/Wound Assessments located in the Assessments tab of the EMR revealed, the resident was being seen by the Wound Clinic however, documentati[TRUNCATED]

Based on observation, interview, record review, and policy review the facility failed to provide supervision to prevent resident injury during assisted transfers utilizing a mechanical lift. The facility failed to develop and implement policies for safe use of mechanical lifts and failed to ensure staff were trained and competent prior to using the mechanical lifts. Three residents (R22, R32 and R34) who required mechanical lift transfer were at risk for serious injury or death during transfers. Direct observation identified unsafe practice when R32 was left unattended while suspended in the lift sling during mechanical lift transfer that placed R32 in immediate jeopardy for severe injury or death. R22 experienced minor injury to lower leg and R34 fell and hit his head with development of a hematoma during mechanical lift transfers. Findings include: Mechanical patient lifts are named after one of the first companies to manufacture them-Hoyer. The mechanical lifts used in the facility were battery powered Invacare Reliant 450. The facility referred to the Invacare lifts as Hoyer lifts. FDA (Food and Drug Administration), NIOSH (National Institute for Occupational Safety and health) and Hoyer manufacturers provide written protocols for operation of mechanical lifts. Sample protocols direct two persons to perform mechanical lift transfer; one person required to operate the lift and the other person assists and guards the patient/resident against injury. The second person can seek needed supplies/equipment such as replacement battery leaving one person with the patient so they are never left unattended. FDA patient Lift Safety Guide at https://www.fda/gov/media/88149/download. page 2; Know your lift. Receive training and practice before operating a lift. !ALERT-Patient falls from lifts may cause injuries including head trauma and death. Page 10: Lift the patient. !DO NOT leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. Slowly lift patient only as high as necessary to complete transfer. Resident R32 Record review: The Plan of Care last reviewed 8/5/22 indicated R32 admitted to the facility with diagnoses that included but not limited to Diabetes, Dementia, Parkinson's disease and age-related osteoporosis. Taber's medical dictionary; osteoporosis means porous bones, a disease that weakens bones making bones more susceptible to fractures. The care plan indicated; [Activities of daily living] ADL self-care performance deficit r/t [related to] Dementia, Impaired balance, Limited Mobility, Neuralgia (nerve pain) and Neuritis (inflamed nerves) Date Initiated: 5/16/2019 TRANSFER: per 1/10/2022: PT [physical therapy] recommends a mechanical liftfor transfer. The care plan indicated R32 was at high risk for falls and had acute and chronic pain r/t Neuralgia and neuritis, bilateral knee pain, and history of pelvic fracture. R32 had Sensor chair and Bed alarms in use for fall prevention purposes. Nursing progress notes dated 8/6/22 at 12:55 PM noted sensor alarm alerted staff and R32 was found sitting on the wheelchair footrests between the bed and the locked wheelchair with no apparent injury. A nursing progress note dated 7/15/22 at 7:00 PM noted R32 was sitting on the floor with her back against the wheelchair seat cushion and her legs spread out in front of her. R32 stated I slid off the chair. Observation: 8/23/22 11:06 AM: R32 lay in bed. A transfer/bed mobility rail was raised on the left side of bed and a fall mat was on the floor on the left side, the bed was in lowest position (at floor). When asked the purpose of the low bed and floor mat, Nursing Assistant (NA) 8 said R32 was impulsive and a high fall risk and recently had a fall. NA8 provided incontinent care for R32. At 11:19 AM, NA8 wheeled R32 out of the room in a high back reclining wheelchair, the Hoyer lift was at the bedside with no other staff in the area. When asked if she transferred R32 with the Hoyer lift by herself, NA8 said yes. Asked about process for Hoyer lift for R32 and her risk for falls. NA8 said she was able to do it [Hoyer transfer] by herself because R32 was cooperative with her. Observation: 8/25/22 10:01 AM. R32 lay in bed as Certified Nursing Assistant (CNA) 10 and CNA11 prepared to use a Hoyer lift to transfer R32 from bed to chair. CNA10 wheeled the Hoyer lift into the room. CNA11 cued resident to roll to her side. CNA10 and CNA11 each stood on a side of the bed. CNA11 verbalized the process as they worked together adjusting the lift sling under the resident. CNA11 said a blue sling was used due to R32's size. Once the sling was attached to the sling bar on the lift, CNA10 stood behind the high-back reclining wheelchair. CNA11 used the lift controls and raised R32 up off the bed. With R32 suspended over the bed, CNA11 went around to the front of the lift and held R32's lower legs to rotate and swing her body off the bed, CNA11 used R32's legs to push the lift back away from the side of the bed. CNA11 then went to the back of the lift and used the controls to raise R32 higher. R32's feet and lower legs dangled. CNA11 pushed the lift toward the wheelchair, R32's right foot was up on the lift frame and the left ankle and foot twisted and nearly became entrapped between the wheelchair and the lift mast. CNA10 saw the foot turn and exclaimed Oh. CNA10 was not in a position to protect the legs and feet and was not in a position to support the resident if she started to slip from the sling or if the sling failed. CNA10 remained behind the wheelchair during the entire Hoyer transfer process. CNA11 reached underneath R32's suspended body and adjusted her feet. Interview followed observation: CNA10 and CNA11 said they were trained on the use of the lift in their nurse aide training program and during facility orientation. CNA10 stated they also had the training in Relias. (Relias is a proprietary online program for health care worker training). When asked their understanding for one or two staff to perform Hoyer transfers CNA11 said the facility preferred two staff for the Hoyer lift. CNA10 said it required two staff and that is what the facility said. When asked what the Relias training taught; CNA11 said the Relias training showed to use two people but it also gave another choice to use one person. When asked how did they know when to use one or two. CNA10 said; the facility says two. On 8/24/22 at 9:14 AM the assistant to the CEO stated the facility did not have a policy on the lifter [referring to mechanical lift]. On 8/25/22 at 9:14 AM an undated document marked Draft, and titled; Resident Lifting/Assisting Transfers was presented. The QA nurse said the lift policy was in process but it was not yet submitted for approval so it was not implemented. When asked the facility expectation regarding one or two staff to perform Hoyer lift transfers. QA nurse said two people were required to use the Hoyer lift in the facility and she was not aware of any exceptions for one-person Hoyer lift. QA nurse said Relias was used for training and she provided staff a list of all required trainings. QA nurse said Relias had a program on mechanical lifts and it was mandatory for all nursing assistants. QA nurse 'ran a print-out' that showed CNA10 and CNA11 completed the Relias training in April 2022. The training was assigned to NA8 however the training was not completed. The printed Relias lesson: Section 1: Transfers: Mechanical Lift directed: Before you start transferring someone with a mechanical lift, you first need to *Check individual's plan of care, your organization's policies and procedures, and the manufacturer's instructions on proper lift use. *Determine if another person is needed to assist with the lift. Most lifts require two people -one to operate the lift and one to guide the sling. ---Only lift the individual as high as needed to clear the transfer surfaces. -pull the lift backwards so the legs are clear of the bed or chair. Interview 8/25/22 at 11:20 AM with QA nurse: Reported observation of NA8 using the Hoyer lift without assistance. QA nurse said the described practice was not consistent with the facility expectation. Reported findings of the mechanical lift transfer observation with CNA10 and CNA11. QA nurse pulled up the Relias training video. The video showed the second staff supporting the legs and standing directly at the side of the suspended resident with hands in contact with the sling as it was maneuvered over the wheelchair and then the second person was shown behind the wheelchair to guide the lowering of the sling into the chair. The User Manual for Invacare 450 obtained on the internet directed; This manual must be given to the user of the product. BEFORE using this product, read the manual and save for future reference. Warnings Signal words are used in this manual and apply to hazards or unsafe practices which could result in personal injury or property damage. Definitions of the signal words included: Signal DANGER Danger indicates an imminently hazardous situation which, if not avoided, will result in death or serious injury. WARNING Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. Page 7 WARNING! DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. Use common sense in all lifts. Special care MUST BE taken with people with disabilities who cannot cooperate while being lifted. WARNING! Although Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. Pages 30-31: * When the resident is clear of the bed, swing their feet off the bed (Detail B). *Use the steering handles, move the lift away from the bed. Detail B is an illustration that shows 2-persons using the lift. One person with hands-on support of the legs and the other person using the steering handles to pull the lift away from the bed. Observation: 8/26/22 10:51 AM: NA8 prepared to assist R32 from bed to wheelchair. R32 reported knee pain, and stated they hurt all the time. NA8 worked alone and placed the lift sling under R32 while she lay in bed. NA8 attached the sling straps to the lift bar and raised R32 very high up off the bed surface. NA8 then held R32's legs, rotated her body off the bed, then pulled on her legs to move the lift away from the bed. NA8 moved the lift into the roommate's area of the room. R32 was suspended in the sling very high off the floor at the level of NA8's chest. NA8 left R32 unattended while suspended in the air. NA8 walked across the room and around the bed to the alcove by the window to retrieve the wheelchair. NA8 placed the wheelchair in the middle of the room, then pushed the lift near the wheelchair. While R32 was still suspended in the sling, NA8 pushed on R32s upper leg moving the sling to the left to clear the wheelchair armrest and used the other hand to manipulate the lift controller to lower R32 into the wheelchair. Lastly, NA8 went behind the wheelchair and pulled on the sling to straighten R32 in the chair. While unattended and suspended in the air in the lift sling, R32 was in immediate jeopardy and at risk for serious injury including head trauma, fractures, and death in the event of a fall from the lift. The facility was informed of IJ on 8/26/22 at 1:14 PM. IJ template presented to the facility DON, Assistant to the CEO, and QA nurse. The facility presented a removal plan that included immediate notification to all staff on duty that residents were not to be left unattended during use of the Invacare Reliant 450 mechanical lift. In-service training to begin immediately with the day shift and continue with the start of each shift until all direct care employees were provided the in-service. The removal plan was accepted on 8/26/22 at 4:05 PM. Observation: 8/26/22 at 4:30 PM: A large group of staff were assembled in the living room of Household 1. QA nurse, DON, and assistant to the CEO led a discussion and in-service regarding use of the Invacare mechanical lift. The in-service was repeated on Household 2. Interviews: On 8/26/22 at 4:55 PM interview with CNA13 confirmed she attended the Hoyer lift in-services. CNA13 stated two staff were needed to transfer-one to operate the lift, and one to manage the resident. CNA13 was able to describe activities for 'managing the resident'. Interview with (training Nursing Assistant) TNA1 conducted 8/26/22 at 4:59 PM; TNA1 described the Hoyer lift training she received that same day and stated she understood two staff were required to transfer residents with the Hoyer lift. Interview conducted 8/26/22 at 5:02 PM; CNA5 confirmed she was trained today on the use of the Hoyer lift. CNA5 stated two staff were needed, one to assist the resident and one to use the lift. CNA5 confirmed that the resident should not be left unattended at any time while in the lift. The IJ was removed on 8/26/22 at 5:03 PM after onsite verification of implementation of the removal plan. A pattern of deficient practice remained at level two no actual harm but potential for more than minimal harm. Resident R22 Record review: R22 admitted to the facility on [DATE] with diagnoses that included Dementia, COPD (chronic obstructive pulmonary [lung] disease), osteoarthritis of the right knee and adult failure to thrive. A Physical Therapy assessment conducted on 3/14/22 noted R22 reported pain in her right knee for one year and did not walk because of her knees. The PT noted R22 was dependent to move from sit to stand and was unable to achieve standing position due to significantly limited knee extension. R22 was dependent in all ADLs including transfers. A mechanical lift was used for all transfers. Record review: Progress notes dated 3/21/22 4:00 PM: CNA reported R22 had a skin tear on her left lateral lower leg that occurred during a transfer. Assessment showed a 2.0 cm length skin tear. Active bleeding was stopped and a dressing was applied. The facility documented an investigation on a QAQI [Quality Assurance] Incident/Complaint Report. The report dated 3/22/22 indicated CNA14 was transferring R22 from bed to wheelchair and foot rests got in the way and caused a skin tear to left lower leg. CNA14 did not notice the skin tear until she was putting booties on the resident. The CNA14 wrote; Next time I will remove the leg rests before transferring. The investigation concluded; as a result of not removing the foot rest on the wheelchair before patient transferring, the foot rest caused a 2.0 cm skin tear on the left lower lateral leg. The report: Describe the corrective measure taken to address immediate hazards related to incident. Written response; Employee review regarding *proper positioning during transfers *Follow resident care plans regarding transfers: >Requires Hoyer lift for all transfers with 2 staff assistance > review Kardex >requires total assistance by 2 staff. *Call for assistance from fell ow CNA if help is needed. *Plan to start skills competency for transfers, mechanical lifts, vital signs, etc. TBD. The QAQI report was signed by QA nurse 3/22/22 Interview: 8/26/22 11:06 AM with QA nurse; When asked how the facility ensured competency to use the Hoyer lift; QA nurse said the facility did not currently have anyone who tracked skills checks. QA nurse said newly hired nurse assistants participated in an 8-hour orientation day that covered a brief presentation by each department head. Once CNAs were on the floor, they worked with a senior CNA and they did hands on training with the equipment such as lifts. When asked about the plan to start skills competency for transfers and mechanical lifts as stated in the 3/22/22 QAQI report, QA nurse said it did not happen yet. Interview: 8/26/22 11:26 AM with ADON (assistant DON). ADON said she supervised the CNAs. ADON said she did not have checklists for skills or competencies. ADON said It is up to the assigned CNA to go over things when they orient new CNAs. ADON referred to the lead CNA. Interview: 8/26/22 11:45 AM with lead CNA (CNA15): CNA15 said newly hired CNAs start with one 8-hour day of general orientation and then shadow a CNA. CNA15 said she paired new hires with senior CNAs for 4 night shifts and 3 day shifts to show them the tasks and how to care for the residents. CNA15 said the CNAs had a checklist with the things like the forms they have to complete and the day to day tasks. CNA15 said there was no skills check. When asked how she determined when a CNA was ready to work independently, CNA15 said she knows they are ready when they say I am ready to work alone. 40844 Resident 34: Review of medical record revealed the facility admitted R34 on 6/16/22 with an admitting diagnosis of Diabetes. Additional diagnoses included rheumatoid arthritis, osteoarthritis, atrial fibrillation (abnormal heart rhythm), spinal stenosis, history of transit ischemic attacks (TIA), and repeated falls. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. The Functional Status section revealed R34 required extensive assistance for transfers, bed mobility, dressing and toiletings. Physician's Orders revealed the following orders with revision date 3/16/22: ASSISTANCE: Total care w/ ADL's REFERRAL: PT/OT eval on admission. An intervention for the ADLs care plan read. TRANSFER: [R34] requires Hoyer Lift with (2) staff assistance for transfers. PT evaluation/recommendations: she requires a Hoyer lift for all transfers. Date Initiated: 3/22/2022 . Revision on: 7/18/2022 Review of the progress notes revealed an incident note dated 8/11/22 4:35 PM. It read, Note Text: 1635 pm [4:35 PM] staff reported to writer that resident was on the floor. Witnessed Fall during transfer and slip out of w/c [wheel chair] and bump head. Head to Toe assessment completed. Alert and oriented x 2 (name/situation) and stated headache. [vital signs]: 185/85, 65 (pulse), 22 (respiratory rate), 97.8, 91% RA (oxygen saturation on room air) and glucose 98. Transfer resident from floor to bed with (3) staffs. 1645 [4:45 PM] writer contacted EMS for transfer to ER department for witnessed fall and hematoma on right side head . Review of the ER clinic notes revealed radiological imaging of head, neck and chest revealed no acute injuries and R34 was discharged back to the facility. Review of the POC Response History (CNA documentation of care provided) revealed the Question TRANSFER: SUPPORT PROVIDED - How resident moves between surfaces to or from: bed, chair, wheelchair, standing position. CNA responses read, One person physical assist 12 out 20 times (60%) between 8/16/22 and 8/22/22. An additional review of the responses recorded during the look back period for the 6/29/22 MDS assessment revealed a similar pattern of one person assistance for transfers. During an interview on 8/29/22 at 3:47 PM the QA Nurse was asked how R34 slipped out of chair. She stated that a nursing assistant was transferring R34 from the bed to the chair by herself with a mechanical lifter and slid out of the chair. She confirmed the care plan called for 2 staff to perform transfers.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure residents' environment remained as free of accident hazards as is possible. Specifically: 1. Postural support The facility failed to ensure one of three residents (Resident (R) 2) with orders for the postural support device was applied correctly. When staff secured the device behind R2's back and R2 repositioned themselves, the device became a strangulation threat posing a serious risk for death or serious harm due to potential for strangulation Furthermore, all three residents (R2, R7, and R31) were not assessed for appropriateness or safety of the device before implementation. This failure resulted in the identification of an Immediate Jeopardy. On 09/22/21 at 04:57 PM, the Director on Nursing and other administrative staff were notified of the Immediate Jeopardy. The facility presented a removal plan which was accepted on 09/23/201 at 09:10 AM. While onsite, it was determined the IJ was removed on 09/24/2021 at 11:15 AM; the deficiency remained at level 3, actual harm that is not Immediate Jeopardy. [Cross reference F604] 2. Thickened liquids The facility failed to have a system in place to ensure that all residents (Residents (R) 1, 7, 8, 22, 31, 32, 39, 41, 47, and 49) who had physician's orders for thickened liquids received the correct liquid consistency when receiving fluids. This failure placed residents at risk for choking and/or aspiration of liquids, which had the potential of causing serious harm or death. This failure resulted in the identification of an Immediate Jeopardy. On 9/23/2021 at 1:11 PM, the Director of Nursing and other administrative staff were notified of the Immediate Jeopardy. The facility presented a removal plan on 9/23/2021 at 2:47 PM, while onsite it was determined that the Immediate Jeopardy was removed on 09/24/21 at 10:09 AM; the deficiency remained at a level 3, actual harm that was not Immediate Jeopardy. 3. Falls The facility failed to ensure 4 of 5 sampled residents (Resident (R) 2, R23, R31 and R49) reviewed for accidents had a root cause review (a systematic process for identifying the cause of a problem and an approach for responding to the problem) for each fall they had, an investigation of the cause of the fall and interventions implemented to prevent reoccurrence of falls. These failures placed the residents at risk for repeat falls, which had the potential of causing serious harm. R2 sustained falls which resulted in actual harm of leg fractures and skin tears, and R23 sustained a fall which resulted in a [CONDITION(S)]. After the fall, R23 was not assessed prior to being picked up from the floor, creating the potential for further injury. 4. Treatment carts unlocked The facility failed to ensure residents' environment were free from hazards, when treatment carts were left unlocked when unattended and/or out of view of the nursing staff. This failure allowed residents access to hazardous items (medicated creams, sharp objects, etc.), which placed residents at risk for avoidable incidents. Findings included: 1. Postural supports: On 09/22/21 at 08:24 AM, observed R2 was sitting in a wheel chair beside the bed. On this day, R2 had a white cloth device wrapped around their torso encompassing the wheel chair. Certified Nursing Assistant (CNA) 18 was preparing to enter the room and stated, I'm gonna put [R2] in bed. CNA18 described the white cloth device as a positioner which kept the resident upright. After donning (putting on) required PPE surveyor requested CNA18 ask R2 in their native language to remove the device. After looking at the device, CNA18 stated It is secured in the back, [R2] cannot take it off. Observed the device was positioned high on R2's upper chest, approximately 1 inch below the neck. CNA18 confirmed the device had shifted during use and was not applied correctly. She further described R2 as 'sometimes combative,' gesturing with her arms like she was struggling or hitting out. During an interview on 09/22/21 at 09:39 AM, the Charge Nurse, Licensed Nurse (LN) 2 was asked about the positioning device. She stated, It is something to hold [R2] in place. [R2] used to be one of those that climb out of the chair . It is almost like a restraint. [R2] wiggles and squirms. That is why it should be here (gestured to upper abdomen) . [R2] is actually capable of taking it off. Review of active orders in the electronic health record (E-HR) on 09/22/21, revealed an order for the positioner dated 03/30/21. It read, May use TORSO SUPPORT, to maintain body posture & positioning - attach & secure daily to ensure above. A review of assessment under the Assessments tab of the E-HR and progress notes revealed a lack of assessment prior to implementing the positioning device. Reviewed R2's care plan on 09/22/21. It revealed a focus area for the torso support positioning device. An intervention read, Apply [R2's] Self release torso support's Velcro strap in the front while seated in wheelchair so she can self release as needed. Date Initiated: 07/21/2021 The facility's policy, Torso Trunk Support (undated) indicated the device maintains proper body alignment and is used for upper torso postural support to prevent tilting and leaning. Under the procedure section of the policy, the following is noted, .2. Physical Therapy will assess resident to determine if Posey trunk support will be beneficial and safe for resident use . Manufacturer's instructions titled Posey Torso Support included the following contraindications, DO NOT use on a patient who is or becomes . combative, agitated . STOP USE AT ONCE: if the patient has a tendency to slide forward or down in the device . Resident 7 R7 had diagnoses that included dementia (memory problems), congestive heart failure (heart does not pump effectively), high blood pressure, and [CONDITION(S)] (gradual loss of kidney function). A Physician's Order, dated 7/14/2021, was reviewed for a Self-Release Torso Support to be applied while seated in a wheelchair. Resident requiring upper support to help reduce tilting, leaning, and falling from chair. On 9/20/ at 11:19 AM, R7 was observed in a wheelchair. R7 had on a posture device that had a seatbelt-like strap over his lap, which was held closed with a hook and loop fastener. There were also two straps that crossed on the back of the wheelchair back and came over the resident's shoulders and Velcroed to the seatbelt-like device. Review of R7's clinical record revealed no Physical Therapy assessment for the use of the torso support device. This was confirmed by the Director of Nursing on 9/22/2021, at approximately 6:00 PM during a group interview. Resident 31: R31 was readmitted to the facility with diagnoses that included dementia (memory problems), diabetes (high blood sugar), and [CONDITION(S)] disease (progressive nervous system disorder that affects movement-tremors, stiffness, or slow movement). Reviewed Physician's Order, dated 7/14/2021, for a Self-Release Torso Support to be applied while seated in a wheelchair. Resident requiring upper support to help reduce tilting, leaning, and falling from chair. A care plan was initiated on 7/14/2021, for the use of the Posey Self-Release Torso Support. The care plan indicated that the device should be used while R31 was seated in a wheelchair to achieve and maintain good body posture and body positioning. Review of R31's clinical record revealed no Physical Therapy assessment for the use of the torso support device. This was confirmed by the Director of Nursing on 9/21/2021, at approximately 6:00 PM during a group interview. The facility was notified of the IJ on 09/22/21 at 04:57 PM, in the presence of the DON, the Quality Assurance/Quality Improvement (QAQI) Nurse, the acting Assistant Director of Nursing (ADON), the Dietary Manager, and the Minimum Data Set (MDS) Assessent Nurse. During the meeting, the DON confirmed there were no assessments for use of the torso supports, and that it should be applied so that it is self-releasing (in the front). The DON acknowledged the risk of strangulation was present when applied improperly. The facility submitted a plan to remove the immediacy of the IJ, which the survey team found acceptable on 09/23/21 at 09:10 AM. The plan included discontinuing the devices, having affected residents assessed by therapy for appropriate device use, implementing monitoring/reporting of the residents every 15 minutes for proper body alignment and comfort, updating the care plan and If additional residents require assistive devices, an assessment will be initiated by nursing and care plan committee prior to application with a doctor's order and PT Evaluation. All staff were to be trained on the plan of removal. Review of documents submitted by the facility revealed R2, R7, and R31 had all been referred to Physical Therapy for a safety assessment, orders for the torso positioners had been discontinued, care plans updated with the removal of the devices, and implantation of the 15-minute safety checks, and training for all staff was completed. 2. Thickened Liquids: The facility's Mechanically Altered Diets and Thickened Liquids policy, with a revised date of 09/16/2018, indicated the following under the Procedure section 3. Food and Nutrition Services should thicken liquids to proper consistency, i.e., juice, milk, coffee, soup, and water. Pre-thickened juice, milk, and water may be desirable where the budget permits. (Send thickened water on each tray.) .4. When thickened water at bedside is required, there are two methods for thickening: a. Send an empty pitcher of a contrasting color on the breakfast carts. Following manufacturer's instructions, send pre-portioned thickeners in covered souffle cups marked 'nectar,' 'honey,' or 'spoon-thick' or b. Send a minimum of 8 oz thickened water or thickened flavored water on each tray and between meals three times daily on the nourishment cart. The bedside water pitcher would not be used The facility policy further documented that when a resident has an order for thickened liquids and also needs additional calorie and protein supplementation, recommend using the Special Nutrition Program. The 2 cal/ml med pass does not thicken well. Two cal/ml med pass is generally acceptable as nectar thick but should be reviewed and approved by the speech therapist. According to form CMS-672, the facility had 45 residents that received mechanically altered diets (pureed and chopped) of that number 10 residents also received thicken liquids. The lists that were posted in the kitchenettes on both units identified the following residents as receiving thickened liquids: Resident 1--Nectar thick liquids Resident 7--Nectar thick liquids Resident 8--Honey thick liquids Resident 22--Nectar thick liquids Resident 31--Nectar thick liquids Resident 32--Nectar thick liquids Resident 39--Nectar thick liquids Resident 41--Nectar thick liquids Resident 47--Nectar thick liquids Resident 49--Nectar thick liquids Resident 31 Resident (R) 31 was readmitted to the facility on [DATE] with diagnoses that included dementia (memory problems), diabetes (high blood sugar), and [CONDITION(S)] disease (progressive nervous system disorder that affects movement-tremors, stiffness, or slow movement). An Annual Minimum Data Set (MDS-mandated assessment tool) dated 7/12/2021, revealed that R31 scored a 5 on the Brief Interview for Mental Status (BIMS-a structured evaluation aimed at evaluating cognition). A score of 5 revealed severe cognitive impairment. Under the functional status section, R31 was assessed to require supervision (oversight, encouragement, or cueing) with setup help only for eating. Under the Swallowing/Nutritional Status section, the assessment indicated that R31 had no signs and symptoms of possible swallowing disorder. Under the oral/dental status section, the assessment indicated the resident had no natural teeth or tooth fragment(s). R31 had Physician's orders for the following: * Order date 9/3/2021,120 cc (cubic centimeters) Med Pass 2.0 twice daily *Order date 1/9/2021, Consistency Carbohydrate (CCHO) diet, Pureed texture, Nectar consistency.( Pureed texture is a diet in which all foods have a soft, milk-shake consistency. The diet consists of foods that are smoother and easier to swallow (no chewing). Nectar thick liquids are thicker than water and fall slowly from a spoon.) A progress note, Communication with Physician, dated 2/8/2021, indicated the following, Assessment (RN)/Appearance (LPN) .Cooperative with care and med[ications] administration .Eating: Eats independently with setup at mealtimes, snack time prn (as needed). Requiring more encouragement and supervision as well. Appetite poor to fair . A Registered Dietician note, dated 8/5/2021, indicated it was an annual review. The assessment included the following information: Current diet CCHO, puree with nectar thick liquids, Supplement: Med Pass 60 120 cc BID (twice daily). Continue to serve diet as ordered, offer snacks PRN (as needed), offer supplements as ordered, honor preferences, offer alternatives as needed, monitor for changes in labs, meds, weights, and intake. R31 had a care plan for therapeutic mechanical altered diet related to poor dentition (condition of teeth), and increased needs related to wound healing with an initiation date of 4/25/2020, and a revision date of 7/19/2021. The interventions included the following: diet as ordered CCHO, puree with nectar thick liquids. There was an additional care plan related to potential fluid deficit due to poor intake of foods and fluids, dated 2/13/2021. The intervention for this plan of care included: encourage [R31's name] intake of meals/fluids, monitor for signs of dehydration, encourage [R31's name] to drink fluids of choice, ensure [R31's name] has access to fluids at bedside and requires nectar consistency and offer and assist with fluid intake, and [R31' name] needs (assistance/encouragement/supervision) with fluid intake in order to meet daily requirements. An observation on the Men's unit in the kitchenette on 9/21/2021 revealed a note posted on the wall. The note indicated Resident Diet Type. The posting revealed 4 of the 30 residents on the unit required thickened liquids. The posting indicated that R31 was to receive Thickened Nectar. On 9/21/2021 at 11:30 AM, R31 was seated in the dining room waiting for the noon meal to be served. A staff person was observed going from table to table offering the residents either coffee or hot tea. R31 was served coffee, R31 picked up the cup and took a sip of the un-thickened hot coffee. On 09/22/2021 at 10:32 AM, observed the interim Assistant Director of Nursing (IADON) passing R31's medications. The AIDON poured medication into medication cup and poured 120 cc of med pass (Hormel 2.0 Med Pass) nutritional supplement into plastic cup. The pills were not crushed and thickener was not added to med pass supplement. The IADON gave the medication and Med Pass 2.0 to the resident. R31 was observed in the dining room on 9/22/2021, at approximately 11:47 AM. The resident was seated at a table that indicated Feeder. R31 was observed feeding himself pureed food from a divided scoop dish. Also, placed near R31 was a cup of coffee and a small glass of juice. Neither of the beverages were thickened. At the end of the meal, a Styrofoam cup with a lid was placed in front of R31. A Certified Nursing Assistant (CNA) who was seated at the table (feeding another resident) indicated it was thickened milk. This surveyor commented that the other fluids were not thickened, the CNA did not address this question but continued to assist another resident. On 9/23/2021 at 8:53 AM, observed the Director of Nursing (DON) passing R31's medications. The DON prepared medications outside the resident's room. The DON placed seven pills into a medication cup, including large calcium pills, and poured 120 cc of med pass (Hormel 2.0 Med Pass) nutritional supplement into plastic cup, The pills were not crushed and thickener was not added to the med pass supplement. Upon entering the resident's room, R31 was observed lying in bed. The DON raised the head of the bed so resident's position changed from lying to about a 30-degree sitting position. The DON placed the pills into R31's mouth and then placed a plastic cup with the med pass supplement near the resident's mouth. R31 started coughing after a few sips of med pass supplement. R31 moved his body and legs towards the edge of the bed where the DON was standing and the DON assisted the resident to sit at the edge of the bed with the resident's feet on the ground while he continued to cough. As R31 coughed, the DON reached for a water pitcher with straw that was on top of side table against the wall across from the resident's bed. The DON placed the straw in R31's mouth. R31 took sips and coughed for a bit more then stopped coughing. On 9/23/2021 at 9:35 AM, R31's room was observed. On the dresser, was a large cup with clear liquid, a lid and a straw. At 10:10 AM, Unit Aide (UA)7 was asked about the water at the resident's bedside. UA7 stated that at the start of his shift he replaced the water at the residents' bedside with a clean cup and fresh water. UA7 stated that all residents received regular water and then staff would thicken the water when offering a resident (who required thickened liquids) a drink. UA7 was asked how staff knew which residents were to receive thickened liquids, UA7 indicated there was a list posted in the kitchenette. UA7 confirmed there was nothing in the residents' rooms indicating what consistency of fluids the resident should receive. On 9/23/2021 at about 8:50 AM, observed the DON passing medications and med pass nutritional supplement to R1. The DON crushed R1's medications and thickened R1's med pass nutritional supplement and then placed crushed medications and thickened med pass onto spoon and spooned into R1's mouth. The DON further stated that R1's eMAR shows it is okay to thicken liquids to decrease coughing. The DON stated that R1 coughs when he drinks and R1 is scheduled to see therapy today. When asked if other residents get their med pass thickened, DON stated that she could not recall. When asked if R31 gets his med pass thickened, DON said no. When asked about R31's coughing during med pass, DON stated that R31 has [CONDITION(S)] and sometimes his swallowing isn't that great, he may have a swallowing delay, and they should probably crush his medications. The DON stated that R31's medications were not crushed. The DON stated the water at R31's bedside was not thickened and further stated I don't thicken his liquids. The DON reviewed R31's eMAR and stated his diet order, dated 1/1/21, was for a carbohydrate consistent diet, nectar thick, and R31 should have received nectar thick liquids. When asked how would staff passing medications know that resident should be receiving nectar thick liquids, the DON stated it depended on who entered the order [in the eMAR] and if that information was shared or not. The DON further stated R31 doesn't usually cough, he'll tell you what he wants. He makes his needs known. It's really hard because we don't have PT (physical therapy), OT (occupational therapy), and I.H.S. (Indian Health Services) decreased their capacity to see residents. During an interview on 9/23/2021 at 9:35 AM, with the DON and Quality Assurance/Quality Improvement/Infection Preventionist Registered Nurse (QAQI), when asked how do you know which residents receive thickened liquids? The DON stated they go by the orders on the resident's treatments which is listed on the eMAR (electronic Medication Administration Record). On 9/23/2021 at 1:11 PM, the DON), IADON, MDS nurse, and QAQI nurse were notified Immediate Jeopardy was identified when R31 received regular consistency liquids when he was supposed to receive nectar thick liquids, per a Physician's Order. On 9/23/2021 at 3:28 PM, CNA31 was asked about the Kardex binder. CNA31 indicated the binder had a copy of each residents' care plan information in it. R31's Kardex, which was located in the Kardex binder, was reviewed. At the top of R31's Kardex, Under the Eating/Nutrition section, dated As of 1/13/21 there was no indication R31 required thickened liquids or a pureed diet. On 9/23/2021 at about 1:08 PM, the IADON was asked about medication pass observation on 9/22/21, and confirmed that she did not crush R31's medication or thicken the med pass supplement. The IADON stated that regular non-thickened water was in the water pitcher in resident's rooms and staff did not thicken water for R31. On 9/23/2021 at approximately 4:00 PM, LN7 was interviewed. LN7 indicated R31 required a pureed diet and nectar thick liquids due to having no teeth and he had some swallowing issues. On 9/24/2021 at 2:57 PM, during a concurrent interview and record review, the DON stated the Hormel brand med pass 2.0 referred to 2 calories per milliliter, and had not been reviewed, approved or accepted as nectar thick for use in the facility as outlined in the facility policy On 09/24/2021 at 3:03 PM during an interview with the Dietary Manager (DM) the DM stated the facility did not have a speech therapist and she was not aware Hormel med pass 2.0 had been reviewed by a speech therapist for meeting the requirements of a nectar thick liquids diet order, as outlined in the facility's policy. On 09/27/2021 at 7:30 AM Pacific standard time Medical Director (MD) stated that he was not aware of immediate jeopardy (IJ) situations last week in the facility. The MD stated that he was called about resident coughing, but did not know it was related to IJ concerns with R31consuming non-nectar thick, regular thin liquids. The MD stated facility staff should be following physician orders, including diet orders for nectar thick consistent liquids, including during medication pass. 3. Falls: The facility policy entitled Falls and Fall Risk Managing (undated) indicated that Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to reduce falls, reduce injury, try to minimize complications from falling and identify patient at risk for falls. Under the Procedures section of the policy, directed .1. The staff with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Under the Monitoring section the following was indicated, 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. If needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified . The policy also included what actions staff should take after a resident fall. These actions included completing an incident form and checking the care plan and redo Fall Scale with IDT [interdisciplinary team]. Resident 2 Review of the Electronic Health Record (E-HR) revealed the facility admitted R2 on 10/25/2019, and readmitted her on 05/07/21, following a hospitalization . The diagnosis tab in the E-HR list included a current [CONDITION(S)] infection ('C-diff' is a bacterium that causes severe diarrhea and inflammation of the colon), heart failure, major depressive disorder, right above the knee amputation, and [CONDITION(S)] (a general term that describes a disease that damages the brain). Nursing notes revealed the resident had a history of falls. A comprehensive Minimum Data Set (MDS) assessment, dated 05/18/21, revealed a BIMS score of 05 which indicated severe impairment of cognitive abilities (intellectual activity such as thinking, reasoning, or remembering), and she required extensive assistance with bed mobility and totally dependent for transfers. During an observation and concurrent interview on 09/21/21 at 11:30 AM, R2 was sitting in a wheel chair beside the bed. Unit Aide (UA) 3 confirmed R2 was on isolation for C-diff. Observed bruising on R2's left hand and elbow area and asked UA3 about it. She stated R2 was combative at times, and was hitting at the wall today getting up. She confirmed she used lift to transfer the resident. On 09/22/21 at 08:24 AM, observed R2 sitting in a wheel chair beside the bed. On this day, R2 had a white cloth device wrapped around their torso encompassing the wheel chair. Certified Nursing Assistant (CNA) 18 was preparing to enter the room and stated, I'm gonna put [R2] in bed. CNA18 described the white cloth device as a positioner which kept the resident upright. After donning (putting on) required PPE surveyor requested CNA18 ask R2 in their native language to remove the device. After looking at the device, CNA18 stated It is secured in the back, [R2] can not take if off. Observed the device was positioned high on R2's upper chest, approximately 1 inch below the neck. CNA18 confirmed the device had shifted during use and was not applied correctly. She further described R2 as 'sometimes combative' gesturing with her arms like she is struggling or hitting out. CNA18 also stated that they used a camera to monitor the resident in her room. [Cross reference F583] During the same observation and interview, CNA18 demonstrated the approaches she used to minimize the risk of falls when in bed. Observed as she utilized the lift to transfer the resident to the bed. The bed was positioned against the far wall in the room and did not have any siderails. After situating the resident comfortably in bed, she lowered the bed to the lowest position and placed a mattress on the floor beside the bed, and then placed 2 smaller floor mats by the edge of the mattress. CNA18 stated I guess [R2] might wiggle off the bed. She set the camera lens to face the resident while in bed before leaving the room. During an interview on 09/22/21 at 09:39 AM, the Charge Nurse, Licensed Nurse (LN) 2 was asked about the positioning device. She stated, It is something to hold [R2] in place. [R2] used to be one of those that climb out of the chair . It is almost like a restraint. [R2] wiggles and squirms. that is why it should be here (gestured to abdomen) . [R2] is actually capable of taking it off. LN2 confirmed R2 was at risk for falls and had several falls in the facility. She indicated the mattress and the then the floor mats should be positioned next to the bed when R2 was in bed. When asked about the camera she stated, That is a way we keep an eye on her sometimes. She described the resident threw herself over the bed, that is how she got that injury. A review of the E-HR revealed the resident had 8 falls over the past 10 months: 11/25/20 Fall An Incident Note dated 11/25/2020 at 03:05 read, Entered room and observed resident on the floor next to bed. Laying in pronation position on stomach. Skin tear sustained to Right elbow (1.8 X 1.2cm). Head to toe assessment completed. The assessment revealed no additional injuries. A fall risk scale titled MORSE FALL SCALE was also completed which scored the resident as High Risk. R2's care plan focus area for actual unwitnessed fall listed this fall. A new intervention, initiated on 11/28/2021, was to use a chair alarm. An interdisciplinary team (IDT) investigation of the fall evaluating and analyzing the hazard risks with a root cause review was absent from the medical record. 11/30/20 Fall An Incident Note dated 11/30/2020 at 18:22, read, Writer got called to Room . to check on resident . who had an unwitnessed fall and found on the floor near big window; Entered room and noted resident laying on her back on top of her Hoyer lift pad and her wheelchair was parked near/behind her head; States she tried to scoot across to get into her recliner chair and her Hoyer lift pad just slipped down with her onto the floor. An assessment revealed no new injuries. A non-slip pad was placed in the wheel chair to prevent slipping out. A fall risk scale titled MORSE FALL SCALE was also completed which scored the resident as High Risk. R2's care plan focus area for actual unwitnessed fall listed this fall. No new interventions were identified during the record review. An interdisciplinary team (IDT) investigation of the fall evaluating and analyzing the hazard risks with a root cause review was absent from the medical record. 12/04/20 Fall An Incident Note dated 12/4/2020 at 15:59, read, CRAWLED OUT OF BED (SUPERFICIAL SKIN TEAR TO CHEST): 2:55 PM, heard resident was yelling, this writer went to check on resident in her room, resident was in bed side lying position, bed was lowest in position and blue mattress (soft padding) to both side of floor Head to toe assessment done. Noted skin tear (superficial, skin flap present 7 cm X 3.4 cm, oozing, no active bleeding) to the resident's chest. Upon Palpation resident c/o tail bone pain but no other obvious injury reported. PROM [Passive range of motion] extremities at baseline and denies pain. The note additionally described recent changes in the resident's behavior and mental status. A physician was called and report of the event, injuries, changes in behavior, and recent falls was given. An order was received to transport the resident to the emergency room (ER) for further evaluation, and this was done. A follow up note dated 12/04/2020 at 21:19, revealed the resident had been admitted to the hospital. A MORSE FALL SCALE was also completed which scored the resident as High Risk. A Nursing Progress note dated 12/6/2020 at 14:43, revealed the resident returned to the facility from the hospital. R2's care plan focus area for actual unwitnessed fall listed this fall. A new intervention initiated on 12/05/2021 read to place a mattress beside the bed when the resident was in bed. An interdisciplinary team (IDT) investigation of the fall evaluating and analyzing the hazard risks with a root cause review was absent from the medical record. 01/21/21 Fall An Alert Note dated 01/21/2021 at 16:31, read, Resident was found on the supine position on the floor in front of [wheel chair]. An assessment revealed Bruising to left elbow and bump anterior to lower leg and R2 was sent to the ER for further evaluation. A follow up note dated 01/21/2021 at 21:31, revealed R2 had been admitted to the hospital for fracture of left leg and a urinary tract infection. A MORSE FALL SCALE was also completed which scored the resident as High Risk. Resident's care plan focus area for actual unwitnessed fall listed this fall. A new intervention initiated on 01/23/2021 read, requires close monitoring to prevent further fall incident. Follow fall precautions. It did not define what close monitoring was, or how this was different from what the staff were doing. An interdisciplinary team (IDT) investigation of the fall evaluating and analyzing the hazard risks with a root cause review was absent from the medical record. 02/09/21 Fall A Post Fall MORSE FALL SCALE dated 02/09/21 at 12:25, was completed and revealed the resident was high risk for falls. Progress notes were reviewed and a corresponding note describing a fall was absent. Resident's care plan focus area for actual unwitnessed fall listed this fall. Two new interventions were initiated on 02/10/2021. One was to lower the bed, and use floor mattress and the other read, continue 15 min. safety checks. An interdisciplinary team (IDT) investigation of the fall evaluating and analyzing the haza [TRUNCATED]

Based on interview and record review the facility failed ensure that a resident received timely treatment and care for a resident who fell and approximately eleven (11) hours later complained of pain and immobility of his leg. No pain medication was given. Four hours after the pain the resident then developed low oxygen levels in the blood, and low blood pressure although the EMS was called, the facility did not notify the physician when there was an approximate 5 hour delay in Emergency Medical System (EMS) response for one resident (Resident 59). This deficient practice resulted in a delay in treatment and unnecessary suffering with pain and breathlessness for Resident 59. This finding is as a result of the investigation into a facility reported incident with intake number AZ 493 of reported fall with fracture that occurred on 1/5/2019. Findings include: 03/15/19 at 06:16 AM, the following was found in the medical record review: Resident 59 was a [AGE] year old male who was a long-time resident of the facility with [DIAGNOSES REDACTED]. The minimum data set (MDS-an assessment tool) dated 11/28/2018 indicated the resident needed limited assistance with most activities of daily living (ADLs), he had limited range of motion on one side of his body, needed human assistance to transfer from surface to surface. The resident used a wheel chair (w/c) for locomotion. He was able to propel himself. He had a history of [REDACTED]. The 12/31/2018 Morse Fall Scale (a fall risk assessment tool) had a fall risk score of 55. Scores over 45 are considered a high risk of falling. The 1/5/2019 (post fall) Morse Fall Scale score was 80. Continued record review on 3/15/2019 read as follows: Incident progress notes dated 1/5/2019 @ 3:45 PM, unwitnessed fall. Staff heard resident yelling from his room and found him lying on his back next to his w/c. Resident stated he was transferring from w/c to bed the w/c slipped out from under him. Stated he landed on his buttocks and laid back. He denied hitting his head. Two staff assisted him to his feet for a full body skin assessment. Skin intact over buttocks, back and posterior legs. Placed in wheel chair (w/c), resident taken to dining hall for evening meal. Vital signs were stable. Oxygen saturations (O2 sats) level on room air (RA) was 94%. (Oxygen saturation is a measurement of oxygen in the tissues of the body. This is measured with an instrument called a pulse oximeter. The device is clipped on a finger and quickly gives a percent of oxygen in the tissues. Normal O2 saturation levels are above 95% according to the National Institute of Health (NIH)). There was communication note to the physician (Staff 34) written on 1/5/2019 at 4:07 PM informing him of the resident's fall. The physician ordered the staff to continue to monitor resident often for skin assessment, mentation changes, and to call back with change in condition (e.g. bleeding, change in skin condition, change in mentation). Incident progress note dated 1/6/2019 @03:09 AM, Resident reported right leg pain with movement. He was unable to independently move around and required assist. There was no documentation that a physician was notified. Review the Medication Administration Record [REDACTED]. Record review continued: on 1/6/2019 @ 06:55 AM, Resident remained in bed, O2 was given at 3 liters by nasal cannula (O2 @ 3L/nc) provided due to room air (RA) O2 sat at 63 -74%. (Resident)Denies SOB (shortness of breath) but continued to complain of pain right leg and low back with attempts to move. Tylenol given. Emergency Medical Services (EMS) notified of needed services. Currently on another call, but will be here to pick rsd (resident) as soon as possible (sic). Called emergency room (ER) with report that resident being sent over for evaluation. 1/6/2019 @07:01 AM, Report to ER nurse Anthony received report. No documentation was found or provided to indicate that the ER physician was consulted for treatment or what to do when the EMS had not arrived. 1/6/2019 @ 08:23 AM, resident was yelling in bed and taking off his oxygen (nasal cannula) .He reported difficulty breathing but wouldn't wear O2 cannula. (He is not) cooperative and moving arms a lot when taking vital signs. Called EMS three times but they are not answering the call. Awaiting EMS to pick him up. Resident still NPO (nothing by mouth). He is complaining pain to right leg with little movement. Oxygen saturation range on room air 75-89% fluctuating and resident is refusing to apply oxygen. Vital Signs (VS) @ 8 AM O2 sat 83% on room air, temperature 100.4 degrees Fahrenheit; Blood Pressure 78/50; respiratory rate 28 and Heart Rate 83. (Normal temperature range 97.6 - 99.6; normal blood pressure range 90/60 - 140/90; normal respiratory range 16-28) There was no documentation provided that a physician was notified of the resident's change of condition or request for consultation on what to do for the resident. After several attempts to get EMS to respond to the resident's needs the staff called the police at 11 AM (four hours after his O2 sats were found to be 63-74%.) EMS arrived and the resident was sent to Chinle hospital ER at 11:47 AM. There was no documentation that a physician was notified of the delay in the EMS response. Review of the Medical records from the Chinle Comprehesive (sic) Health Care Facility (CCHCF) ER did not include in the chief complaint the resident's hypoxic and hypotensive episodes during the morning. The vital signs on 1/6/2019 at 01:53 PM; were Temp 100.1 degrees Fahrenheit; BP; 84/51; and O2 Sat 91%. Follow up with the ER doctor reported to the facility at 2:45 PM on 1/6/2019 the resident had a [MEDICAL CONDITION] and a fever. 03/15/19 at 07:47 AM, when asked about the incident, Staff 20 reported the following; It took a long to transfer him to the ER, the EMS is at the hospital. She called the hospital for EMS services. When asked if this delay in EMS response was a common problem Staff 20 said it depends. When asked if she had notified the physician of the low O2 Sat, she said she called the ER Nurse and reported to day shift at the facility to notify the attending physician. She stated, the attending (doctor) does not answer calls at night. She did not call the Medical Director at that time, because she stated she was told that staff were not to call him at night. Review of the No. NV-CA-18-0011 Collaborative Agreement Between Chinle Comprehesive (sic) Health Care Facility (CCHCF) Navajo Area Indian Health Service and Chinle Nursing Home (CNH): the following read in pertinent part: .1. CCHCF AGREES: B. These services shall fulfill the requirements of the Federal Regulations for Primary Medical Provider for IHS beneficiaries residing the in the home. These services include but are not limited to: .5. On-call after hours physician services are available to I.H.S. beneficiaries residing in the home for purposes of medical consultation, clarification of orders, and urgent queries . 03/15/19 at 08:40 AM, when asked to speak with the attending physician. Staff 2 stated she received notice that Resident 59's attending physician would not be available to talk with surveyors, until after the survey was completed. 03/15/19 at 12:20 PM, on a phone interview: When asked if he was aware of the delay in EMS response for Resident 59; The Medical Director stated he was not aware of the extent of the delay of services for this resident; however he was aware that the Chinle EMS system sometimes responded late. He stated that the facility did not know what else they could do about it. In regards to Resident 59's situation; he stated the night shift nurse should have notified the physician when the resident had pain and couldn't move his leg on 1/6/2019 at 03:09 AM. They should have called the CCHCF emergency room and spoke with the doctor at the hospital for direction. When informed that Staff 20 informed the surveyor that she was told they were told not to call the attending physician or the medical director at night; he stated that the Chinle hospital (CCHCF) ER doctors cover for night shift and weekends and they do speak directly to the facility nurses. When informed of the resident's 02 sat levels at 6:55 AM of 63-74% he stated they should have taken the resident directly to the ER when EMS was not available. He said that they should have put the resident in a wheelchair and taken him across the parking lot to the ER. According to an article about complications of [MEDICAL CONDITION] in the elderly the following Webster https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 33/ read in part as follows: .Mortality incidence due to fat embolism syndrome (FES) varies among varied studies, probably because of its underdiagnosis.(27) Acute fulminant FES may lead to death due to right heart failure, while majority of deaths are usually due to [MEDICAL CONDITION]. Though prognosis for neurological defects is good, deaths have also been reported. Incidents of acute coronary syndrome, probably due to circulating fat globules have also been reported.(57) Overall, the mortality is estimated to be 5-15%.

Based on observation, record review, policy review, and interview the facility failed to ensure hazardous chemicals and materials were secured and not accessible. Specifically, for one sampled resident (R16), with behaviors of ingesting hazardous chemicals and materials, the facility's failure to properly store and secure hazardous materials constituted a finding of Immediate Jeopardy. The facility's deficient practice has the likelihood to place R16 and all 57 residents in the facility at risk for injury. Findings Include: Observation on 03/12/19 between 5:00 PM and 5:25 PM of the Women's unit identified an unlocked/unattended housekeeping room that revealed the following chemicals left unattended and accessible to unauthorized or cognitively impaired residents: OASIS 499 HBV disinfectant- full gallon jug; OASIS 100- full gallon jug; Advance Antibacterial Clean and Smooth- approximately ¼ gallon; OASIS 499 HBV disinfectant- 400cc (cubic centimeters) in spray bottle Spray bottle without a label of contents containing clear fluid- written on the bottle For furniture, beds, wheelchairs; Foaming Hand Sanitizer 19 full containers- 1200cc; Peroxide disinfectant and glass cleaner- two full bottles; Clorox toilet wand refills- five packages of six scrubbers; Windex- approximately 1/8 gallon; Sysco spray bottle with yellow fluid- approximately half full; Liquid bleach- full bottle; Bottle with purple fluid- approximately half full; One-Step detergent/disinfectant- approximately half full; Sysco spray bottle with blue fluid- approximately half full; Spray bottle with purple fluid- approximately half full; Sysco air freshener- one can. Interview with Housekeeper 26 on 03/12/19 at 5:00 PM stated the door should be locked, I left it open while I took out the trash. Housekeeper 26 described the trash is taken way out there and confirmed the housekeeping room that contained chemicals was left unattended and unlocked. Observation on 03/12/19 at 5:25 PM identified the Clean Supply Room on the Women's unit identified the door was propped open with a small trash can with the following hazardous items present: Two Spray bottles with clear liquid-approximately half full; Six 0.5 gram tubes of McKesson Skin protectant ointment with Vitamin A; Two 4 gram containers of Theracalazinc Body Shield (a skin protectant). Observation on 03/12/19 at 5:30 PM identified the following items were unattended in an unlocked Examination Room on the Women's unit: Top Care nail polish remover six ounces (oz); Sunmark [MEDICATION NAME] iodine 10% 8oz. (skin disinfectant); Two four oz. [MEDICATION NAME] (skin protectant); 40 tubes of [MEDICATION NAME] cream 1% 0.9gm; Sesame Street Baby Wash 10 oz; Sesame Street Baby Shampoo; Zinc Oxide ointment 16 oz (skin protectant); Caviwipes disinfectant wipes 1 lb., 3oz tub; EcoLab Digiscan (a foaming hand sanitizer) container; Observation o 03/12/19 at 5:40 PM identified the storage room door on the Women's unit was able to be opened without a key. A purple paper was placed in the door latch plate to prevent the latch from engaging. The following items were observed in the unlocked/unattended room: SunMark hand sanitizer 8 oz; McKesson Hand Sanitizer 8oz; Clorox Wipes 1lb10oz; 3M High Strength Contact Adhesive 17.6oz; Krylon Metallic spray paint (Brilliant Gold) 15oz. Review the Face Sheet in the electronic medical record identified R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (end of look back period) of 01/04/19, identified Brief Interview for Mental Status (BIMS) score 14 of 15, indicating intact cognition and able to make decisions, and Functional Status identified independence for ambulation. Review of the Care Plan last reviewed on 01/15/19 revealed R16 is dependent on staff for meeting emotional, intellectual, physical, and social needs with a goal for the resident to attend and participate in activities of choice 4-6 times a week. The care plan failed to address R16's alcohol seeking and dependence and failed to identify R16 as alcohol seeking and a danger to herself. The Progress Note dated 12/10/18 revealed Resident would like to make all decisions for herself and there is no Power of Attorney in place. The Progress Note dated 12/15/18 revealed the resident was sent to the hospital for acute confusion, increased sleepiness, wandered without knowing where she was, incontinent, decreased coordination, shaking. The Progress Note dated 12/20/18 revealed the resident was sent to the hospital for increased confusion and agitation, wandering and being uncooperative. A nurse Incident Note dated 12/23/18 at 8:03 AM revealed R16 was intermittently confused during the night exhibiting disorientation, confusion and combative behaviors. The nurse's assessment revealed a musty breath odor with shaky/flapping arms and co (complaints of) RUQ (right upper quadrant of abdomen) discomfort. At 5:41AM, Emergency Medical Services was called. R16's room was searched for possible exacerbation of confusion, 3 bottles of hairspray and a bottle of APAP ([MEDICATION NAME]- an over the counter pain medication) was found in drawer. Confiscated items and noted 1 hairspray empty. The Progress Note dated 12/23/19 at 5:41 AM revealed Emergency Medical Services was called for possible exacerbation of confusion, 3 bottles of hairspray and a bottle of [MEDICATION NAME] found in drawer. Confiscated items and noted 1 hairspray empty. Returned from ED. Nurse documented ED notes states suggested the patient drank hairspray. The Progress Note dated 01/01/19 revealed the physician was called to report resident was unarousable. Physician recommends to send Resident{sig} her condition does not improve. Nursing found a can of aerosol hairspray in the resident's room. Resident was sent to the emergency room . The Behavior Note dated 02/16/19 at 7:17 AM revealed, two Certified Nursing Assistants (CNA) searched R16's room because the resident observed hiding a green bottle the previous day. The CNA's found empty bottles of hand sanitizer and perfume/body spray. The CNA's also found a paper towel wrapped in a white powder substance. The CNA's reported that when the resident goes out on pass to home, this is the behavior she displays upon return. The Communication Note dated 02/18/19, written by Social Worker 4 revealed R16's case manager was coming to see her. The care manager notified the social worker that R16 required transfer to the behavior health facility for her safety no 02/18/19 at 11:24 AM. The facility was to send a transfer packet to Winslow Campus of Care. R16's sister was notified of the need to transfer the resident. The Communication Note dated 2/19/19 written by Social Worker 4 revealed R16 came in to the social worker office requesting to leave this place. R16 stated that the devil is talking to me and that she was hearing voices, saying take off and kill yourself, these guys are naughty. God is here, he cast out the devil. The communication note indicated the Director of Nursing (DON) is aware of the suicidal ideation and 1:1 was recommended to the DON and a possible transfer out to a behavioral unit where (R16) can get the help she needs. The Communication Note written by Social Worker 4 on 02/21/19 at 3:23 PM revealed the social worker conducted a follow-up counseling session related to R16's suicidal thought The Nursing Admission Screening/History dated 02/28/19 untimed, revealed R16 returned from the acute care hospital after a stay that began on 02/23/19. R16's behavior was documented as has a flat affect and sad with anxiety. The Behavior Note dated 02/28/19 at 3:22 PM revealed the resident used her craft scissors to remove the band of her exit door alarm ankle bracelet after setting off the door alarms she was near. R16 stated I'm no child at a playground area. You guys don't need to keep track of me. Leave me alone. The Behavior Note written 02/28/19 at 7:34 PM revealed INCREASED VERBAL STATEMENTS OF NON-COMPLIANCE . I don't need any help I want to sit right here. and You people are just jealous of me and think you can tell me what to do, I can do whatever I want to do. The Wandering Risk Scale dated 02/28/19 revealed R16 is independent with ambulation, has a history of wandering and is at high risk of wandering. The Behavior Note dated 03/05/19 at 7:21 AM revealed Inappropriate behavior this shift. She was holding candy in her hand and was talking to them, each one had a name. The Behavior Note dated 03/06/19 revealed resident was not oriented to time, appeared confused, eyes glazed and not focusing. The nurse discussed the findings with physician and will likely send resident to return to ER (emergency room ) due to increased irritability, increased confusion/altered Mental status. Review of R16's Discharge Planning Review dated 03/11/19 revealed resident has an anticipated length of stay of Long Term/Short Term, is expected to be discharged to another facility, determination has not been made regarding discharge to the community, if the resident were to return home she would be alone and does not have a support network, requires assist with medication administration and some activities of daily living, The Overall Summary for Potential Discharge indicates R16 has had a behavior issue within the last month. Elopement, SI ([MEDICAL CONDITION]) and consuming alcohol when she goes home OOP (out on pass) and states she does not like to stay here in the facility and wants to leave. Interview with Social Services 4 on 03/13/19 at 10:30 AM revealed the facility did not place the resident on one-to-one observation as recommended to the Director of Nursing. Interview with Social Services Coordinator/Certified Nursing Assistant (SSC/CNA) 4 on 03/14/19 at 8:30 AM revealed R16 has medical [DIAGNOSES REDACTED]. The SSC/CNA confirmed the tribal police were in the facility on 3/11/19 and removed a container of apple juice that contained an unknown substance. The SSC also confirmed R16 is has been ingesting hairspray and foaming hand sanitizer and has stated she would look everywhere to find her hairspray. The SSC acknowledged that if the resident were looking for substances to ingest and chemicals were unsecured, R16 could access the chemicals and cause harm to herself. Interview with the Assistant Director of Nursing on 03/14/19 at 11:40 AM confirmed the facility lacked a policy to direct staff to ensure chemicals are secured and unable to be accessed by residents. On 03/12/19 at 7:03 PM, the Director of Nursing, Assistant Director of Nursing, Quality Assurance and the Dietary Manager were notified that the facility's failure to properly store and secure hazardous chemicals, from R16 and residents at risk for wandering, independently mobile and with a cognitive impairment constituted findings of Immediate Jeopardy. The Immediate Jeopardy was determined to first exist on 03/12/19 at 7:03 PM when the facility failed to ensure chemicals and hazardous materials were secured. The facility presented an acceptable plan for removal of the Immediate Jeopardy on 03/15/19 at 6:40 PM, which time the survey team validated that the Immediate Jeopardy was removed with the facility' implementation of staff education on proper storage of chemicals.

Based on interview and record review the facility failed to notify and consult with a physician after a resident developed low oxygen levels in the blood approximately 4 hours after the resident complained of pain and immobility of his leg. In addition the facility did not notify the physician when there was an approximate 5 hour delay in Emergency Medical System (EMS) response for one resident (Resident 59). This deficient practice resulted in a delay in treatment and unnecessary suffering with pain and breathlessness for Resident 59. This finding is as a result of the investigation into a facility reported incident with intake number AZ 493 of reported fall with fracture that occurred on 1/5/2019. Findings include: 03/15/19 at 06:16 AM, the following was found in the medical record review: Resident 59 was a [AGE] year old male who was a long-time resident of the facility with [DIAGNOSES REDACTED]. The minimum data set (MDS-an assessment tool) dated 11/28/2018 indicated the resident needed limited assistance with most activities of daily living (ADLs), he had limited range of motion on one side of his body, needed human assistance to transfer from surface to surface. The resident used a wheel chair (w/c) for locomotion. He was able to propel himself. He had a history of [REDACTED]. The 12/31/2018 Morse Fall Scale (a fall risk assessment tool) had a fall risk score of 55. Scores over 45 are considered a high risk of falling. The 1/5/2019 (post fall) Morse Fall Scale score was 80. Continued record review on 3/15/2019 read as follows: Incident progress notes dated 1/5/2019 @ 3:45 PM, unwitnessed fall. Staff heard resident yelling from his room and found him lying on his back next to his w/c. Resident stated he was transferring from w/c to bed the w/c slipped out from under him. Stated he landed on his buttocks and laid back. He denied hitting his head. Two staff assisted him to his feet for a full body skin assessment. Skin intact over buttocks, back and posterior legs. Placed in wheel chair (w/c), resident taken to dining hall for evening meal. Vital signs were stable. Oxygen saturations (O2 sats) level on room air (RA) was 94%. (Oxygen saturation is a measurement of oxygen in the tissues of the body. This is measured with an instrument called a pulse oximeter. The device is clipped on a finger and quickly gives a percent of oxygen in the tissues. Normal O2 saturation levels are above 95% according to the National Institute of Health (NIH)). There was communication note to the physician (Staff 34) written on 1/5/2019 at 4:07 PM informing him of the resident's fall. The physician ordered the staff to continue to monitor resident often for skin assessment, mentation changes, and to call back with change in condition (e.g. bleeding, change in skin condition, change in mentation). Incident progress note dated 1/6/2019 @03:09 AM, Resident reported right leg pain with movement. He was unable to independently move around and required assist. There was no documentation that a physician was notified. Review the Medication Administration Record [REDACTED]. 1/6/2019 @ 06:55 AM, Resident remained in bed, O2 was given at 3 liters by nasal cannula (O2 @ 3L/nc) provided due to room air (RA) O2 sat at 63 -74%. (Resident)Denies SOB (shortness of breath) but continued to complain of pain right leg and low back with attempts to move. Tylenol given. Emergency Medical Services (EMS) notified of needed services. Currently on another call, but will be here to pick rsd (resident) as soon as possible (sic). Called emergency room (ER) with report that resident being sent over for evaluation. 1/6/2019 @07:01 AM, Report to ER nurse Anthony received report. No documentation was found or provided to indicate that the ER physician was consulted. 1/6/2019 @ 08:23 AM, resident was yelling in bed and taking off his oxygen (nasal cannula) .He reported difficulty breathing but wouldn't wear O2 cannula. (He is not) cooperative and moving arms a lot when taking vital signs. Called EMS three times but they are not answering the call. Awaiting EMS to pick him up. Resident still NPO (nothing by mouth). He is complaining pain to right leg with little movement. Oxygen saturation range on room air 75-89% fluctuating and resident is refusing to apply oxygen. Vital Signs (VS) @ 8 AM O2 sat 83% on room air, temperature 100.4 degrees Fahrenheit; Blood Pressure 78/50; respiratory rate 28 and Heart Rate 83. (Normal temperature range 97.6 - 99.6; normal blood pressure range 90/60 - 140/90; normal respiratory range 16-28) There was no documentation provided that a physician was notified of the resident's change of condition. After several attempts to get EMS to respond to the resident's need the staff called the police at 11 AM (four hours after his O2 sats were found to be 63-74%.) EMS arrived and the resident was sent to Chinle hospital ER at 11:47 AM. There was no documentation that a physician was notified of the delay in the EMS response. Review of the Medical records from the Chinle Comprehesive (sic) Health Care Facility (CCHCF) ER did not include in the chief complaint the resident's hypoxic and hypotensive episodes during the morning. The vital signs on 1/6/2019 at 01:53 PM; were Temp 100.1 degrees Fahrenheit; BP; 84/51; and O2 Sat 91%. Follow up with the ER doctor reported to the facility at 2:45 PM on 1/6/2019 the resident had a [MEDICAL CONDITION] and a fever. 03/15/19 at 07:47 AM, when asked about the incident, Staff 20 reported the following; It took a long to transfer him to the ER, the EMS is at the hospital. She called the hospital for EMS services. When asked if this delay in EMS response was a common problem Staff 20 said it depends. When asked if she had notified the physician of the low O2 Sat, she said she called the ER Nurse and reported to day shift at the facility to notify the attending physician. She stated, the attending (doctor) does not answer calls at night. She did not call the Medical Director at that time, because she stated she was told that staff were not to call him at night. Review of the No. NV-CA-18-0011 Collaborative Agreement Between Chinle Comprehesive (sic) Health Care Facility (CCHCF) Navajo Area Indian Health Service and Chinle Nursing Home (CNH): the following read in pertinent part: .1. CCHCF AGREES: B. These services shall fulfill the requirements of the Federal Regulations for Primary Medical Provider for IHS beneficiaries residing the in the home. These services include but are not limited to: .5. On-call after hours physician services are available to I.H.S. beneficiaries residing in the home for purposes of medical consultation, clarification of orders, and urgent queries . 03/15/19 at 08:40 AM, when asked to speak with the attending physician. Staff 2 stated she received notice that Resident 59's attending physician would not be available to talk with surveyors, until after the survey was completed. 03/15/19 at 12:20 PM, on a phone interview: When asked if he was aware of the delay in EMS response for Resident 59; The Medical Director stated he was not aware of the extent of the delay of services for this resident; however he was aware that the Chinle EMS system sometimes responded late. He stated that the facility did not know what else they could do about it. In regards to Resident 59's situation; he stated the night shift nurse should have notified the physician when the resident had pain and couldn't move his leg on 1/6/2019 at 03:09 AM. They should have called the CCHCF emergency room and spoke with the doctor at the hospital for direction. When informed that Staff 20 informed the surveyor that she was told they were told not to call the attending physician or the medical director at night; he stated that the Chinle hospital (CCHCF) ER doctors cover for night shift and weekends and they do speak directly to the facility nurses. When informed of the resident's 02 sat levels at 6:55 AM of 63-74% he stated they should have taken the resident directly to the ER when EMS was not available. He said that they should have put the resident in a wheelchair and taken him across the parking lot to the ER. When asked if the facility had discussed the EMS slow response time in QAPI he stated he did not think so. 03/15/19 at 02:15 PM during an interview when asked how often the EMS is late responding to their calls, Staff 5 stated it happens pretty often; however it usually was not this bad. When asked if they had included this issue in their QAPI, she said everyone is aware of the problem; however we did not discuss it because we didn't think we could do anything about it. She said that she will make sure it is addressed ASAP. Requested a list of calls made to the EMS and their response time. Staff 5 stated the facility did not keep track of that information. However she said she would call the EMS to obtain the information. According to an article about complications of [MEDICAL CONDITION] in the elderly the following Webster https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 33/ read in part as follows: .Mortality incidence due to fat embolism syndrome (FES) varies among varied studies, probably because of its underdiagnosis.(27) Acute fulminant FES may lead to death due to right heart failure, while majority of deaths are usually due to [MEDICAL CONDITION]. Though prognosis for neurological defects is good, deaths have also been reported. Incidents of acute coronary syndrome, probably due to circulating fat globules have also been reported.(57) Overall, the mortality is estimated to be 5-15%.

Based on observation, interview and record review: 1. The facility failed to provide supervision to prevent falls for Resident 10 identified in need of supervision to prevent falls. Resident 10 fell from the wheelchair and suffered fractures of the shoulder and hip which constituted actual harm. 2. The facility failed to ensure the environment remained free of accident hazards associated with the use of electric space heaters in 2 resident sleeping rooms. This failed practice placed 28 residents who resided on the A wing at risk for injury from exposure to smoke and/or fire. The concern related to the use of the space heaters in Resident 13 and 14's rooms was referred to the Life Safety Code Surveyor and an immediate Jeopardy (IJ) situation was identified. Cross reference LSC survey tag# K781 for details of the IJ and the plan of corrective action. 3. The facility failed to store chemicals in a safe manner on 2 of 2 resident wings and failed to maintain furniture on the A wing. 4. The facility failed to ensure adequate supervision to ensure safe use of assistive devices used for positioning in wheelchairs for Resident 16 who used a torso support device. This failed practice placed Resident 16 at risk for injury related to improper or unsafe use of the assistive device. Findings include; 1. The facility provided a facility form titled Interdisciplinary Post-Fall Assessment (IP-FA) dated 11/5/17 that noted Resident 10 had a fall on 11/5/16 with no falls in the prior 180 days. On 11/5/17 at 7:00 PM Resident 10 slid out of the wheelchair and landed on the floor in front of the wheelchair, he was not injured. The IP-FA noted [DIAGNOSES REDACTED]. Resident 10 did not ambulate, had severely impaired mental status and a pain medication, Fentanyl, caused side effects of weakness and dizziness. The IP-FA identified a probable cause for the fall from wheelchair was the incontinent pad placed under him. The IP-FA included recommendations from review by the team: Dycem to be placed on w/c (wheelchair) so that resident does not slide out and removal of incontinent pad. (Dycem is a proprietary product made of non-slip and anti-slip materials supplied in rolls, pads, etc.) A nursing progress note dated 11/3/16 at 7:15 PM noted Resident 10 Gets around slowly on own in wheelchair. A progress note titled Incident Note and dated 11/5/16 at 7:16 PM indicated Resident 10 slipped out of his wheelchair and landed on his buttocks, he was able to move extremities and did not hit his head. A fall intervention/Care Plan dated 11/5/16 listed other interventions: Apply a resistant slip 'Fruit Roll up Red Plastic grippy thing to seat of wheelchair. And directed staff to look at another named resident's Fruit Rollup on chair. A progress note incident note dated 11/21/16 by Staff 391 indicated Resident 10 slipped off wheelchair on 11/5/17, no injuries noted. Dycem placed on wheelchair and under resident to aid in preventing further incidents. Resident stable, no further incidents. Will continue to follow weekly X 4. An IP-FA dated 11/22/16 described a second fall from wheelchair on 11/22/16 at 3:20 PM. Resident 10 was sliding out of the wheelchair and tried to pull himself up, he lifted his buttocks and the wheelchair moved from under him. He landed on his right side of body and fractured his shoulder. He was sent to the hospital for emergency care. An ED (Emergency Department) note dated 11/22/16 noted Resident 10 was treated at the ED for right shoulder pain after he fell out of wheelchair, fell on his right side and had pain rated at 9 of 10., he yelled when his right arm was moved and he had ecchymosis (bruising) to the right humerus (upper arm bone). An ED note the next day 11/23/16 noted Resident 10 was seen in the ED on 11/22/16 with a [DIAGNOSES REDACTED]. Complained of right hip pain but that was missed, Resident 10 did not get a full hip evaluation on 11/22/16. The ED diagnosed a hip fracture and ordered air ambulance to transport Resident 10 to a regional hospital for orthopedic surgery. The IP-FA form included a section for a 6 month review of falls for this resident. With questions to the reviewer such as; are there any patterns or trends related to these falls? The response was no. The facility identified the probable cause for the fall, Resident with Dycem to w/c but covered with pad. Sliding out of wheelchair no brakes. The facility investigation of the 11/22/16 fall noted Resident 10 was brought to the nursing station at 3:20 PM by a housekeeper. The housekeeper left Resident 10 and reported to CNAs who were in a room with another resident doing ADL care; that new resident (10) is about to slide out of his wheelchair. The CNA reported she was going to check on Resident 10 when she heard a loud thud and an immediate cry for help. As she approached the nurse's station, she observed Resident 10 on the floor, he was complaining of pain to his right side. The facility investigation report for the fall that occurred on 11/22/16 concluded the fall was avoidable. The facility determined there was a white-pad {incontinent pad) on top of the Dycem that was on top of the wheelchair cushion and the housekeeper should have remained with the resident until another staff could be located to offer assistance The facility failed to ensure the corrective interventions were consistently implemented to prevent falls following the fall on 11/5/16 which included removal of incontinent pad from the wheelchair. Additionally housekeeping staff observed and identified that Resident 10 was in imminent danger of sliding or falling from the wheelchair. Although staff was aware of the danger, the staff left the resident alone and unattended to seek assistance. While unattended, Resident 10 fell from the wheelchair and fractured his shoulder and hip. 2. During a conversation on 9/25/17 at 9:30 A.M., with Resident 14 in her room, a space heater a space heater sat on a wheeled overbed table across the room from the resident. The space heater was on and the front of the heater was too hot to touch. On 9/25/17 at 9:35 A.M., all resident rooms were immediately inspected. Resident 13 had a small portable space heater sitting on her cluttered bedside table next to her bed. The space heater sat within 4 inches of the privacy curtain and the curtain felt hot to touch. Surveyor moved the space heater away from the privacy curtain and notified staff. The space heater had a warning printed on the front that cautioned user to keep combustibles at least 3 feet away from the front of the space heater. When asked about the space heater, the resident stated that facility staff provided it for her. Resident 13 said she had the heater for about one year and just started using it again since her room was cold today. On 9/27/17 at 9:40 A.M. a space heater was observed in Resident 14's room. The resident sat in her wheelchair wearing a hat, jacket, socks, with a blanket on her lap and over her shoulders. The resident had a space heater that was located on a wheeled over-bed table. There was nothing else on the table the space heater was plugged into the wall outlet but was not turned on. The resident said her family brought the space heater in for her because her room was uncomfortably cold. On 9/27/2017 at 9:50 A.M., during an interview the maintenance supervisor stated that the heating system was on air conditioning (A/C) because it was still hot during the day. He stated that because the building and heating system were so old he could not turn the A/C on or off on a regular basis. He stated that once most of the resident's complained of the cold he would turn on the system wide heater. In the meantime he had space heaters he provided to the residents. On 9/27/17 at 10:12 AM Staff 401 was observed in Resident 13's room near the bedside table. Staff 401 said she was turning up the space heater because it was just warm and the resident needed more heat. The space heater was moved back even closer to the privacy curtain. The facility was immediately informed about the space heater. In an interview at 10:15 AM Staff 107 said the facility did not have any space heaters in use. When informed about the space heater in Resident 13's room, Staff 107 said he was not aware. Staff 107 then also acknowledged he knew Resident 14 had a space heater but said she did not get it from the facility. 3. During initial tour of the A Wing on 9/25/17 at 10:00 AM a hard plastic molded chair in the nourishment center was chipped and splintered at the front edge of the seat creating a jagged and sharp surface where a person's legs would contact the chair when seated. Staff 147 said the chair would be used for residents if needed. Staff 147 acknowledged the broken seat and said it should be replaced. The following conditions were observed during a facility-wide environmental observation tour conducted on 9/28/17 from 8:15 AM to 11:30 AM: The chair described above remained in the A-Wing nourishment center. A wire holder mounted on the wall near the A Wing nurse station held a container of bleach wipes. The holder was not secure, the wipes could be easily removed from the holder. The A Wing soiled work room was unattended and the door was found unlocked and open. A 1-gallon container of bleach and a container of bleach wipes were in the open on the counter. The A Wing storage room was unlocked and unattended. The storage room contained 2 gallons of bleach and multiple containers of bleach wipes. The B Wing storage room opened onto the main corridor and had a keypad lock but the latch was taped over so the door did not latch or lock and could simply be pulled open. The room contained two 1- gallon containers of bleach solution, 3 containers of bleach wipes and an open box of razors located on a low shelf easily accessible to ambulatory or wheelchair bound residents. Residents were observed to move about freely in the corridor. 2 of 2 shower rooms on the B Wing had a small wall shelf mounted on the wall near the door approximately four feet off the floor. Each shelf held a container of bleach wipes and a plastic container for disposal of used needles and sharps. The bleach wipes and sharps containers were not secured and could be easily removed from the shelf. During the initial tour on 9/25/17 at 10:45 AM the DON indicated many of the residents in the facility did not speak or understand and could not read English. The warnings and precautionary statements on the bleach and the bleach wipes were printed in English. The bleach products warned they may cause skin and eye irritation and may be confused for personal care wipes. 4. Admission records showed Resident 16 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (comprehensive assessment) calculated a BIMS score of 4. BIMS (Brief Interview for Mental Status) is a test given by medical professionals that helps determine a patient's cognitive understanding; a score of 0-7 indicates severe cognitive impairment. A new admission physical therapy (PT) assessment noted Resident 16 agreed to transfer to a tilt-in-space wheelchair. PT issued a tilt-in-space wheelchair for safe ADL (activities of daily living) and per daughter's request. A PT note on 8/11/17 noted Resident 16 was seated in a wheelchair with left lateral trunk lean with forward flexion and PT issued and fitted a postural Velcro support to reduce risk of falls. The care plan for Resident 16 documented limited physical mobility r/t (related to)) Parkinson's disease, decreased strength, and impaired posture. Interventions for Resident 16 included; to wear Velcro postural support daily to reduce risk of falls and injury. The care plan did not indicate the specific type of support or how to apply it. The care plan did not note under what conditions it should be applied such as time of day and whether to use in bed or chair. The care plan did not indicate potential adverse effects or precautions for the use of the postural support. On 9/25/17 at 12:10 PM Resident 16 was observed seated in a wheelchair in the dining room. A cloth support device was attached around the back of the wheelchair and over the resident's shoulders. A wide band or belt encircled the back of the wheelchair and the resident's abdomen and fastened in the front of the resident with Velcro. Two cloth straps attached to the belt behind the wheelchair and crossed over Resident 16's shoulders to attach to the belt in front with Velcro. Resident 16 leaned forward against the belt and straps. On 9/26/17 at 6:45 AM Resident 16 waited for his meal in the dining room. The postural support belt was at the waist and was very loose. When asked what the belt or straps were for, he did not respond. Staff who passed by while serving meals said Resident 16 was able only to give yes or no responses and understood Navajo but was confused. On 9/27/17 at 12:50 PM Resident 16 sat in his wheelchair in the hall near the dining room. Postural belt or strap was not fastened and both ends sat in his lap. The straps were in place over both shoulders. On 9/27/17 at 3:30 PM Staff 223 was interviewed regarding the postural support devices. Staff 223 said The torso supports just got started. Staff 223 said a few of the gentlemen leaned too far forward or to the right and it was recommended by Staff 391 at the stand-up meeting to try the torso devices. Staff 223 said it was referred to PT to follow it up. Staff 223 said a consent was not required because it was not considered a restraint. When asked if the facility conducted an assessment prior to use, Staff 223 said the resident was assessed to see if they could remove the support. Staff 223 said if the resident cannot remove the support, then the facility has to come up with an alternative. Staff 223 said the facility did not conduct an assessment to ensure the torso supports were safe for the resident to use because they were not considered restraints. Staff 223 said she would not expect a resident with a BIMS score of 4 to be able to understand what the torso support was for or be able to remember how to remove it. Staff 223 confirmed the BIMS score was 4 for Resident 16. Staff 223 consulted Staff 286. Staff 286 said if Resident 16 did not have the vest on he leaned down forward and the facility was afraid he would fall out of the chair and get hurt without the vest. When informed of the observation with the belt unfastened and shoulder straps in place, Staff 286 said she did not know if he understood what it (torso support device) was or what it was for. Staff 286 said We tell him, but he is confused and forgets. Staff 223 said she did not know if the facility had a policy and procedure for the use of the torso support. Staff 223 later confirmed the facility did not have a policy or procedures regarding the application and use of the torso postural support. The Therapy staff stated they did not have any torso supports in central supply and had no package inserts or instructions to reference. The application instructions for the Posey torso support were obtained online from Posey Company. The indications for use included: Patients requiring upper torso support to help reduce tilting, leaning, and falling from chairs. Contradictions included: STOP USE AT ONCE if the patient has a tendency to slide forward or down in the device. Do NOT use on a patient who is unwilling or unable to follow instructions, and is at risk of a fall or re-injury from self-release. Application Instructions: 1. Seat the patient with the hips against the back of the chair. 2. Wrap the chest strap around the patient and the chair. Press hook and loop (Velcro) firmly together. The patient should be comfortably seated and breathing easily. 3. Bring the shoulder straps over the shoulders, crossing them in an X behind the seat. Secure the straps to the chest strap. The instructions included warnings. WARNING If the patient has, poor upper trunk control or has a tendency to slide or fall off the chair, it should not be used over the torso in a chair without a belt or pelvic piece over the lower pelvis/lap area. WARNING Straps must always be snug but not interfere with breathing or circulation. After application, slide an open hand (flat) between the device and the patient to ensure proper fit. Makes sure that the straps are secured at the juncture of the frame, out of the patient's reach and cannot slide in any direction, as this would change the position of the device. If a patient's body weight becomes suspended off the chair, chest compression and suffocation could result. Restraints with a pelvic piece may be necessary to reduce sliding down. * There is a risk of chest compression or suffocation if the patient's body is suspended off the chair seat. Use extreme caution with chair cushions. If a chair cushion dislodges, straps may loosen and allow the patient to slide out of the seat. * Monitor per facility policy to ensure that the patient cannot slide down, or fall off the chair seat and become suspended.

Based on interview and record review the facility failed to ensure adequate monitoring to evaluate the effectiveness of psychoactive medications, failed to recognize duplicate therapy, and failed to recognize and monitor side effects. These failures affected 3 of 9 sampled residents (R10, R6 and R3) reviewed for medication regimen. The failure monitor for side effects resulted in actual harm for R10. Findings include; Resident 10 (R10); Admission records revealed R10 admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. The admission diagnoses did not indicate a [DIAGNOSES REDACTED]. A progress note titled Order Note dated 9/28/16 indicated the order entered for [MEDICATION NAME] triggered the following drug protocol alert/warning: drug to drug interaction: and read in part; severity Moderate; Interaction: use of Donazepil HCL tablet 5 mg with [MEDICATION NAME] tablet 1 mg may precipitate unexpected central nervous system toxicity including tremors, gait instability, and protruding tongue. Review of the admission comprehensive assessment (MDS) with a reference date of 10/11/16 indicated R10 had no mood problems and no behavior problems. In an interview on 9/27/17 at 1:15 PM Staff 223 said she completed the MDS assessment and noted that the MDS was inaccurate, it should have indicated the antipsychotic medication use and the risk of drug to drug interactions. When asked if an assessment such as AIMS or another format was conducted to serve as a baseline to monitor for serious side effects, Staff 223 said no AIMS test was conducted because the EHR did not trigger it. Staff 223 acknowledged that the EHR did not trigger an AIMS test due to the MDS inaccuracy. Staff 223 acknowledged that an AIMS test was indicated and should have been conducted. Progress notes dated 10/9/16 and on 10/29/16 noted R10 repetitively chewed his mouth and made his mouth bleed. During a clinic visit on 10/12/16 R10 was diagnosed with [REDACTED]. A review of the October 2016 Behavior monitor sheet for October 2016 found the facility monitored for behavior code 37 uncooperative. The facility did not identify that uncooperative behavior is not a clinical indication for the use of an antipsychotic medication. The October 2016 Side effects Monthly Flow Sheet indicated only sedation on night shift of 10/6/16 and 10/7/16. The facility did not indicate the presence of symptoms of tardive dyskinesia, biting the mouth to the point of bleeding. Please refer to additional information in F428, F157, and F278. Resident 6 (R6): Review of admission records revealed R6 admitted to the nursing home on 4/20/17 with a readmission on 5/2/17 with diagnoses that included dementia and [MEDICAL CONDITION] with no [DIAGNOSES REDACTED]. [MEDICATION NAME] 15 mg QHS (daily at bedtime) for dementia without behavioral disturbance and Trazadone 25 mg QHS with no indication for use stated. The facility did not request medical rationale for the concomitant use of two antidepressants. Refer to F428 for additional information. Review of the care plan found notation that R6 used [MEDICAL CONDITION] medications, [MEDICATION NAME] related to chronic pain in [MEDICAL CONDITION], in progressive ataxia, and [MEDICAL CONDITION]. Review of R6's EHR and hard chart found no evidence of monitoring for sleep. The care plan listed only information about the [MEDICATION NAME] with no mention of Trazadone and no non-medication approaches for [MEDICAL CONDITION]. The facility did not identify how R6 manifested behavioral disturbance, no specific behaviors were identified. Behavior Monthly Flow Sheet for September 2017 indicated monitoring of behavior code 12, depressed or withdrawn the flow sheet indicated no occurrences of this behavior with no response for 8 of 48 shifts. Please refer to F428 for additional information. Resident 3 (R3); During a record review on 09/28/2017 revealed R3 was admitted on [DATE] with diagnoses of [MEDICAL CONDITIONS] Disorder and [MEDICAL CONDITION]. The the Medication Administration Record [REDACTED]. The Behavior monitoring flow sheet was incomplete for September 1st thru September 4th, 2017, September 7th thru September 9th, 2017, September 12th thru September 16th, 2017 and September 18th thru September 22nd, 2017. During an interview on 09/28/2017 at 8:00 A.M., Staff 401 stated that the behavior monitoring was not completed for resident per policy and order. Staff 401 further explained that the nurses are supposed to document any observed behaviors on the flow sheet and the blank spaces on the dates listed means that it was not done.

Based on observation, interview, and record review, the facility did not ensure that the resident's physical environment was secured to prevent the elopement of residents and the entry of unauthorized individuals; and did not ensure that residents received supervision and assistive devices to prevent accidents. Findings include: 1. The facility failed to secure its premises to prevent the elopement of residents and/or the entry of unauthorized individuals into the facility especially during off-hours. For example: a. During the initial tour of the B-wing (male unit) on 11/17/14, a motion detector was observed in the short hallway across from the nursing station before the double doors leading out of the facility. While the motion detector was activated when passed, the double doors emitted a single chirping sound when opened. No facility staff was observed in the nursing station nor was there a staff member who checked the double doors to determine the reason for the alarms. While a camera was noted outside above the doors, exposed wiring indicated it had not been connected. Immediately past the doors were unpaved and uneven ground and a line of shrubbery. Past the shrubbery, building construction was in progress where the ground had been graded and foundation was being laid. Because there was no fencing around the facility, the construction site as well as a nearby access road was within reach of any resident who may wander around the premises after going past the doors. From the outside, the double doors also opened allowing easy entrance back into the facility without staff being aware in spite of the single beep from the door and motion detector. During an interview on 11/17/14 at about 3:45 p.m., an unlicensed facility staff member stated that the door alarm setting should have been set to continuous alarm (instead of a single chirping sound) so that facility staff would have to come to the door to reset the alarm and shut it off. The staff had no explanation as to why the door alarm was set to a single chirping sound. b. Review of the facility layout and during the facility tour on 11/18/14 at 3:45 p.m., four doors were observed leading out of both A and B-wings into the courtyard between the two wings. While the doors--one from each conference room on both wings, and one (side-door) from each hallway adjacent to the entrance to both wings were observed wired, no alarm systems however were installed. The doors opened easily without alerting staff. Further, at the end of the courtyard past two storage sheds, wire fencing was observed where a door was attached. A door however was not secured to prevent unauthorized exit by residents from the courtyard and/or entrance by unauthorized individuals into the facility. Past the fence was an access road behind the facility and a cluster of houses across from the road. There was no system in place to alert staff that the fence had been opened and that someone may have entered or left the facility premises. During an interview at 4:30 p.m. on 11/18/14, the facility administer (FA) stated that the neighborhood in back of the facility included drug dealers, drunks, and others who used (illegal) drugs. c. During the same tour on 11/18/14, the double doors located in the A-wing (female unit) was observed. The entry way which was across from the nursing station opened into a driveway that connected to an access road. Beyond the road, several structures including residential homes were noted. While a motion detector was observed inside the short hallway several feet before the double doors, the detector however was not operational. During the environmental tour on 11/20/14 , MS1 stated that the battery inside the detector needed to be replaced. When the doors were opened, the alarm system emitted a single chirping sound. During a confidential interview, a facility staff member stated that the alarm system should be set to continuous alarm (instead of a single chirp) so that facility staff would come to the door to reset it and therefore determine the reason why the door was opened and identify who was leaving or entering the building. The same staff stated that because the double doors served as the primary entrance to and exit out of the facility when the front door was closed after 5:00 p.m., that staff would be overwhelmed and would spend all their time going to the door and resetting the alarm. After 5:00 p.m., the staff explained that the doors were used primarily by staff, visitors, family members, and the drop-off site for any deliveries. In the same interview, the staff member added that residents in the A-wing included several who were described as elopement risks and that within the last three months (prior to the survey) about 6 residents have made it past the double doors into the driveway before being discovered. The staff also identified several residents who had the capacity to push the doors open unassisted. Review of the facility's policy and procedures for "Wanderers/Elopement" (revised 9/05/12) required that for monitoring devices, "Exit monitoring system will be kept operational 24 hours a day;" that "Maintenance personnel are responsible for ensuring that alarms are operational for 24-hour service and are checked routinely;" and that documentation of the checks are made in a log book. There was no indication that the alarm system was being monitored to ensure that the appropriate setting was used to prevent elopement of residents from the facility. On several occasions during the survey, including on 11/17/18, 11/18/14, 11/19, and 11/20/14, the alarm system emitted a single chirping sound when the doors were opened. Observations further revealed that facility staff did not always identify those entering or leaving, and in several instances, no facility staff members were observed in the nursing station to ensure that the doors were monitored. d. During an interview on 11/18/14 at 4:30 p.m., the facility administrator (FA) stated that video cameras were installed in several areas including nursing stations, main corridors, and conference rooms. FA added that the monitors were kept in his office which he then monitors. While FA added that the video monitoring system was for the safety of residents, cameras mounted outside the double doors in both A and B-wings however were not operational. In the same interview, FA added that two months ago, an unidentified male who was "drunk" entered the facility at night using the A-wing entrance and was subsequently found by staff "passed out" in the hallway. In another instance, FA described a break-in where an individual used a knife to pry open a door, entered the facility, and broke into the maintenance office. When documentation of the facility's investigation of the incidents was requested, a report involving a vehicle theft in July 2014 was provided but none about the incidents mentioned. There was no evidence that an investigation of the events was conducted to identify threats and vulnerabilities, improve the current system, and ensure the safety of residents. e. During the environmental tour on 11/20/14, an audio alarm system ("Code Alert") was observed on the wall in the dining room adjacent to the rear door of the financial office. In an interview, MS1 stated that the alarm system was to alert facility staff that the double doors in both A and B-wings were opened. MS1 added that because facility staff were to be in the dining room during meal times to supervise and assist residents, the alarm, when activated was to let staff know that someone had entered or left the facility through the doors. During two meal observations including observations made while activities were in progress in the dining room, the Code Alert system was never activated. When this was brought to attention, MS1 explained that because the double doors in the A and B-wings were set to a single chirp, the Code Alert was deactivated; thus should anyone, including residents, leave or enter the facility (through the doors), staff would not be aware. During the tour, MS1 did verify that the Code Alert was deactivated because the audio alarm setting for the A-wing double doors was set to a single chirp. MS1 added the Code Alert was to be on at all times. f. During the initial tour on 11/18/14, the courtyard between the A and B-wings was observed unpaved and had an uneven surface which could potentially become a tripping hazard not only to residents but to other individuals using the courtyard. While a walkway connecting both wings was paved, the ground on both sides (of the walkway) consisted of soft dry earth which did not ensure firm and even footing. (Cross-refer to F465.) Further, two storage sheds were observed in the courtyard in front of the wire fencing that enclosed the back of the facility. While one of the storage shed was closed, the other was open so that equipment including a welding machine as well as other items such as several fire extinguishers that were on the ground were easily accessible to residents. 2. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The last quarterly minimum data set ((MDS) dated [DATE] assessed the resident's Brief Interview for mental Status (BIMS) score of "7" that indicated severe cognitive impairment. The resident had adequate vision and hearing, with clear speech, able to understand others and able to make self understood in Navajo language. She exhibited depressed moods and wandering behavior. The resident was able to walk in room and corridors with supervision and one person physical assist. She was identified to move between locations on and off unit with supervision and set up help only. The admission MDS dated [DATE] related to Activity Preferences revealed the resident gave the highest importance for her "to go outside to get fresh air when the weather is good." On 11/18/14 at 10:15 a.m. - 10:40 a.m., the resident was observed in the activities/dining area sitting in a chair for a few minutes and wandered in the hallways. Interview with activity staff on the same day at 10:40 a.m. revealed the resident walks all over the facility. She also stated the resident got out of the facility recently. The activity staff indicated the resident was new admit and she used to live in the canyon and took care of sheep. Review of the Admission assessment dated [DATE] revealed the resident had stayed home and raised her children, tend to livestock, cornfields and wove Navajo rugs most of her life. The resident never worked or attended school, she speaks and understands Navajo language only. On 11/19/14 at 9:30 a.m., Resident 14 was observed sitting in a chair next to another resident. Both residents were seated close to the nurses' station. At 9:35 a.m., the resident stood up and the Posey chair sensory pad alarm went off and a licensed nursing staff checked on the resident. At 9:45 a.m., Resident 14 got up from the chair and the Posey chair sensory pad alarm went off again. This time, there was no available nursing staff in the nursing station or in the hallway nearby. The resident sitting next to Resident 14 turned off the Posey chair alarm. Resident 14 proceeded to walk in the hallway towards the back door exit. Review of the Incident Note dated 10/19/14 revealed the resident wandered out of the building and was found outside around the Indian Health Service (IHS) housing area. On 11/19/14 at 4:20 p.m., during an interview, the CNA stated the elopement incident happened on a Sunday and the front doors are locked on weekends from Friday at 5:00 p.m. through Monday at 8:00 a.m. She stated that the 2 CNAs on the floor were busy assisting the "grandmas" to bed for a nap after lunch, approximately 1:00 p.m. to 1:30 p.m. They were not aware that Resident 14 got out of the building until the Activity staff called the nurses' station. They were not sure if the other resident turned off Resident 14's sensor alarm located in the resident's chair. She stated they were not sure if the resident got out from the South exit door because the resident could not push the door to open. She stated that they searched all over the facility and found the laundry exit door was propped open with a chair to keep the door open. It was the activity staff who saw the resident outside through the glass windows. She stated the resident had no injuries and there were no other attempts of elopement on that day. The facility's Incident Description dated 10/18/14 at 13:69 revealed the resident was found outside of the facility wandering on facility property. Resident brought back into facility without further incident, no wounds, bruises, or skin tears noted. On 10/19/14 at 10:00 a.m. in an interview with the activity staff confirmed the resident eloped from the facility on 10/19/14. She saw the resident outside of the facility through the glass windows. A lady who was the wife of a worker from the Developmentally Disabled facility found the resident wandering aimlessly. Resident 14 flagged her down in the parking lot. The lady took Resident 14 back to the facility. Review of the Care Plan Problem of ambulation for Resident 14 dated 7/28/14 related to mobility/safety had an approach that stated "Resident to ambulate using a front wheel walker (FWW), contact guard assist (CGA) *1 recommended at all times." Interview with a licensed nursing staff revealed the resident used to walk using FWW, however she has improved and walks independently now. This care plan was not revised when the resident's ability to walk independently improved to link with behavior of wandering and elopement. There was no comprehensive and individualized care plan related to resident's exit-seeking behavior and individual risk of an accident related to elopement. On 11/18/14 at 10:45 a.m., Resident 14 was observed sitting in a chair in the nurses' station with a licensed nursing staff monitoring the resident. The resident kept asking, "Where's the sheep?" as interpreted by the nursing staff. During an interview, the licensed nurse stated the resident has a behavior of wandering in other resident rooms, trying on a sweater/jacket of other resident's or lying in other resident's bed. She also stated that some residents would get upset with near physical altercations. The licensed nurse also confirmed that although these behaviors may not be aggressive in nature, they may precipitate a negative response from others resulting in verbal, physical and emotional harm. Review of Progress Notes dated 9/27/14 revealed that a new bruise/discoloration was observed under the resident's left cheek bone. The area was tender to touch and the etiology was unknown. There was no further investigation or documentation to rule out a fall or physical abuse. A Progress Note dated 10/3/14 revealed an episode of crying, stating, "I miss my brother." The resident's wandering progressed throughout the day into evening, worst during evening hours. Resident wandered into other resident's rooms without permission, touching other residents without permission causing them to be upset. On 10/15/14, a certified nursing assistant (CNA) heard loud voices from the resident's room and saw Resident 14 reaching for bed items from her roommate - Random Sample Resident (RSR) 23, who slapped Resident 14's hand when Resident 14 made a fist at her. Another Care Plan problem dated 8/2/14 was Activities of Daily Living (ADL) Function. The resident was identified as unable to bathe, dress, groom, self independently related to impaired sense of balance and altered cognitive function. One of the approaches include "Requires supervision, and constant redirection with cueing." This plan of care was not comprehensive to reflect adequacy of supervision related to Resident 14's cognitive impairment. Supervision was not defined as to the type and frequency, based on the resident's assessed needs and identified hazards in the resident environment. 3. On 2/23/14 Resident 16 was found walking on the north side of the facility near the housing units. When asked for the reason for leaving the facility, the resident stated "I want skoal." The preventive measures initiated by the charge nurse to prevent similar elopement problems in the future was "to fix the code alarms in the building." The resident has Code Alert. On 11/20/14 at 11:40 a.m., during an interview, a CNA stated that the elopement happened on a weekend. at approximately 9:00 a.m. to 9:30 a.m. As the CNA was pulling the Hoyer lift pad from another resident she observed Resident 16 walking by the pavement going to the housing construction. She checked and ran to the middle door of B-unit, ran across the field and called out the resident's name. The resident stated he was going to the store to get a can of "skoal" (chewing tobacco). The CNA stated that she was able to convince the resident to go back to the facility. The CNA stated the resident went out of the loading dock area, the side door has an alarm on it. The resident had a Code Alert bracelet on his wrist. He has attempted to exit the back door but facility staff was able to catch him right away because of the code alert alarm. 4. Resident 24 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Nursing Progress Note dated 10/10/14 revealed the resident "wandered and attempted to elope x3. Facility doors opened by resident, alarm activated and staff witnessed near attempt to exit the building. Frequent monitoring/supervision during ambulation done." 5. The complaint alleged that Resident 3 was found outside the facility without her wandering alarm sounding in the summer during hot weather. A nurse, who was not on duty, happened to find the resident outside. Record review on 11/18/14 beginning at 6:30 a.m. revealed that the resident, 85-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. Her most recent quarterly minimum data set (MDS), dated [DATE], documented that she wandered 1-3 days during the assessment period. Her care plan in her record documented: "Focus: Behavior problem related to elopement/wandering. Goal: Will not leave facility unattended. Interventions included: Monitor location every minute; wander alert device, and distract." Interview on 11/19/14 beginning at 8:00 a.m. with the DON revealed that the resident had been found outside the facility on 2 occasions: 12/21/13 and 7/21/14. Review on 11/19/14 beginning at 8:40 a.m. of documentation on the 12/21/13 elopement revealed: "1100: x1 attempt when drivers escorting rsd's (residents) out of the building on to the facility van rsd (Resident 3) attempted to propel pass them. (Staff person's name) @ the time propelled rsd back into the building. Instructed CNA (name) to assist rsd to stationary chair. Moments later this writer (charge nurse) was in the med room and all cna's were w (sic) their residents when (Staff person's name) (OFF DUTY) escorted rsd back into the building. Instructed CNA to assist rsd into stationary chair-completed. Assigned CNA's notes: CNA was doing another care with a resident when this elopement happen (sic). Measures added to the Care Plan Book located @ the Nurse's Station: 1. Monitor resident whereabouts. 2. Reassure resident her livestock are in corral et (sic) sleeping, lambs are fed. sleeping (sic) with their mothers. 3. Sit down 1:1/converse to distract resident's mindset for wandering outside." Review on 11/19/14 beginning at 8:40 a.m. of documentation on the 7/21/14 elopement revealed: "1100: x1 attempt when drivers escorting rsd's (residents) out of the building on to the facility van rsd (Resident 3) attempted to propel pass them. (Staff person's name) @ the time propelled rsd back into the building. Instructed CNA (name) to assist rsd to stationary chair. Moments later this writer (charge nurse) was in the med room and all cna's were w (sic) their residents when (Staff person's name) (OFF DUTY) escorted rsd back into the building. Instructed CNA to assist rsd into stationary chair-completed. Current measures were ineffective because: CNA was doing another care with a resident when this elopement happen (sic)." When the DON was asked if disciplinary action was taken on the CNA (who was to assist Resident 3 into a stationary chair and monitor her for both incidents), the DON stated that during both incidents, she was not in the DON position. She stated that after she was appointed to be DON last week, she reviewed the CNA's personnel file and discovered that no disciplinary action had been taken. Interview on 11/18/14 beginning at 11:15 a.m. with the licensed nurse (LN) who found the resident on both occasions, revealed that she was off duty during both incidents. Each time, she found the resident in her wheelchair in the dirt near the bushes just outside the south exit doors. The facility failed to ensure that Resident 3 did not wander out of the facility on 2 occasions. 6. The complaint alleged that Resident 17 left the facility with a staff member without signing discharge papers. Record review revealed that Resident 17, 77-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. Interview on 11/20/14 beginning at 9:52 a.m. with Social Services (SS) revealed that the resident had come to her in early May 2014 and said that he had spoken to his daughter (who lived in Salt Lake City, UT.), and said that she would come on 6/6/14 to drive him to her home to live with her. The resident said that he was discharging himself from the facility on 6/6/14 on his own request, stating that he is his own guardian, and that he can sign the 30-day discharge papers on his own. SS prepared the discharge papers in anticipation for him to sign on 6/6/14. When she arrived at the facility on 6/3/14, the daughter learned that between 5/31/14 evening to 6/1/14 morning, the resident had found out that his daughter changed her mind and would not be coming on 6/6/14 to drive him to Utah. He was upset. On 6/1/14, he asked Unit Aide 1 (UA 1; worked 4:00 a.m. to 8:00 a.m.) to give him a ride to Many Farms (a city approximately 15-20 miles away) when she would be leaving the facility at 8:00 a.m. SS said Resident 17 was related to UA 1, who lived in Many Farms. Resident 17 had a home in Many Farms. SS stated that Resident 17 left with UA 1 on 6/1/14 a.m. SS stated on 11/20/14 beginning at 9:52 a.m., that resident had returned briefly to facility on 6/9/14 to pick up some items and did sign discharge papers. Review of the 6/3/14 social services notes, documented by the SS revealed, Resident asked why he wasn't informed of signing any forms or medications when he informed the CN 1 (charge nurse on duty that morning) he is leaving. He continued, "the CN 1 knew of his packed bags in his room et was standing there when he departed from facility out the door"...Rsd stated he has his own house...doesn't want other family members involve with him...he can take care of himself. He is upset d/t (due to) his dtr lying to him. This writer inform rsd he needed to meet with CN 1 on duty for his medications...as in hurry to leave again. (Name), Unit Aide (UA 1), states she's driving him today. The staff wish him well...to take care of himself, he wave to everybody...left the facility happy." Record review on 11/20/14 in the morning, revealed that CN 1 on duty on 6/1/14 a.m. documented: "Resident discharged self without signing discharge papers or receiving (sic) medication. I explained prior to hoim (sic (him)) leaving the facility that he must notify the writer of time he was leaving and that he must sign himself out. @ approx 0900 I went into residents (sic) room to get papers signed he was nowhere in building...notification of appropiate (sic) staff. (sic) at the last contact with resident @ approx. 0830 resident was in no acute distress..." Interview on 11/20/14 beginning at 10:24 a.m. with the CN 1 on duty on 6/1/14 a.m. revealed that he saw, on 6/1/14 at 8:00 a.m., UA 1 with the resident near his room, and learned that he was planning to leave that morning. He told Resident 17 to not leave without signing his discharge papers. The CN 1 said he would return to the resident's room in 15 min. to have him sign the papers. The CN 1 said that when he returned to the resident's room at 9:00 a.m., he found that the resident had left the facility. Interview on 11/20/14 beginning at 11:12 a.m. with UA 1 revealed, she was not a relative of Resident 17. On 6/1/14, the resident asked Unit Aide 1 (UA 1) to drive him to his home in Many Farms. UA 1 said that the resident needed a relative to take him out of the facility. The resident said that he checked himself into the facility, and that he can check himself out of the facility. UA 1 asked the resident if he had told the charge nurse that morning that he wanted to leave. The resident said he did. UA 1 said as she and the resident were walking out of the facility exit doors in front of the B Wing nurses station, a CNA walked out with them to say good-bye to the resident. During an interview on 11/20/14 beginning at 11:55 a.m. with CN 1 and the Adm., CN 1 was asked if any staff saw Resident 17 leave the facility on 6/1/14. CN 1 stated no. The CN 1 and the Adm. were told that UA 1 stated that a CNA walked out of the facility with the resident and the UA 1. CN 1 and the Adm. stated that they were never aware of this. The Adm. stated that he did inform UA 1 (after this incident) that she was wrong in taking the resident out of the facility. The facility failed to ensure Resident 17 was safely discharged from the facility when he potentially eloped with a staff member. 7. The complaint alleged that Resident 3 was found outside the facility without her wandering alarm sounding in the summer during hot weather. A nurse, who was not on duty, happened to find the resident outside. Record review on 11/18/14 beginning at 6:30 a.m. revealed that the resident, 85-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. Her most recent quarterly minimum data set (MDS), dated [DATE], documented that she wandered 1-3 days during the assessment period. Her care plan in her record documented: "Focus: Behavior problem related to elopement/wandering. Goal: Will not leave facility unattended. Interventions included: Monitor location every minute; wander alert device, and distract." Interview on 11/19/14 beginning at 8:00 a.m. with the DON revealed that the resident had been found outside the facility on 2 occasions: 12/21/13 and 7/21/14. Review on 11/19/14 beginning at 8:40 a.m. of documentation on the 12/21/13 elopement revealed: "1100: x1 attempt when drivers escorting rsd's (residents) out of the building on to the facility van rsd (Resident 3) attempted to propel pass them. (Staff person's name) @ the time propelled rsd back into the building. Instructed CNA (name) to assist rsd to stationary chair. Moments later this writer (charge nurse) was in the med room and all cna's were w (sic) their residents when (Staff person's name) (OFF DUTY) escorted rsd back into the building. Instructed CNA to assist rsd into stationary chair-completed. Assigned CNA's notes: CNA was doing another care with a resident when this elopement happen (sic). Measures added to the Care Plan Book located @ the Nurse's Station: 1. Monitor resident whereabouts. 2. Reassure resident her livestock are in corral et (sic) sleeping, lambs are fed.sleeping (sic) with their mothers. 3. Sit down 1:1/converse to distract resident's mindset for wandering outside." Review on 11/19/14 beginning at 8:40 a.m. of documentation on the 7/21/14 elopement revealed the same documentation as 12/21/13 noted above: "1100: x1 attempt when drivers escorting rsd's (residents) out of the building on to the facility van rsd (Resident 3) attempted to propel pass them. (Staff person's name) @ the time propelled rsd back into the building. Instructed CNA (name) to assist rsd to stationary chair. Moments later this writer (charge nurse) was in the med room and all cna's were w (sic) their residents when (Staff person's name) (OFF DUTY) escorted rsd back into the building. Instructed CNA to assist rsd into stationary chair-completed. Current measures were ineffective because: CNA was doing another care with a resident when this elopement happen (sic)." When the DON was asked if disciplinary action was taken on the CNA (who was to assist Resident 3 into a stationary chair and monitor her for both incidents), the DON stated, she reviewed the CNA's personnel file and discovered that no disciplinary action had been taken. Interview on 11/18/14 beginning at 11:15 a.m. with the licensed nurse (LN) who found the resident on both occasions, revealed that she was off duty during both incidents. Each time, she found the resident in her wheelchair in the dirt near the bushes just outside the south exit doors. The facility failed to ensure that Resident 3 did not wander out of the facility on 2 occasions. 8. Review of the medical record on 11/20/2014 revealed that Resident 11 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the nurse's notes dated 9/27/2014 regarding an episode of elopement read in part as follows: A CNA saw Resident 11 ambulating in the main parking lot after the resident left through the south exit. The resident told staff she wanted to visit her family in the town. There was an undetermined amount of time that the resident was unsupervised. Staff assisted the resident back into the facility without difficulty. The resident was unharmed. Preventative measures placed included reorient the resident and provide bus rides and visits in town more times during each month, encourage the resident to participate in more activities, and encourage family to visit more often. There were no actions taken to increase supervision. During an interview on 11/20/2014 at 10:15 a.m., a LN stated the facility knew the resident was prone to wandering; however they did not have any alarms or wander guard system at the time. She stated she was not sure what system was currently in place to monitor residents. She stated the facility recently put in camera's mostly pointed at the nurse's station, but not at the entrance or exit doors. She stated the video monitors were located in the CEO's office and staff did not have access to these in order to monitor for resident safety. At 5:00 p.m. on 11/18/14, a meeting was held with the facility administrator to convey the determination that Immediate Jeopardy to residents' life and safety existed by the facility's failure to implement and maintain the current security system in a manner that ensured adequate surveillance and monitoring; the failure to ensure that the entryway where the metal fencing enclosing the courtyard had a system in place to alert staff when the door was opened; and the failure to ensure that staff responded to alarms in a prompt manner to control entrance to and exit out of the facility. These failures resulted in the elopement of residents from the facility as well as the entry of unauthorized individuals in the facility especially after off-hours. Because of the facility's failure to submit credible allegation that the Immediate Jeopardy had been addressed and removed, the survey team determined that Immediate Jeopardy had not been abated. This was communicated to the facility administrator at 3:00 p.m. on 11/21/14 during the exit conference. On 12/05/14, the facility submitted a plan of correction that addressed the findings of the Immediate Jeopardy identified on 11/18/14. Implementation of the plan of correction was verified during an onsite follow-up survey on 12/10/14 including installation of a video surveillance system that enabled staff to monitor entrance to and exit from the facilit

Based on observation, interview and record review the facility failed to assure that one of 25 sampled residents (Resident 8) received care and services to attain or maintain the highest practicable level of functioning when no assessment, care planning or treatment was provided when Resident 8 showed a rapid decline in speech and strength over a two month period. Findings include: During the initial tour on 11/17/2014 beginning at 11:25 AM, Resident 8 was in her wheel chair in the dining room waiting for lunch. When approached with a staff member who spoke Navajo, the resident did not speak; however smiled with her eyes. The staff member stated Resident 8 did not speak. Another staff member on the tour stated Resident 8 had declined recently over the last two months, especially her speech. The staff member stated the resident may have had a stroke a couple of months ago. Review of the medical record, including the hard chart and Electronic Health Records (EHRs) indicated Resident 8 was admitted to the facility 10/09/2013 with [DIAGNOSES REDACTED]. As of 7/4/2014 additional [DIAGNOSES REDACTED]. The minimum data set (MDS - an assessment tool) and Care Area Assessment (CAA) dated 10/15/2013 and 7/18/2014 indicated the resident had adequate hearing and clear speech. She was able to make herself understood and to understand others. The residents Brief Interview for Mental status (BIMS) score was 9 of 15 indicating the resident's mental status was moderately impaired. The resident had limitation of range of motion (ROM) in all extremities. The MDS and CAA dated 10/18/2014 showed no change in the resident's speech or ROM. On 11/18/2014 at 12:10 PM, when asked about Resident 8's status, a licensed nurse (LN) stated the resident had a rapid decline in the last couple of months, especially with speech and swallowing. When asked to show assessments of the residents decline, the LN reviewed the medical record including the hard chart, the SA and PCC Electronic Health Records (EHRs) and could not find any assessments, care plans or diagnostic tests or treatments regarding the resident's [MEDICAL CONDITION] (inability to speak). Physician notes dated after 7/4/2014 revealed no documentation that the resident was aphasic (unable to speak). Review of progress notes in the PCC EHR revealed the following: A noted dated 9/3/2014 - Titled Communication with family: ... "The family state she (Resident 8) had declined tremendously when ...home on pass. (Resident 8) verbal responds had declined ...The family made effort talking to (Resident 8), she did respond (had) with good eye contact but no verbal responds. This writer had visit with (Resident 8) in her room, she responds with good eye contact with a smile but no verbal responds .... " The documentation suggested a room change with residents who require the same amount of assistance; however there was no documentation on how the treatment team would assist the resident to communicate or attain her highest practicable level of functioning. Another noted dated 9/17/2014 titled Restorative Program Note: " ...This morning (Resident 8) alert, very quiet, tried talking to her/no response from her ...Progress: ...quiet as usual, tried talking to her & not a word from her ... " 11/4/2014 - Titled Communication with family: " (Antidepressant) prescribed ...(due to) decreased in her verbal responds with sad facial expressions. (Family) reported (Resident 8) tends to sleep a lot with no verbal responds like she used to. (Resident 8) had gone for Speech Evaluation ...Currently (Resident 8) with more one Navajo words ...Have (resident) respond with one or two Navajo words ... with each contacts. The family were informed of one verbal responds ... (Recommends) ...keep questions short et simple et appraised (resident) for making effort trying to responds at time by moving her lips ... " (Sic) This information was not included on the care plan. When asked about this method of working the resident for communication at different times during the survey, several direct care staff stated they did not know about this approach. A note dated 11/10/2014 - Restorative Program Note: "Subjective: Resident non-verbal, no responding to physical therapist or restorative staff ...Communicating via gesturing ...DC from restorative services ..." During a concurrent interview, the RNA stated he/she reported this to the Physical Therapist (PT). The PT decided to discontinue RNA program as the resident was no longer able to benefit from the program. During an interview on 11/20/2014 at 4 PM, when asked if she was aware of Resident 8's [MEDICAL CONDITION] and leaning to the right side, the resident's physician stated she was not aware of the resident leaning to the right side; however she was aware that the resident had become aphasic; however no work-up was done to identify why the [MEDICAL CONDITION] had occurred. She stated it was probably due to the resident's dementia. When asked if a speech evaluation was ordered, the physician stated that only a swallow evaluation was done. When asked why speech evaluation had not been done or speech therapy had not been attempted, the physician stated, this was a rural area and it was difficult to get staff out there. When asked if the family had been involved in the decision not to do a work-up of the cause of the [MEDICAL CONDITION] or provide speech evaluation or therapy, the physician stated, "No." During an interview on 11/19/2014 at approximately 10 AM, Resident 8's family stated their mother/grandmother had stopped talking and was leaning to one side for the last couple of months. In addition she was having difficulty moving her limbs especially her right side. When asked if this was reported to the physician, the interviewee said it was reported; however no one did anything like a CT scan or MRI to determine the cause. The interviewee said the resident still speaks with her eyes and shows that she wants to talk and get better.

An Immediate Jeopardy (IJ) situation was identified on 9/25/2013 at 9:30 AM. 1. Based on observation, interview and record review the facility failed to have an infection control program that assured staff were trained to clean resident care equipment according to manufactures guidance. Staff were observed cleaning soiled bedside commodes and single use wash basins improperly and sharing these commodes for multiple residents. The Infection Control Preventionist (ICP), a licensed particle nurse (LPN), was not aware of appropriate cleaning practices for resident care equipment and was not effectively trained for the position of ICP. Direct Care Staff (DSC) were not trained by Administrative Staff to properly clean patient care equipment. These practices had the potential to cause serious infections in all residents. After notification of the IJ on 9/25/2013 at 9:30 AM, the facility researched manufactures guidance on cleaning bedside commodes and single use wash basins. They identified the cleaning solution they were using was not recommended to be used on the commodes or wash basins, and obtained appropriate cleaning solutions. The wash basins were discarded and all bedside commodes were cleaned according to manufacturer's instruction. They developed a training plan and in-serviced all staff responsible for the cleaning of the personal care equipment. They revised their infection control policy and developed a monitoring tool to assure compliance. Two plans of correction were presented; however were not accepted until 9/26/2013 at 4:45 PM. After verification of implementation of the POC the IJ was abated. 2. In addition, staff did not consistently follow hand hygiene practices; did not handle linens properly and did not label personal care items; The facility did not assure all staff bathrooms contained a functional soap dispenser; Findings: 1. During observations on 9/24/2013 at 8:50 AM, a direct care staff (DCS) was observed handling wet linens with bare hands. He/she came out of a resident room holding the wet linens at arm's length, and proceeded to place them in the soiled linen container in the hallway. He/she then went directly to the clean linen cart, removed clean linen and then went back into the resident's room. He/she immediately came back out of the resident's room and preceded down the hall to another resident's room without washing his/her hands. At this point the surveyor asked the DCS what the procedure was after handling soiled linen, the DCS stated, "Oh, I forgot to wash my hands." After washing his/her hands, the DCS continued into another resident's room - a room with four residents. In this room was a pink plastic wash basin that was unlabeled. When asked about this the DCS stated, "This (the wash basin) should be cleaned. So we don't label them because other residents re-use them." He/she proceeded to take the wash basin to the A Wing Soiled Work Room. He/she opened the door and placed the wash basin on a counter next to a large, double sink. On the counter on the opposite side of the sink were several bedside commode bucket turned upside down on a towel. When asked about this the DCS state the night shift DCS clean the commodes the resident's use at night. On 9/24/2013 at 4:30 PM, when asked what DCS staff used to clean the commode buckets and basins, the DSC stated he/she was not sure. Observations of the B Wing soiled work room on 9/24/2013 at 4:38 PM revealed six pink wash basins in one side of the large, double sink. There was a printed noted on the paper towel dispenser that read, "Night CNAs - Please wash out B.M. (fecal matter) before throwing it into the hamper. We put some back in the dirty work room for you to was off B.M." There were six commode buckets on a towel on the counter next to the sink. There was a "Hopper" described as a low, ceramic wash basin with a spray nozzle, a splash shield and flush feature next to the sink, near the wall. Above the Hopper was a wire rack with a spray bottle labeled, "Foamy Q & A" Acid Disinfectant Cleaner. At 9/25/2013 at 6 AM, during observations on A Wing, a DSC was seen walking down the hall, returning a soiled commode to the soiled work room. He/she entered the work room and set the commode down. He/she then exited the workroom, went to the medication cart to obtain gloves and returned to the work room. He/she then opened the lid on the commode and removed the commode bucket. There were brown smears on the sides of the bucket and a small amount of yellow liquid in the bottom of the bucket. The DCS took the Foaming Q & A, sprayed the bottom and sides of the bucket and then placed the bucket in the sink. He/she leaned up against the sink with his/her abdomen touching the sink and partially filled the bucket with water. He/she then took a hand held cleaning mop that was wood with a cotton mop head and rubbed the cleaning solution/water around the bucket. He/she then rinsed the bucket and set it on a towel on the counter next to the sink. The DCS then removed his/her gloves, opened a metal trash can and through away the soiled gloves. He/she then opened the work room door and preceded to the nurse's station to wash his/her hands. When asked why he/she left the room to get gloves, the DCS stated there were no gloves in the work room. When asked how long he/she was supposed to let the cleaning solution/disinfectant to stay on the surface of the bucket, he/she said, "I don't know. I just leave it for about 30 seconds, fill it water, scrub it, rinse it and let it air dry." When asked how he/she cleaned the pink wash basins, he/she said, the same way." When asked why he/she did not wash his/her hands in the work room, the DCS made no comment. As the first DCS was leaving the room another DCS brought in another commode bucket. He/she left the commode bucket in the room and went back to resident rooms without washing his/her hands. The second DCS returned to the work room with another commode. Observations of that DCS revealed that he/she followed the same cleaning procedure as the first DCS. Both DCS were interviewed at 7:05 AM, when asked who instructed them to clean the commodes as listed above, they both said, "On orientation another (DCS) taught us to clean them like this. " When asked if they knew the wet time for the cleaning/disinfecting solution, they both said, "No." When asked to read the label on "Foaming Q & A Acid Disinfectant Cleaner", they read the following: "...Five Minute Disinfection Action: For five -minute disinfection activity against bacteria and viruses in the presence of organic soil. 1. Spray directly on soiled surface. 2. Allow foam to wet surface for five minutes. 3. Wipe off with a damp cloth or sponge. 4. Rinse surfaces thoroughly with water. Preliminary cleaning is required for heavily soiled areas. Extremely heavy soils may require agitation with a mild scrubbing pad or brush." Further reading of the label included the following information: "Foamy Q & A kills Staphylocidal, Pseudomonicidal, Salmonellacidal, and Virucidal; HIV-1, Herpes Simplex Type 2 and Influenza A/Hong Kong viruses and Pandemic 2009 H1N1 influenza A virus; Effective against antibiotic-resistant bacteria, MRSA and VRE " There was no indication on the label that this product would kill Clostridium Deficile spores (a very dangerous potentially deadly infectious and contagious organism that is spread through feces). A Note read as follows: "Foamy Q & A contains phosphoric acid. ...Use of Foamy Q & A on older sinks and tubs, polished marble or aluminum, galvanized metal, resilient flooring, terrazzo or carpeting may cause etching or other damage ..." There was no indication on the label that this product was safe to use on plastic. Observations in the B-Wing on 9/25/2013 at 7:20 AM, revealed DCS' cleaning commode buckets and wash basins the same way as they did on A Wing. The DCS' handled the trash can lid, and door knob with contaminated gloves and bare hands. They left the work room to wash their hands at the Nurse's station sink. They obtained gloves from the medication cart. In addition there were approximately 15 urinals, labeled with resident's names and room numbers. These had already been cleaned. They were upside-down draining on a towel on a counter across the room from the large, double sink. When asked how they cleaned the urinals, the DSCs stated they spray Foaming Q & A inside the urinals, fill them with water, swirl them around, dump out this liquid, rinse them with clean water and air dry on the towel. The residents did not share urinals; However resting them on a towel where wicking action can cause cross contamination of nearby objects has the potential to spread infections. During an interview on 9/25/2013 beginning at 8:10 AM, when asked how the facility expected the DCS to clean bedside commodes and wash basins, two Administrative Staff stated the senior DCS teach new DCS how to clean. Housekeeping conducted in-services about cleaning about every 6 months. The DON has meetings where he/she reminds the DCS' to use spray disinfectant and then bleach wipes when cleaning toilets. The ICP stated the DCS were to fill the big sink in the soiled work room with water and a disinfectant cleaner "DMQ" place the personal care items in there, then let them air dry. When asked what the policy was for cleaning the bedside commodes and wash basins, the Administrative staff stated they did not have one. When asked what infections the facility had in the past 6 months, the ICP provided the infection control log with recordings from January 2013 - August 2013. In that time they had several infections, mostly of the skin/wound, respiratory system, urinary tract infections, candidiasis infection of the genitals and oral cavity. They did not list any lower gastrointestinal infections. Many of the infections had cultures ordered; however no results of these laboratory tests were available. The ICP stated the cultures were sent to the hospital next door; however they did not send back the results. He/she acknowledged there was no follow up to get the results. On 9/25/2013 at approximately 9 AM, when presented with the above findings, one of four Administrative Staff was able to identify areas that posed a danger to the residents; however none of the Administrative Staff were knowledgeable about manufacturer's guidance for wet time, or the appropriateness of using acid disinfectant/cleaner on plastic. The Administrative Staff validated that new DCS were oriented and trained by senior DCS. They acknowledged there was no monitoring system present to assure DCS were competently using infection control practices. They acknowledged there was no personal protective equipment (PPE), including gloves, gown/apron, or face shield in the soiled work room. They acknowledged air drying personal care equipment on a towel had the potential to spread infection since these items were not cleaned according to manufacturer's guidance. The survey team followed the protocol for determining if an IJ situation was present. The team agreed the above situation met the criteria for an IJ. The team called their supervisor, whom also agreed this was an IJ. The IJ was called at 9:30 AM. The facility immediately removed all wash basins. They discontinued use of the Foamy Q & A Disinfecting Cleaner. They agreed staff would take residents to the toilet rather than then use the bedside commodes that night. Administration prepared an in-service training the staff to use Standard Precautions and to clean the toilets with bleach wipes between uses. At approximately 3 PM, a phone interview was conducted with the wash basin manufacturer representative. When asked if the wash basins were for multiple resident uses, He/she stated, "Only if they are cleaned properly." When told what the facility used to clean the wash basins, he/she stated the acid cleaners may damage the plastic and that caused micro-cracks where microorganisms can hide. On 9/ 25/2013 at 4:45 PM, the Administrative Staff provided an acceptable plan of correction. 2. On 9/24/2013, the staff bathroom on Unit A was observed. It was noted that the soap dispenser, which is used for washing hands was not working. There was no soap for staff to use to wash their hands. On the outside of the bathroom facility there was a sink for handwashing; the soap dispenser at that faucet was in working condition. Staff would have to pass through two doors without washing their hands to get to the sink at the nursing station. On 9/26/2013, during the 8:00 AM environmental tour, the Maintenance Supervisor (MA) was shown the soap dispenser on Unit A. The MA stated that it was not in working condition and indicated that a plastic piece was missing and the soap dispenser could not work without that plastic piece. The MA stated that it would be replaced. During the same environmental tour, the staff bathroom on Unit B was also observed. The MA stated that this soap dispenser was also not in working order. The MA stated that he would fix the soap dispenser. The staff bathroom on Unit B had the same physical configuration as the staff bathroom on Unit A. This also meant that, after using the bathroom facility, staff would have to pass through two doors to get to the sink at the nurse' station, which was located outside of the staff bathroom. The lack of soap for hand washing in the staff bathrooms posed a potential for infection to both staff and residents.

On 9/25/2013 at approximately 4:45 PM, an Immediate Jeopardy (IJ) situation was identified. Based on observation, interview and record review the facility failed to maintain the highest practicable wellbeing for one of one resident who used a Hoyer Lift (Un-sampled Resident 17). Administrative Staff did not repair or replace a broken manual Hoyer Lift (a hydraulic machine to lift non-weight bearing residents for transfer from/to chair or bed) for two months after notification that the Hoyer Lift was broken. The facility's deficient practice lead to actual harm of Resident 17 causing pain and abrasion to the resident's buttocks when staff had to drag the resident across the hard side of a lip mattress (a mattress with raised edges) and across wheel chair surfaces during transfer. The Direct Care staff continued to report the problem to Administrative Staff that the Hoyer Lift did not fit under the bed when it was in the lowest position. The Hoyer Lift had a noticeable oil leak on the floor where the Lift was stored in Resident 17's room. The Administrative staff stated, he/she had an in-service to teach the staff how to use the broken Hoyer Lift by using different loops on the sling that held the resident, thus pulling the resident progressively closer to the bars that held the sling (the support surface where the resident was placed while lifted) which allowed for better clearance over the bed and seat of the wheel chair; however as the lift lost more oil the hydraulic pressure in the lift could not raise Resident 17 high enough to clear the wheel chair seat or the hard sided lip mattress. Administrative Staff was able to locate an electric lift that needed a battery and replaced the broken manual lift on 9/25/2013 at 6:35 PM. When asked why this electric lift was not provided when Direct Care Staff first reported the broken Hoyer Lift, Administrative Staff made no comment. After replacement of the Hoyer Lift, observation of Direct Care staff competence to use the electric lift, and an acceptable Plan of Correction (POC) that included routine preventative maintenance and ordering new electric Hoyer Lifts, the IJ was abated on 9/26/2013 at 10:30 AM. Findings: During observations on 9/25/2013 beginning at approximately 1 PM, a wet spot was observed on the floor under a Hoyer Lift in Resident 17's room. Direct Care Staff (DCS) stated the Hoyer Lift was leaking. Staff stated the Hoyer Lift would not go up all the way. The staff had to, "Drag (Resident 17) across the chair. (Resident 17) already has a red (buttocks)." DCS said they had informed Administrative Staff about the broken Hoyer Lift several times over the prior two months. Administrative Staff told them to use the new lift. The DCS said they told Administrative Staff that the new lift was not appropriate for Resident 17. The new lift was a Standing Lift (lifts the person to a standing position). Resident 17 had bilateral amputations at the hip level and was therefore non-weight bearing and needed a "Non-weight bearing" lift. DCS proceeded to use the broken Hoyer Lift to transfer Resident 17 from the wheel chair to the bed. Three DCS were needed to assist with this transfer. One DCS was observed to pump up the Hoyer Lift; however it did not raise the resident high enough to clear the seat of the wheel chair. Two additional Direct Care Staff tried to manually lift resident by lifting the canvas sling while the third DCS moved the Hoyer Lift to the bed. As the DCS dragged Resident 17 over the edge of the Lip Mattress, the resident moaned. The edge of the Lip Mattress felt like hard plastic. Observation of the resident's buttocks revealed red excoriated skin. One of the DCS interpreted Navajo, when the surveyor asked the resident how transferring with the Hoyer Lift felt. The resident said in Navajo, "I hate it. When (staff) has to drag me, it rubs my bottom and makes it sore." The resident had tears in her eyes. On 9/25/2014 at approximately 4:45 PM during an interview, when asked what he/she knew about Resident 17's Hoyer Lift, Administrative Staff stated he/she received notice on 7/26/2013 that the Hoyer Lift was broken. He/she stated he/she replaced the resident's bed with a lower bed so that the Hoyer Lift would clear. When asked how the Hoyer Lift hydraulics worked the Administrative Staff stated there was a cylinder with oil in it and a series of rubber seals. As the handle was pumped the seal allowed small amounts of oil into the cylinder below the seals increasing the pressure to hold up the bar. He/she stated, "The seals must be cracked, that is why the bar won't go up all the way." At this time Administrative Staff provided documentation of a work order titled, "Maintenance Work Request" dated 7/26/2013. The form indicated the "room [ROOM NUMBER] Manual Lifter for (Resident 17) does not go up - it will only go 1/4th of the way. (Resident 17) really needs this manual lifter to get (him/her) up for meals/[MEDICAL TREATMENT] (sic). " A box titled "Emergency" was checked. There were several areas on the form where corrective measures could be listed. Most of the form was blank; however the column titled Parts and/or Material column had a hand written note "switch out the bed with 12A (sic)." The column titled, "Date Issued" was blank. During a joint interview and observation on 9/25/2013 beginning at 5:20 PM, Administrative Staff and surveyors observed three DCS lift the resident with the broken Hoyer Lift. The DCS were not able to lift the resident high enough to clear the wheel chair or lip mattress. There was a plastic bag wrapped around the bottom of the broken lift. The plastic bag had black oily substance in it. When asked what the substance was, the Administrative Staff made several suggestions; however after feeling the substance acknowledged the lift was leaking hydraulic fluid. The Administrative Staff acknowledged the Hoyer Lift was defective. They acknowledged the hard side of the Lip Mattress would cause further harm and pain to the Resident 17. Administrative Staff acknowledged they were aware of the defective lift on 7/26/2013. They acknowledged that further use of the defective Hoyer Lift had the potential for further accident to Resident 17 and DSC should the hydraulics fail while the residents was in the lift. An IJ was declared at 5:20 PM on 9/25/2013. The Administrative Staff removed the Lip Mattress and replaced it with a flat mattress. At 6:35 PM, the Administrative Staff was able to locate an electric Hoyer Lift in storage. The Administrative Staff stated, "It just needed a new battery." When asked how long the electric Hoyer Lift had been available, the Administrative Staff made no comment. On 9/26/2013 at 10:30 AM, the IJ was abated when the facility provided an acceptable plan of correction that included 1. Removal of the defective manual Hoyer Lift; 2. Replace lip mattress; 3. Use of Electric Hoyer Lift to lift Resident 17 from wheelchair to/from bed. 4. Staff were in-serviced; 5. Two new electric Hoyer Lifts were ordered; and 6. Routine Periodic Maintenance Program was established.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well being related to an abrasion, in accordance with the comprehensive assessment and plan of care. Finding includes: 1 Resident 3 was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident 3 was able to understand and be understood. The MDS also revealed the resident was totally dependent with one person physical assist for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. She was also identified as frequently incontinent for bowel and bladder function. Review of the nurses' progress notes dated 10/29/13 at 7:16 P.M., revealed the licensed nurse (LN) 1 received report from certified nursing assistant (CNA) that during transfer from lifter to the wheelchair (w/c), Resident 3 sustained a superficial abrasion to mid-back. The CNA reported that as she transferred the resident with the mechanical lifter, the resident was "not properly positioned onto the w/c seat causing (Resident 3) to slide off the w/c seat onto her foot rests. (Resident 3) did not fall to the floor, but remained suspended onto her footrests. The w/c is a hard plastic material which when the resident slid down caused some superficial abrasions." Further review of the nurses progress notes indicated that the area was cleansed and [MEDICATION NAME] ointment was applied. Review of the physician's orders [REDACTED]." There was no specific treatment or medication ordered. Interview with LN1 on 12/3/13 at 1:15 p.m., revealed the physician order [REDACTED]. The protocol listed nine (9) minor skin breakdown conditions that was not marked as applicable to Resident 3's skin condition. The LN pointed out item #2 Minor Abrasion. The protocol reads: "Cleanse/flush the wound with Normal saline or a Commercial cleanser. Apply [MEDICATION NAME] oitment and a dry dressing (if needed) every day until healed." The Physician Standing Order form was signed by physician and dated 06/25/13. It should be noted the resident was readmitted on [DATE] and the skin abrasion was identified on 10/30/13. On 12/4/13 at 9:30 a.m., Resident 3's abraded area was observed with the assistance of two facility CNAs during continent care. The resident's mid back and sacral skin areas were noted intact. Review of the treatment records for October and November, 2013 revealed the skin treatment of [REDACTED]. Further review of the treatment record revealed there were two days in November, 2013 that were left blank. Interview with LN1 revealed that when spaces in the treatment sheet were left blank, the treatments were not done on those days. LN1 was unable to find documentation of the reasons the treatments were missed on 11/1/13 (Friday) and 11/5/13 (Tuesday). 2. Review of Resident 9's record revealed the resident was admitted with dementia, diabetes, depression and [MEDICAL CONDITION] joint disease. The minimum data set (MDS - an assessment tool) dated 11/13/2013 indicated he/she walks with a walker and needed minimal assistance with activities of daily living. He/she had limited range of motion (ROM) in the lower extremity on one side. The resident required verbal/cueing for hand placement and step sequencing/safety precautions. The resident had a history of [REDACTED]. Resident 9 had wounds that needed daily treatment. The resident had two skin tears and an abrasion. The physician recapitulation orders for the month of November 2013 included the following: Treatments: initial date of order = 7/21/2013 "Skin/Wounds -Skin Breakdown-Minor Abrasions-Scratch to Scrotum and 10/10/2013 = "Skin/Wounds -9/18/13 2.5cm circumfrence ST Lt.Lat. Elbow" (Sic)(Skin tear left lateral elbow) There was no order for the treatment of [REDACTED]. During an interview on 12/3/2013 at approximately 4 P.M., when asked what treatments were ordered for the two wounds listed above, the licensed nurse (LN) stated the physician's orders [REDACTED]. These orders were not located in the electronic record; however were a hard copy in the residents charts on the nursing units. The Standing Orders for "Minor Skin Breakdown Protocol" included 9 options which required the LN to [DIAGNOSES REDACTED]. This action is outside the scope of a LN's practice. See the Arizona Board of Nursing Scope of Practie at R4-19-401 and 402 at the following website: http://www.azbn.gov/Documents/npa/RULES-Effective%20September%2010% 3.pdf The treatment administration record was documented on the Emar record (electronic medication administration record). Those reviewed were for the months of September 2013 and October 2013. There was no date on the records when printed from the computer. The LN had to research nurses notes to find the coorisponding EMAR. She then wrote the months on the EMARs. Review of Resident 9's treatment record (EMAR) included instructions for each of three wounds as follows: Dates listed below each wound listed were dates wound care was not provided. Wound #1: 7/21/2013 Skin Breakdown - Minor Abrasions - Scratch to scrotum- instructions- Every shift, Clean w/wound cleanser. Apply [MEDICATION NAME] (ointment) until healed. Notify Med. Provider if not improving. The September 2013 EMAR revealed wound care was documented on Sundays: 9/1/13, 9/8/13, 9/15/13, 922/13, and 9/29/13 at 10 A.M.; and 9/22/13 and 9/2913 at 8 P.M. The October 2013 EMAR revealed wound care was documented on Sundays: 10/6/13, 10/13/13, 10/20/13, 10/27/13 at 10 A.M. and 1/6/13, 10/20/13, and 10/27/13 at 8 P.M. Wound # 2: 9/8/2013 - 2.5 cm circumfrence ST (skin tear) - instructions; QD (every day) Cleanse Lt.Lat. (left lateral) Elbow, dry, apply [MEDICATION NAME] and non adherent dressing. Monitor for infection." (Sic) The September 2013 EMAR revealed wound care was documented as done ever day as prescribed. The October 2013 EMAR revealed missing documentation of wound care on the following dates: 10/3/13 and 10/5/13. Wound #3: 10/1/2013 Skin Breakdown - Skin Tear on Left Lateral Wrist - instructions- QD (every day) Cleanse Skin Tear with NS(normal saline) apply steri-strip, watch for s/s(signs and symptoms) of infection. The October 2013 EMAR revealed missing documentation of wound care on the following dates: 10/1/13, 10/3/13, 10/5/13, 10/14/13 and 10/17/13. When asked why this information was missing the LN review the EHR as well as hard copy notes and found no reason documented whey the above treatments were not documented. She stated if it was not documented then they do not consider it done. When asked who made the decision on which treatment a resident needed, the LN stated the LN did. When asked if the treatment to the Left Lateral Wrist was implemented as noted on the EMAR, that is "apply steri-strip to the skin tear each day", the LN stated, "No, that would injury the skin more." When asked what treatment was applied the LN stated, "If the skin tear needs steri-strips we only apply them once, then we cleanse with wound cleanser, apply [MEDICATION NAME] and cover it with a dry dressing". When asked where the physician's orders [REDACTED].

Based on observation, interview and record review the facility failed to assure the facility was free of accidents and hazards for 3 of 16 sampled residents (Residents 1, 4 and 8 and two unsampled residents(Unsampled residents 17 and 19) for residents on Unit B. On 9/25/2013 at approximately 4:45 PM, an Immediate Jeopardy (IJ) situation was identified. Based on observation, interview and record review the facility failed to maintain the highest practicable well being for one of one resident who used a Hoyer Lift (Un-sampled Resident 17). Administrative Staff did not repair or replace a broken manual Hoyer Lift (a hydraulic machine to lift non-weight bearing residents for transfer from/to chair or bed) for two months after notification that the Hoyer Lift was broken. The facility's deficient practice lead to actual harm of Resident 17 causing pain and abrasion to the resident's buttocks when staff had to drag the resident across the hard side of a lip mattress (a mattress with raised edges) and across wheel chair surfaces during transfer. The Direct Care staff continued to report the problem to Administrative Staff that the Hoyer Lift did not fit under the bed when it was in the lowest position. The Hoyer Lift had a noticeable oil leak on the floor where the Lift was stored in Resident 17's room. The Administrative staff stated, he/she had an in-service to teach the staff how to use the broken Hoyer Lift by using different loops on the sling that held the resident, thus pulling the resident progressively closer to the bars that held the sling (the support surface where the resident was placed while lifted) which allowed for better clearance over the bed and seat of the wheel chair; however as the lift lost more oil the hydraulic pressure in the lift could not raise Resident 17 high enough to clear the wheel chair seat or the hard sided lip mattress. Administrative Staff was able to locate an electric lift that needed a battery and replaced the broken manual lift on 9/25/2013 at 6:35 PM. When asked why this electric lift was not provided when Direct Care Staff first reported the broken Hoyer Lift, Administrative Staff made no comment. After replacement of the Hoyer Lift, observation of Direct Care staff competence to use the electric lift, and an acceptable Plan of Correction (POC) that included routine preventative maintenance and ordering new electric Hoyer Lifts, the IJ was abated on 9/26/2013 at 10:30 AM. Findings include: 1. During observations on 9/25/2013 beginning at approximately 1 PM, a wet spot was observed on the floor under a Hoyer Lift in Resident 17's room. Direct Care Staff (DCS) stated the Hoyer Lift was leaking. Staff stated the Hoyer Lift would not go up all the way. The staff had to, "Drag (Resident 17) across the chair. (Resident 17) already has a red (buttocks)." DCS said they had informed Administrative Staff about the broken Hoyer Lift several times over the prior two months. Administrative Staff told them to use the new lift. The DCS said they told Administrative Staff that the new lift was not appropriate for Resident 17. The new lift was a Standing Lift (lifts the person to a standing position). Resident 17 had bilateral amputations at the hip level and was therefore non-weight bearing and needed a "Non-weight bearing" lift. DCS proceeded to use the broken Hoyer Lift to transfer Resident 17 from the wheel chair to the bed. Three DCS were needed to assist with this transfer. One DCS was observed to pump up the Hoyer Lift; however it did not raise the resident high enough to clear the seat of the wheel chair. Two additional Direct Care Staff tried to manually lift resident by lifting the canvas sling while the third DCS moved the Hoyer Lift to the bed. As the DCS dragged Resident 17 over the edge of the Lip Mattress, the resident moaned. The edge of the Lip Mattress felt like hard plastic. Observation of the resident's buttocks revealed red excoriated skin. One of the DCS interpreted Navajo, when the surveyor asked the resident how transferring with the Hoyer Lift felt. The resident said in Navajo, "I hate it. When (staff) has to drag me, it rubs my bottom and makes it sore." The resident had tears in her eyes. On 9/25/2014 at approximately 4:45 PM during an interview, when asked what he/she knew about Resident 17's Hoyer Lift, Administrative Staff stated he/she received notice on 7/26/2013 that the Hoyer Lift was broken. He/she stated he/she replaced the resident's bed with a lower bed so that the Hoyer Lift would clear. When asked how the Hoyer Lift hydraulics worked the Administrative Staff stated there was a cylinder with oil in it and a series of rubber seals. As the handle was pumped the seal allowed small amounts of oil into the cylinder below the seals increasing the pressure to hold up the bar. He/she stated, "The seals must be cracked, that is why the bar won't go up all the way." At this time Administrative Staff provided documentation of a work order titled, "Maintenance Work Request" dated 7/26/2013. The form indicated the "Room 2 Manual Lifter for (Resident 17) does not go up - it will only go 1/4th of the way. (Resident 17) really needs this manual lifter to get (him/her) up for meals/dialysis (sic). " A box titled "Emergency" was checked. There were several areas on the form where corrective measures could be listed. Most of the form was blank; however the column titled Parts and/or Material column had a hand written note "switch out the bed with 12A (sic). "The column titled, "Date Issued" was blank. During a joint interview and observation on 9/25/2013 beginning at 5:20 PM, Administrative Staff and surveyors observed three DCS lift the resident with the broken Hoyer Lift. The DCS were not able to lift the resident high enough to clear the wheel chair or lip mattress. There was a plastic bag wrapped around the bottom of the broken lift. The plastic bag had black oily substance in it. When asked what the substance was, the Administrative Staff made several suggestions; however after feeling the substance acknowledged the lift was leaking hydraulic fluid. The Administrative Staff acknowledged the Hoyer Lift was defective. They acknowledged the hard side of the Lip Mattress would cause further harm and pain to the Resident 17. Administrative Staff acknowledged they were aware of the defective lift on 7/26/2013. They acknowledged that further use of the defective Hoyer Lift had the potential for further accident to Resident 17 and DSC should the hydraulics fail while the residents was in the lift. An IJ was declared at 5:20 PM on 9/25/2013. The Administrative Staff removed the Lip Mattress and replaced it with a flat mattress. At 6:35 PM, the Administrative Staff was able to locate an electric Hoyer Lift in storage. The Administrative Staff stated, "It just needed a new battery." When asked how long the electric Hoyer Lift had been available, the Administrative Staff made no comment. On 9/26/2013 at 10:30 AM, the IJ was abated when the facility provided an acceptable plan of correction that included 1. Removal of the defective manual Hoyer Lift; 2. Replace lip mattress; 3. Use of Electric Hoyer Lift to lift Resident 17 from wheelchair to/from bed. 4. Staff were in-serviced; 5. Two new electric Hoyer Lifts were ordered; and 6. Routine Periodic Maintenance Program was established. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/26/2013 at 10:05 AM, during an interview with the CNA taking care of Resident 1, the CNA stated that Resident 1 had gotten into her wheelchair by herself earlier that same morning of 9/26/13. The CNA further stated that Resident 1 is a "stand-by assist." The CNA also stated that Resident 1 takes her alarm off. The CNA stated that she was helping another Resident take a shower and was unable to assist Resident 1 when she transferred to her wheelchair. The CNA stated that they do not always have enough CNAs on staff to ensure that all of the residents can have their needs met. The care plan for Resident 1, which is dated 11/15/2013 indicates under "approaches" to "Supervise resident with all transfers." Resident 1 has a history of falls in the facility. The dates of the falls include 1/27/13, 3/11/13, 7/8/13 and 9/9/13. The "Incident Report: Falls," indicates that a fall occurred on 1/27/2013 and was an unwitnessed fall. 3. On 9/28/2013 at approximately 9:35 AM, the sewing room on Unit B was observed. Upon entering the sewing room, it was observed that the door was unlocked. The Maintenance Supervisor stated that the door to the sewing room should be locked. The Maintenance Supervisor further stated that there was Clorox, Azores and other sharp objects in the room and that he would not want the residents to get into those items. 4. On 9/28/2013 at approximately 9:40 AM, an observation was made of the water fountain located on the wall near the Maintenance Supervisor's office. Two screws that were there to hold the water fountain to the wall were very loose and not screwed securely into the wall. This posed an accident hazard in that residents or staff passing by the fountain could be injured if the water fountain were to fall from the wall. 5. On 9/28/2013 at approximately 10:15 AM, the call light plate adjacent to the bed of Resident 8 was observed. There was no call light cord in place and the plate was noted to be loose and had loose wires in the hole where the call light cord would normally be placed. 6.. During the initial tour (on 9/24/13 beginning at 8:43 AM), the linoleum floor at the foot of the bed of Resident 19 was observed to be raised. At this same area was where 2 pieces of linoleum came together. Where the section was raised, it was observed to be slightly splitting. When questioned, the resident said that he has gotten the top of his shoe caught in this raised section and has almost tripped. 7.. Resident 4, 88-years-old, was admitted on [DATE] with [DIAGNOSES REDACTED]. 9/26/13 (in the morning) review of the record revealed that on 8/11/13 at 8:25 PM, the resident had fallen forward out of her wheelchair (w/c) and had sustained a 1/2" laceration to her right temple. Review of the care plan for "Falls" (edited on 8/8/13) that was in place at the time of the fall revealed that one approach was to have the resident in view of staff at all times in the facility. During an interview (on 9/27/13 at 8:30 AM) with one of the direct care staff (DCS) on duty in the A Wing (where the resident resided) during the time of the fall, she stated that the resident was sitting stretched slightly back in her w/c, which was located on the left side of the shower door (located not too far from the right of the side exit door), and was set back away from the hallway, which caused her to not be in view of DCS and administrative staff (Adm. Staff) whenever they were in the hallway. The care plan was not implemented.

Based on observation, interview and record review, the facility did not ensure that the residents received adequate supervision to prevent accidents for 4 of 10 sampled residents (Residents 3, 4, 5, and 9). In addition the facilities failure to completely evaluate and analyze accidents could lead to missed opportunities in identifying risks for other residents and could contribute to the occurrence of more avoidable accidents. Findings include: 1. Resident 4 was admitted to the facility with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that Resident 4 was able to be understood and able to understand, had clear speech; however had problems with temporal orientation (unable to state current year, month and day). The MDS further noted that the resident had no behavior symptoms; was frequently incontinent of bladder function; required supervision in most activities of daily living except for dressing and toilet use where she needed extensive assistance; and that she was "not steady" when "moving from a seated to standing position," and "moving on and off toilet." Review of the medical record revealed that on 9/26/13, a care plan for falls was developed because of Resident 4's history of falls as well as her potential for other falls and injury. Care plan interventions included ensuring adequate lighting and clutter-free areas of ambulation, assisting the resident in ambulation when unsteady, assisting in all transfers, using an alarm to alert staff and ensuring that the alarm was attached to the resident and her wheelchair if using the wheelchair, and assisting to toilet or monitoring her within view to prevent accidents. Review of the electronic medical record revealed that Resident 4 had several falls including on 9/27/13, 10/01/13, 10/04/13, and again on 10/11/13 which were unwitnessed by staff. On 10/01/13 at 7:42 p.m., Resident 4 was described in nurses notes as having been found on the floor. On 10/04/13 at 2:20 p.m., nurses notes revealed that the resident was found sitting on the bathroom floor by an activity staff member after being informed by another resident in the room. While the resident was unhurt, the licensed staff noted that the "resident's Tab (alarm) monitor was not intact," and that the "resident may have removed monitor." While the falls categorized as "unwitnessed" were investigated, review of the medical record revealed the lack of evidence that attempts were made to identify potential antecedent behaviors (contributing to the falls) so these could be addressed. In addition, while the falls occurred in the bathroom, there was no evidence that the resident was assessed to determine the level of supervision needed, how toileting was to be provided, and whether care plan interventions continue to be appropriate based on the resident's condition. While the care plan noted that Resident 4 was to be assisted to the toilet every 2 hours, and as needed during the day, there was no documentation if care plan interventions were followed, and if not, why not. Further, while the resident was to have a Tab alarm to alert staff (during the fall on 10/04/13), there was no documentation as to why the alarm was not in place and why staff were unable to get to the resident on time to meet her needs and prevent further falls. At 6:44 p.m. on 10/11/13, nurses notes revealed that Resident 4 was described as having another "unwitnessed fall" in the bathroom. Accordingly, the resident prior to the fall was observed in her wheelchair with the Tab alarm attached to her back and that she was "demanding" a CNA to take her to the bathroom. As a response, nurses notes indicated that the resident was told to be "patient" as other residents were being attended to by CNAs. Nurses notes revealed that while the "assigned" CNA was informed that the resident had asked two other residents to remove her alarm prior to the fall, there was no documentation that the information was acted upon. Shortly thereafter, nurses notes revealed that Resident 4 had a fall from her wheelchair in the bathroom as she was trying to get to the toilet. The notes revealed that the resident was unhurt and that the wheelchair brakes were not engaged. A roommate was also observed pulling the resident's arm and twirling her on her buttock when staff arrived. Review of the medical record on 12/14/13 revealed the lack of documentation that the incident was investigated to determine the cause, identify potential risk factors, and evaluate the care plan for the failure to prevent the fall. While the resident was informed not to ask other residents to release her alarm and was encouraged to be "patient," the care plan however was not revised. While nurses notes documented that if the alarm was attached, "this fall could have been prevented," there was no mention about the way staff failed to respond to the Tab alarm when it was removed and why staff failed to assist the resident to the toilet when the request was initially made. During an interview on 12/04/13, a licensed staff stated that the fall had occurred around dinner time on 10/11/13 when Resident 4 had finished her meal and wanted to go to the bathroom. When she could not wait for assistance, Resident 4 went to the bathroom and fell . The staff added that because facility practice was that all staff members helped in the main dining room during mealtime, there were no staff members to help residents who remained on the units. 2. Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident 3 was able to understand and be understood. The MDS also revealed the resident was totally dependent with one person physical assist for bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. She was also identified as frequently incontinent for bowel and bladder function. Review of the nurses' progress notes dated 10/29/13 at 7:16 P.M., revealed the licensed nurse (LN) 1 received report from certified nursing assistant (CNA) that during transfer from lifter to the wheelchair (w/c), Resident 3 sustained a superficial abrasion to mid-back. The CNA reported that as she transferred the resident with the mechanical lifter, the resident was "not properly positioned onto the w/c seat causing resident to slide off the w/c seat onto her foot rests. Resident did not fall to the floor, but remained suspended onto her footrests. Her w/c is a hard plastic material which when resident slid down caused some superficial abrasions." Review of the Care Plan for activities of daily living (ADL) function last edited on 2/4/13 revealed a problem that Resident 3 was unable to perform/complete ADLs independently related to Alzheimer's disease and altered cognitive function evidenced by unable to remember task long enough to complete. A goal that the resident will complete ADLs with 1 staff assistance and resident will maintain her highest functional ability. One of the approaches stated, "resident is non-weight (wt.) bearing, 2 persons assist with (w/) all transfers or mechanical (mech.) lifter use. On 12/4/13 at 9:00 A.M., a CNA was observed getting ready to transfer Resident 3 from the wheelchair to the toilet commode using the mechanical lifter. The CNA stated that she felt very nervous because it was the first time that a surveyor will be observing her providing resident care. When asked if she can safely transfer the resident by herself using the mechanical lifter, she asked the surveyor if she can ask for assistance from another CNA. When asked if she usually transfers the resident alone, she stated that she does it by herself but for this observation, she would like to ask for help because she was nervous. On 12/4/13 at 11:50 A.M., during an interview, the physical therapist (PT) stated the last in-service related to transferring residents was held on 5/8/13. However, the in-service was focused on the use of gait belt when transferring the resident from a wheelchair to bed. She also stated that she did not give any in-service regarding the use of the stand-up mechanical lifter. Review of the In-Service Training Report dated 5/18/13 from 10 A.M. to 11:20 A.M. provided by the PT revealed personnel attendance that included 2 Restorative Certified Nursing Assistants (RCNAs) from Nursing, 6 from Dietary, 6 from Housekeeping, 3 from Activity, 1 from Maintenance and 3 from Administration. Review of the CNA staffing revealed 28 CNAs are employed by the facility. On 12/4/13 at 2 P.M., LN1 stated that the maintenance supervisor gave the in-service of the Hoyer lift when they were cited during the last recertification survey, However, there was no in-service given for the use of stand-up mechanical lifter. Review of the Nurses' Progress Notes dated 11/23/13 revealed an "unwitnessed slip off low bed" The notes dated 11/23/13 at 2:25 P.M., read the resident was found sitting on left hip on the floor. Resident's bed was in the lowest position. Resident did not have a bed alarm attached to resident, but assigned CNA stated that the resident did not have the bed alarm attached to right shoulder shirt and alarm clip was still in a closed clasp. No alarm sounded after the resident slipped off the bed. The soft floor mat was not in place by bed. The resident was assisted to the wheelchair by 2 person assist. Assessment was conducted and the resident complained of pain on palpation. There was no bruising to the area. Active range of motion (AROM) to the left leg/hip with resident voicing pain to the left hip area. Resident stated radiating pain from the left hip to left knee with AROM. Resident is non-ambulatory and wheelchair bound. The resident was medicated with Tylenol 650 mg by mouth (p.o.). The physician was notified and ordered the resident transferred to the acute hospital for evaluation. On 11/23/13 at 3:55 P.M., the resident returned to the facility with no complaints of pain. On 9/13/13, the physician ordered included the use of tab alarm as fall mobility precautions. Interview with LN1 revealed the resident is able to slide off the tab alarm without sounding it off. Review of care plan for falls last edited on 11/14/13 identified the resident with history of falls and potential for injury related to reduced muscular strength and inability to transfer independently as evidenced by extensive to total assistance with all transfers; history of falls with injury and unable to recognize hazard of transferring independently. Approaches include: Assess for environmental hazards, position bed in lowest position at all times when resident is in bed, may place mats to bedside floor for added protection, when down in bed/at hours of sleep (HS), and place (Resident 3's name) near the nursing station, in full view of staff. Avoid non-visible areas. The resident was not adequately supervised during this event of unwitnessed fall causing pain to the resident left hip. 3. During an interview and electronic medical record review with a licensed nurse on 12/04/2013 it was revealed that the last fall Resident 5 had occurred on 10/25/2013. The electronic notes indicated the fall was witnessed and it occurred in the male shower room. Per the notes, the cause for the fall was related to shower drain cover moving and the shower chair wheel entered into the drain. The wheel entering into the drain contributed to the unbalanced shower chair the resident fell out and landed on the left side of his body. The notes read (SIC) "SHOWER DRAINAGE COVER IS NOT SECURE AND NO LIGHT IN SHOWER ROOM." Additionally, the records reflected that a Maintenance request was put into place immediately for the "shower drainage cover to be secured and a new light bulb to be installed". Maintenance Supervisor "notified verbally over the telephone". On 12/04/2013 during an interview the Director of Nursing stated that incident did not require reporting the Centers for Medicare and Medicaid Regional Office (CMSRO) and that an internal investigation had been completed. Later on the same day, observations occurred in all the facility shower rooms with the Maintenance Supervisor. There are total 4 shower rooms on the male wing and a total of 4 shower rooms on the female wing. The Maintenance Supervisor acknowledged that on the male wing 3 of the 4 shower drain covers were still loose, easily movable and could contribute to new accidents. On the female wing the Maintenance Supervisor acknowledged 4 of the 4 drain covers were loose, easily movable, and could contribute to new accidents. On that same date all Maintenance Request for the past year were reviewed, there was no written request for aforementioned actions. On further investigation the Maintenance Supervisor denied being informed of the accident and the needed work request however he did stated now that he was aware of the problems it would be corrected immediately. 4. Review of Resident 9's record revealed the resident was admitted with dementia, diabetes, depression and degenerative joint disease. The minimum data set (MDS - an assessment tool) dated 11/13/2013 indicated he/she walks with a walker and needed minimal assistance with activities of daily living. He/she had limited range of motion (ROM) in the lower extremity on one side. The resident required verbal/cueing for hand placement and step sequencing/safety precautions. The resident had a history of [REDACTED]. On 8/15/2012 the fall risk score was 65, indicating the resident was at high risk for falls. There was no comment regarding why the resident's risk had increased. Review of physical therapy (PT) records revealed an initial PT evaluation was conducted on 04/14/2012. Review of the resident's (Sic)"Appt sheet w/ Med/TX/other & Adv.Directives" (a summary sheet of the residents current status, treatments [DIAGNOSES REDACTED]. Review of the "Incident Report: Falls" form revealed the following two incidents: On 10/2/2013 at 2:13 A.M., the resident fell while staff was in the room assisting another resident. Resident 9 stated he/she slipped in the bathroom and hit his/her nose. He/she sustained a bloody nose, a bruise on the right knee and two skin tears on the right wrist. On 10/5/2013 at 3:30 A.M., the resident sustained [REDACTED]. He/she sustained no injury. Although licensed nurses (LN) assessed the resident after the falls, the investigation was incomplete. Review of the incident report for the fall dated 10/5/2013 revealed the LN requested a physical therapy (PT) evaluation be conducted since the resident fell twice within four days. Review of the record revealed no PT evaluation since a routine annual evaluation conducted on 08/09/2013. Review of the current "Care Plan Problem" dated 11/21/2013 for Resident 9 titled "Activities of Daily Living" (ADL) included the following approaches: Supervision needed with transfers, and while walking in room and corridor. Limited assistance needed with toileting. The care plan was not updated after the two falls in October 2013 that occurred while the resident was toileting him/herself. 5. During a meeting on 12/5/2013 beginning at 8:15 A.M., when asked to elaborate on falls that occurred between the exit date of the recertification survey on 9/27/2013 through this revisit survey concluding on 12/5/2013 administrative nursing staff provided a report titled, "RI FALLS - QAA meeting Report." The report revealed there were 36 falls affecting 18 of 64 residents total residents which included 4 of 10 sampled residents (Residents 3, 4, 5 and 9). Review of investigative reports revealed incomplete investigations. The administrative nursing staff stated all falls received a preliminary investigation; however only those with major injury were fully investigated and reported to CMS. There was not root cause analysis done to determine the causes of the falls.

Based on observation, interview and record review the facility failed to administer in a manner that enabled it to use its resources effectively and efficiently by: 1. Failing to assure the safety and physical wellbeing of Resident 17 when equipment was not maintained resulting in an Immediate Jeopardy (IJ) situation. Cross reference F309; F323 and F456; 2. Failed to provide sufficient and qualified nursing staff as evidenced by 1. Avoidable falls for 2 sampled residents (Resident 1 and Resident 4); 2. Failure to assure consistent wound care due to staffing issues; 3. Failure to assure sufficient support services to allow nursing staff to provide quality nursing care; and 4. Failure to assure staff assigned to administrative duties received adequate training to function in their assigned roles as the ICP (Infection control Preventionist), and Restorative Nursing Assistant (RNA) was assigned as a Physical Therapy Assistant (PTA) without training. : Cross reference F323 and F407. 3. Failed to assure the infection control program functioned to assure staff were trained and implemented infection control practices which resulted in an immediate Jeopardy (IJ) situation that placed all residents at risk for infection. Cross Reference F441.

Based on observation, interview and record review the facility failed to maintain resident care equipment for one of one resident who required the use of a Hoyer Lift (Un-sampled Resident 17). Administrative Staff did not repair or replace a broken manual Hoyer Lift (a hydraulic machine to lift non-weight bearing residents for transfer from/to chair or bed) for two months after notification that the Hoyer Lift was broken. The facility's deficient practice lead to actual harm of Resident 17 causing pain and abrasion to the resident's buttocks when staff had to drag the resident across the hard side of a lip mattress (a mattress with raised edges) and across wheel chair surfaces during transfer. (Please reference F309 and 323) Findings: During observations on 9/25/2013 beginning at approximately 1 PM, a wet spot was observed on the floor under a Hoyer Lift in Resident 17's room. Direct Care Staff (DCS) stated the Hoyer Lift was leaking. Staff stated the Hoyer Lift would not go up all the way. The staff had to, "Drag (Resident 17) across the chair. (Resident 17) already has a red (buttocks)." DCS said they had informed Administrative Staff about the broken Hoyer Lift several times over the prior two months. Administrative Staff told them to use the new lift. The DCS said they told Administrative Staff that the new lift was not appropriate for Resident 17. The new lift was a Standing Lift (lifts the person to a standing position). Resident 17 had bilateral amputations at the hip level and was therefore non-weight bearing and needed a "Non-weight bearing" lift. DCS proceeded to use the broken Hoyer Lift to transfer Resident 17 from the wheel chair to the bed. Three DCS were needed to assist with this transfer. One DCS was observed to pump up the Hoyer Lift; however it did not raise the resident high enough to clear the seat of the wheel chair. Two additional Direct Care Staff tried to manually lift resident by lifting the canvas sling while the third DCS moved the Hoyer Lift to the bed. As the DCS dragged Resident 17 over the edge of the Lip Mattress, the resident moaned. The edge of the Lip Mattress felt like hard plastic. Observation of the resident's buttocks revealed red excoriated skin. One of the DCS interpreted Navajo, when the surveyor asked the resident how transferring with the Hoyer Lift felt. The resident said in Navajo, "I hate it. When (staff) has to drag me, it rubs my bottom and makes it sore." The resident had tears in her eyes. On 9/25/2014 at approximately 4:45 PM during an interview, when asked what he/she knew about Resident 17's Hoyer Lift, Administrative Staff stated he/she received notice on 7/26/2013 that the Hoyer Lift was broken. He/she stated he/she replaced the resident's bed with a lower bed so that the Hoyer Lift would clear. When asked how the Hoyer Lift hydraulics worked the Administrative Staff stated there was a cylinder with oil in it and a series of rubber seals. As the handle was pumped the seal allowed small amounts of oil into the cylinder below the seals increasing the pressure to hold up the bar. He/she stated, "The seals must be cracked, that is why the bar won't go up all the way." At this time Administrative Staff provided documentation of a work order titled, "Maintenance Work Request" dated 7/26/2013. The form indicated the "Room 2 Manual Lifter for (Resident 17) does not go up - it will only go 1/4th of the way. (Resident 17) really needs this manual lifter to get (him/her) up for meals/[MEDICAL TREATMENT] (sic). " A box titled "Emergency" was checked. There were several areas on the form where corrective measures could be listed. Most of the form was blank; however the column titled Parts and/or Material column had a hand written note "switch out the bed with 12A (sic)." The column titled, "Date Issued" was blank. During a joint interview and observation on 9/25/2013 beginning at 5:20 PM, Administrative Staff and surveyors observed three DCS lift the resident with the broken Hoyer Lift. The DCS were not able to lift the resident high enough to clear the wheel chair or lip mattress. There was a plastic bag wrapped around the bottom of the broken lift. The plastic bag had black oily substance in it. When asked what the substance was, the Administrative Staff made several suggestions; however after feeling the substance acknowledged the lift was leaking hydraulic fluid. The Administrative Staff acknowledged the Hoyer Lift was defective. They acknowledged the hard side of the Lip Mattress would cause further harm and pain to the Resident 17. Administrative Staff acknowledged they were aware of the defective lift on 7/26/2013. They acknowledged that further use of the defective Hoyer Lift had the potential for further accident to Resident 17 and DSC should the hydraulics fail while the residents was in the lift. On 9/25/2013 at approximately 5:30 PM, Administrative Staff removed the Lip Mattress and replaced it with a flat mattress. At 6:35 PM, the Administrative Staff was able to locate an electric Hoyer Lift in storage. The Administrative Staff stated, "It just needed a new battery." When asked how long the electric Hoyer Lift had been available, the Administrative Staff made no comment.

Based on interview and record review, the facility failed to provide pharmaceutical services that assures accurate administration of all as needed drugs and biologicals by not having a system that provided for a readily retrievable media for documentation of "as needed" only medications. Findings include: 1. During a confidential interview on 09/28/11 at approximately 8:05 P.M., a staff member stated that it was difficult to know if certain medications were given the shift before. a On 09/28/11 Random Resident 19's record was reviewed. Random Resident 19 is [AGE] years old with a history of diabetes mellitis type 2, hypertension, and a heel pressure ulcer. Random Resident 19's physician's orders [REDACTED]."tolbutamide 500 mg PO (by mouth) BID (twice a day) ( a blood sugar lowering medication)" and for Random Resident 19's pain medications included "Tylenol 650 mg po (by mouth) TID (three times a day) ." Under "PRN Medications" listed "Tylenol 650 mg. PO PRN (by mouth as needed for) Pain" and "Humulin R SSI (sliding scale insulin) for increased blood sugars." In the electronic medical record, the day shift LPN was able to pull up the actual parameters for the sliding scale insulin for Random Resident 19. However, the LPN could not pull up when Random Resident 19 last had insulin and how much he received. A review of Random Resident 19's printable EMAR, "EMAR Med Sheet" for August and September 2011 did not have any "as needed" medication orders listed. A review of the report "Glucose and O2 (oxygen) report" had the date, time, and result of the blood glucose check but did not reveal the amount of regular insulin given to the resident. All of Random Resident 19's glucose checks were above normal limits (normal limits =70-110). b Record review for Random Resident 16, [AGE] years old, revealed that the resident had [DIAGNOSES REDACTED]. Review of the Resident's physician's orders [REDACTED]. 6/13/11 - Assure 3 Test Strip (hand held glucose monitors) before meals and at bedtime 6/24/11 - Lantus 5 u SQ at bedtime 6/28/11 - Lantus 3 u SQ at bedtime 6/24/11 - Novolin R - SSI (Reg) only before meals 1/23/11 - Monitoring - weekly accu-check listing - send copy every week to _______(provider) to review. Send every Friday 3/5/08 - Monitoring BS: Notify Med. on call or send to ERD (outside hospital) for BS <70 w/SX. or Decrease Responsiveness. Review of the Resident's June 2011 electronic medication record evidenced that the Novolog 5 u SQ with meals if BS >200 was present. The resident was noted to have received 5 units of Novolog on the following dates and times: 6/1/11 at 4:30 P.M. - glucose was 117 so no insulin should have been given. 6/3/11 at 11:00 A.M. and 4:30 PM - glucose 456 and 323, respectively; insulin given. 6/4/11 at 6:30 A.M., 11:00 A.M., and 4:30 P.M. - glucose HI, 599, 451, respectively; insulin given. 6/5/11 at 6:30 A.M. and 4:30 P.M. - glucose 425 and 380, respectively. No documentation of the 11:00 A.M. glucose being done or of any insulin being given. 6/6/11 at 6:30 A.M. and 11:00 A.M. - glucose 340 and 317, respectively; insulin given. No insulin was documented for 4:30 P.M. glucose of 277. 6/7/11 at 6:30 A.M. - glucose of 373. No insulin was documented for 11:30 A.M. glucose of 329. The Resident was not given 5 units of Novolog on the following dates and times for the listed glucose value: 6/15/11 at 11:00 A.M. - glucose 227. 6/20/11 at 11:00 A.M. - glucose 249; at 4:30 P.M. - glucose of 237. Random Resident 16 was hospitalized [DATE] to 6/28/11. After the hospitalization the sliding scale and amount of insulin given was not listed on the medication sheet. Only the routine insulin was on the medication sheet. Random Resident 16's charting note on 07/18/11 at 11:48 P.M., stated "2000 BS was Hi, has been given Reg insulin, unsure of amt, by day nurse@ 1930 for 1600 BS of 450- BS was rechecked at 2100 and still reading Hi,...resident was given 10 units Reg insulin @2015 per sliding scale for BS over 500..." A review of Random Resident's 16 "Glucose and O2 report for 07/18/11, had Random Resident's 16 blood sugar levels of 331 at 11:00 A.M., 450 at 4:00 P.M., 600 at 11:23 P.M. No where in Random Resident 16's record was how much insulin Random Resident 16 received for these high blood sugar levels. On 07/23/11, Random Resident 16 was admitted to the nearby hospital where she expired on 07/25/11. Random Resident 16 was given incorrect doses or no insulin or there was no documentation to show follow up with the resident's care or that the physician was notified of the significant glucose results. c Record review for Resident 14 revealed that the resident had [DIAGNOSES REDACTED]. Review of the Resident's "physician's orders [REDACTED]. 8/11/10 - Novolin N 40 units (u) every morning 4/10/09 - Humulin R 10 u every morning 8/10/10 - Novolin N 15 u every evening 4/10/09 - Humulin R 5 u every evening 4/10/09 - Accucheks before each meal and bedtime 4/10/09 - Novolin R Sliding Scale. There was a page with the orders that did not have a date, name, or any identifiers on it. It had only the following sliding scale on it: 65 - 100=0 units 151 - 200=0 units 201 - 250=2 units 251 - 300=4 units 301 - 350=8 units >350=10 units. Review of the Resident's electronic medication sheets for July, August, and September, 2011 (months were not labelled on print outs) revealed that the scheduled doses of insulin and the Accucheks were documented. There was no evidence of the actual sliding scale or of the times when the Resident received it based on his blood glucose levels. Review of the Resident's "Glucose and O2 Report" sheets for July, August, and September, 2011 evidenced that there was no sliding scale insulin noted as being given, there were no repeat glucose levels when the Resident's blood glucose was low or high, and there were no physician notifications charted. The following examples demonstrate the failure to document information related to the diabetic management (date, time, blood glucose, sliding scale that should have been given based on physician orders, none charted as given): 7/12/11 at 11:34 A.M. - 214, 2 units should have been given, nothing charted. 7/14/11 at 7:22 P.M. - 203, 2 units should have been given, nothing charted. 7/21/11 at 10:54 A.M. - 63, 120 ml boost, no further follow-up (f/u) noted. 7/27/11 at 11:57 A.M. - 60, 120 m boost, no further f/u noted. 7/30/11 at 7:21 P.M. - 211, 2 units should have been given, nothing charted. 8/5/11 at 11:43 A.M. - 59, Asym (asymptomatic), 60 cc Reg Nova (supplement), no f/u. 8/6/11 at 7:44 P.M. - 227, 2 units should have been given, nothing charted. 8/12/11 at 6:52 P.M. - 242, 2 units should have been given,nothing charted. 8/28/11 at 4:20 P.M. - 242, 2 units should have been given, nothing charted. 9/22/11 at 7:46 P.M. - 238, 2 units should have been given, none; next level was noted on 9/23/11 at 12:05 P.M. 9/25/11 at 4:00 P.M. - 66, 8 oz orange juice; next level was noted on 9/26/11 at 6:10 A.M. d. Resident 3's medical record revealed the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's EMAR for 9/11 showed the resident had an elevated blood sugar of 266 on 9/23/11. There was no documentation of sliding scale insulin being administered for the elevated blood sugar. Review of the physician orders [REDACTED]. At approximately 10:40 A.M., on 9/29/11 the day shift LPN was asked how she finds when a PRN insulin was given. She stated she goes to the EMAR Med Sheet and it "should show up." The LPN then went to the EMAR and then stated,"oh, it didn't." when the PRN insulin did not appear on the EMAR Med Sheet. At approximately 1:35 P.M., the facility's consultant pharmacist stated that he did not look at amounts of PRN insulins given to residents, he just looked at their Hemoglobin A1Cs (a marker for blood glucose stabilization). On 09/29/11 at approximately 3:05 P.M, the DON stated that the LPNs are annotating that the PRN insulin is being given, however one cannot retrieve that information so the LPNs were writing the PRN insulins in free form in electronic medical record charting but that could only be viewed only for 24 hours prior. The DON also stated that the LPNs were not always consistent with their documentation here. The DON continued to state that all diabetics received sliding slide insulin and then provided a list of all diabetics. The list dated 09/29/11 contained 20 residents and included Residents 1, 3, 5, 6, 9, 13, 14, and 18. This list did not include Random Resident 19 who had a sliding scale insulin order per his physician orders. 2. On 09/27/11, the facility stated that all residents received standing orders from their primary care physician. The standing orders included 5 pages of "as needed" medications for 18 different ailments plus routine laboratory orders and what the sliding scale insulin should be if ordered (there was a space for a check mark to mean an order). For fever, the standing orders stated, "Acetaminophen (also known as Tylenol) 325 mg (2 tablets) for oral temperature greater than 100 degrees. For headache/minor pain, the standing order read, "Acetaminophen 325 mg (two tablets), monitor response..." As written, these orders had no parameters as to how much acetaminophen these residents could receive. A review of Random Resident 19's and 21's EMAR Med Sheet for August 2011 and September 2011, both had routine orders for Acetaminophen. Random Resident 19 had an order that stated "Tylenol 650 mg po TID for pain" (total 1950 mg or 1.95 g a day) and Random Resident 20 had an order that stated " Tylenol 650 mg po QID (four times a day) for pain." (total 2600 mg or 2.6 g a day) According to the drug reference "Lexi-comp Drug Information Handbook," under "acetaminophen, dosage", it listed, "do not exceed 4 g (grams) a day. On 09/29/11 at approximately 3:05 P.M, the DON could not produce documentation to indicate if these residents received their PRN doses of acetaminophen, or if the dosage exceeded over 4 grams per day. On 09/29/11 at approximately 10:00 A.M., the MDS coordinator stated that the reason why the PRN medications were not showing up on the EMAR Med Sheets was due a "glitch" in the system since October 2010 when MDS 3.0 went into effect. An immediate jeopardy was declared on 09/29/11 at 3:20 P.M. due to the failure to provide pharmaceutical services by not effectively communicating all "as needed" (prn) medications to ensure the accurate administration of all drugs and biologicals to residents and not having that information in a readily retrievable media for all clinical staff for effective monitoring. The immediate jeopardy was abated on 09/30/11 at 9:50 A.M. with an acceptable plan of correction that included a paper system that documents the "as needed" medications until the software technician can come and fix the electronic medical record. The facility demonstrated that all clinical staff had been trained on the new paper system. 4. On 9/29/11 at 5:32 P.M., during the observation of a medication pass with LS, she prepared to administer medication to Resident 24. The Resident's electronic Medication Record listed Calcium 600 mg (milligrams) Vitamin D 400 u (units). The LS took a Calcium 600 mg Vitamin D 200 u tablet from the resident's medication card and cut it into two pieces. Once the LS was ready to leave the medication cart to administer the Resident's medication, the surveyor stopped the LS. The surveyor asked about the dosage of the Calcium and Vitamin D. The nurse confirmed that the dosage that she had prepared was not correct. She was unable to find the correct dosage and held the medication. Review of the Resident's medication card evidenced that 13 tablets had been used from the current card. The Director of Nursing (DON) was asked many times if the pharmacy had filled that prescription. She was unable to provide that information. On 13 occasions, Resident 24 had received the incorrect dose.

Based on observation, interview and record review, the facility failed to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable for one of 15 sampled residents. Resident 5 failed to receive specialized rehabilitation to ambulate after a recent left [MEDICAL CONDITION] that stopped her progress in recovery from the [MEDICAL CONDITION] and increased the risk of complications in ambulating in the future. Findings include: 1. Resident 5 was an [AGE] year old female admitted [DATE]following repair of a left trochanteric fracture and a rehabilitation stay in another nursing home. The resident reported in an interview conducted with an interpreter on 9/29/11 at 1 P.M. that she was walking prior to a fall that occurred 8/6/11. During this survey week, the resident was observed to be wheelchair bound and was not observed walking at any tme. The resident's record contained a Discharge Summary from another nursing home dated 9/9/11 which described the resident as able to "Stand amb (ambulate) 9/6-25 ft (feet) without pain and with FWW (front wheel walker) so far. Needs further PT for WBAT (weight bearing as tolerated) and gait training". The resident did not receive a physical therapy evaluation from admission to 9/30/11, the last day the surveyor was onsite at this nursing home. The resident was evaluated by a PT aide on 9/21/11 who reported on 9/29/11 at about 11 A.M. that she had the resident walk with assistance thru parallel bars, but that she stopped the resident from walking further because she heard crunching sounds that she was concerned about. She reported the resident continued with therapy, but only in a wheelchair and only for upper body strengthening. The "Mobility Assessment" report dated 9/21/11 stated: "STOP, will wait until PE/PT evaluation is completed, now pending for both". The surveyor discovered a consult from the resident's orthopedic surgeon dated 9/6/11 (6:34 P.M.) and under "Impression & Plan Summary", the following was noted along with the impression the resident had suffered a "fx closed trochanteric NOS (Left) - new". Recommendation: "This patient has a left trochanteric fracture. This appear stable. I recommended weightbearing as tolerated ambulation with a walker. She can do therapy for this. She should followup in another 6 weeks. We'll repeat x-rays AP lateral left hip". On this consult note was a hand written note indicating the facility reviewed the information on 9/27/11 at 4:20 P.M, more than 2 weeks after the resident's admission. The facility failed to order and obtain an evaluation from a physical therapist and failed to include this information in the resident's admission orders [REDACTED] 2.The resident was observed to be in the bathroom on 9/29/11 at 12:30 P.M. and there was no staff around to assist her. After the surveyor waited about 5 minutes and no assistance was received, a CNA was notified who went to this resident's bathroom to check on the resident. The CNA came out of the bathroom and stated the resident was fine and did not need/want assistance. The resident's care plan stated that she would receive one person assistsance for all transfers. 3. In an interview conducted on 9/29/11 at 1 P.M., the resident stated she has waited too long for assistance to the bathroom more than once in the early morning, resulting in accidents where she wet herself. The resident's care plan for Activities of Daily Living (ADL) states: "Resident is able to bear weight for transfer. Please assist". The lack of specialized rehabilitation evaluation and clear guidance for therapy assistants and staff, as well as oversight of the work of the therapy staff, limited Resident 5's recovery and progress to be able to walk again. The lack of assistance during transfers caused her to have embarrassing accidents and increased her risk of injury from a fall.

Based on observation, record review, and staff interview, that the facility failed to provide adequate supervison to prevent accidents and to ensure that the environment was as free of accident hazards as possible placing 2 of 15 sampled residents (Residents 2 and 10) at greater risk for falls. Findings include: FALLS 1. Record review for Resident 2 revealed that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Resident's 9/17/11 annual Minimum Data Set (MDS) assessment evidenced that the resident was assessed to require limited assistance with toilet use and personal hygiene; supervision with transfer, locomotion on and off the unit, and dressing; had not walked in the room or corridor; and was independent with bed mobility and eating. The Resident was assessed to use a walker and wheelchair and had impairment on one side in the lower extremity. He was coded as having had no falls since the prior assessment. Review of the Resident's incident report dated 11/14/10 revealed that the Resident experienced a fall outside of the building when he could not go through the main hallway since it had been mopped. This Resident in his wheelchair and an ambulatory resident went out into the backyard (courtyard) to get around the blocked section of the hallway. The Resident's wheelchair tipped backwards on the uneven concrete sidewalk where there were dips for water runoff and drainage. He was found lying on his back with a large hematoma to the back of his head (occipital) and was transported to the hospital. Review of the Resident's chart evidenced that he was hospitalized from [DATE] to 11/18/10 due to the head injury and seizure activity. Review of the facility report which was submitted to the Regional Office evidenced that the facility developed the following suggestion/recommendations after investigating and reviewing their findings: "1. Maintenance staff to install sensor alarm monitors to all exit doors. 2. Re Evalluate (sic) all wheel chairs for rear anti=tip bars by I.H.S. PT staff. 3. Maintenance staff to cover the water runoff canals in the courtyard of facility. 4. Housekeeping Manager to in-service to the residents and employees on the yellow wet sign precautions when in use. ...." Review of the Housekeeping policies provided to the surveyor did not address the use of caution signs or mopping part of the hallway so that residents still have access. No Housekeeping staff inservice information was provided to surveyor. On 9/29/11 at 11:50 A.M., an observation made from the "A" unit nurses station evidenced that the entire width of the hallway leading to the exit door was wet from mopping. Two signs were placed to the right side of the hallway. People were observed entering and exiting over the wet floor. 2. Resident 10 is [AGE] years old with a medical history of [REDACTED]. A review of Resident 10's record revealed on 02/13/11 at 12:30A.M, Resident 10 fell as she self transferred from her wheelchair to her bed. A review of Resident 10's annual MDS dated [DATE] under G 0300 "balance during transitions and walking" for A. Moving from seated to standing position, B. Walking (with assistive device if used), C. Turning around and facing the opposite direction while walking, D. Moving on and off toilet, and E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) were all coded as "2" meaning, "Not steady, only able to stabilize with human assistance." A review of Resident 10's records regarding her falls revealed Resident 10 fell on [DATE] at 01:36A.M. where she "slip (sic) off the wheelchair." The record continued to state "CN (charge nurse)did an overall assessment that revealed no injuries." Furthermore, under "Measure(s) to be implemented to prevent future similiar problem(s) : ... apply w/c (wheelchair) and bed alarm to alert staff." The record also revealed Resident 10 fell on [DATE] at 12:15P.M. when she "rolled off bed and onto floor." A review of "Medication and /or [DIAGNOSES REDACTED]." Furthermore, the record stated, "Measure(s) to be implemented to prevent future similar problem(s): ... apply w/c and bed alarm to alert staff." On 09/29/11, the CNA that was assisting Resident 10 the early morning of 02/13/11 was interviewed. The CNA stated that Resident 10 had a history of [REDACTED]." Furthermore, the CNA had stated that night Resident had A and D ointment applied to her feet since they were dry. A review of Resident's 10 record notes regarding the 02/13/11 fall stated, "Immediate corrective action taken by charge nurse at time of resident's fall... apply alarm to bed to monitor/ wheelchair to monitor / alert staff of resident's independent transfer attempts. Resident 10 failed to receive fall prevention measures as noted in plans designed to address her history of falls. A review of the fall investigation conducted by the facility after the fall that occurred on 2/23/11 revealed Resident 10 was transferred to Hospital A where after an x-ray was diagnosed with [REDACTED]. 3. During the environmental tour on 9/29/11 at 2:00 P.M. with the Maintenance Director the outside center courtyard to the facility was checked. The area was fenced in and had a gazebo area which the resident could access. There was a sidewalk area that ran along the build between the A wing and B wing of the facility. The doors accessing this sidewalk from both A wing and B wing were not alarmed. The sidewalk was noted to have four dips in the sidewalk which were dips in the cement for water/rain runoff from the building which presented a trip hazard. These areas were specifically checked due to a resident having a fall from a wheelchair from this sidewalk. The facilities plan of action to prevent further accidents from this hazard was to alarm the two doors leading to this sidewalk and correct the dips in the cement walkway. However these actions had not been completed and the hazards were still present and confirmed by the Maintenance Direct. Additionally the second sidewalk joining the A wing and B wing to the gazebo was noted to have areas with a drop off from the sidewalk. The Maintenance Direct reported he had planned to level to ground at the edge of the sidewalk but had not completed the project. He confirmed that residents did use the area and it presented a hazard for residents either walking or in wheelchairs. ELECTRICAL HAZARDS: 4. During the initial tour on 9/27/11 from 8:00 A.M. to 9:30 A.M. with LS noted the following electrical hazard. The observation of room 2A revealed the call light for bed three had loose wiring. The end of the call light used by the resident was frayed and not working. The air mattress for room 3A bed 1 had exposed wiring where the plug went into the wall electrical socket. During the environmental tour on 9/29/11 at 2:00 P.M. with the Maintenance Director the electrical hazard were checked. The Maintenance Director confirmed the above issues and reported he had not been notified of the frayed wiring. 5. On 9/27/11, starting at 8:05 AM, during the initial facility tour of the "B" unit in the presence of CNA, the right arm rest on Resident 1's wheelchair observed to be torn. This created a potential for skin tears. 6. On 9/27/11 at 3:45 PM, during an observation of one of the shower rooms located at the nurses' station on the "B" unit, there was a razor lying on the sink in the toilet room. No staff or residents were present at the time of the observation. 7. On 9/28/11 and 9/29/11, a cart containing supplies was sitting in the hall at the nurses' station on "B" unit. The cart was left there unattended and not in use or placed in the unlocked shower rooms. The cart contained razors and cleaning supplies for peri-care. 8. On 9/28/11 at 8:25 P.M., a CNA was observed taking Resident 14 to a shower room on the "B" unit. The Resident used the handrail in this area to pull to a standing position. When the Resident's leg dressing was removed by the CNA and LS, the LS bumped the handrail. The handrail was pulled out of the wall at the end, making the handrail loose. The LS attempted to fix it but it was still loose. On 9/29/11 at 8:10 A.M., the surveyor reported the concern about the loose handrail to the Maintenance Supervisor. He was not aware of the loose handrail in that shower room.

Based on interview and record review, the facility failed to provide pharmaceutical services that assures accurate administration of all as needed drugs and biologicals by not having a system that provided for a readily retrievable media for documentation of as needed only medications. Findings include: 1. During a confidential interview on 09/28/11 at approximately 8:05 P.M., a staff member stated that it was difficult to know if certain medications were given the shift before. a On 09/28/11 Random Resident 19's record was reviewed. Random Resident 19 is [AGE] years old with a history of diabetes mellitis type 2, hypertension, and a heel pressure ulcer. Random Resident 19's physician's orders [REDACTED].tolbutamide 500 mg PO (by mouth) BID (twice a day) ( a blood sugar lowering medication) and for Random Resident 19's pain medications included Tylenol 650 mg po (by mouth) TID (three times a day) . Under PRN Medications listed Tylenol 650 mg. PO PRN (by mouth as needed for) Pain and Humulin R SSI (sliding scale insulin) for increased blood sugars. In the electronic medical record, the day shift LPN was able to pull up the actual parameters for the sliding scale insulin for Random Resident 19. However, the LPN could not pull up when Random Resident 19 last had insulin and how much he received. A review of Random Resident 19's printable EMAR, EMAR Med Sheet for August and September 2011 did not have any as needed medication orders listed. A review of the report Glucose and O2 (oxygen) report had the date, time, and result of the blood glucose check but did not reveal the amount of regular insulin given to the resident. All of Random Resident 19's glucose checks were above normal limits (normal limits =70-110). b Record review for Random Resident 16, [AGE] years old, revealed that the resident had [DIAGNOSES REDACTED]. Review of the Resident's physician's orders [REDACTED]. 6/13/11 - Assure 3 Test Strip (hand held glucose monitors) before meals and at bedtime 6/24/11 - Lantus 5 u SQ at bedtime 6/28/11 - Lantus 3 u SQ at bedtime 6/24/11 - Novolin R - SSI (Reg) only before meals 1/23/11 - Monitoring - weekly accu-check listing - send copy every week to _______(provider) to review. Send every Friday 3/5/08 - Monitoring BS: Notify Med. on call or send to ERD (outside hospital) for BS <70 w/SX. or Decrease Responsiveness. Review of the Resident's June 2011 electronic medication record evidenced that the Novolog 5 u SQ with meals if BS >200 was present. The resident was noted to have received 5 units of Novolog on the following dates and times: 6/1/11 at 4:30 P.M. - glucose was 117 so no insulin should have been given. 6/3/11 at 11:00 A.M. and 4:30 PM - glucose 456 and 323, respectively; insulin given. 6/4/11 at 6:30 A.M., 11:00 A.M., and 4:30 P.M. - glucose HI, 599, 451, respectively; insulin given. 6/5/11 at 6:30 A.M. and 4:30 P.M. - glucose 425 and 380, respectively. No documentation of the 11:00 A.M. glucose being done or of any insulin being given. 6/6/11 at 6:30 A.M. and 11:00 A.M. - glucose 340 and 317, respectively; insulin given. No insulin was documented for 4:30 P.M. glucose of 277. 6/7/11 at 6:30 A.M. - glucose of 373. No insulin was documented for 11:30 A.M. glucose of 329. The Resident was not given 5 units of Novolog on the following dates and times for the listed glucose value: 6/15/11 at 11:00 A.M. - glucose 227. 6/20/11 at 11:00 A.M. - glucose 249; at 4:30 P.M. - glucose of 237. Random Resident 16 was hospitalized [DATE] to 6/28/11. After the hospitalization the sliding scale and amount of insulin given was not listed on the medication sheet. Only the routine insulin was on the medication sheet. Random Resident 16's charting note on 07/18/11 at 11:48 P.M., stated 2000 BS was Hi, has been given Reg insulin, unsure of amt, by day nurse@ 1930 for 1600 BS of 450- BS was rechecked at 2100 and still reading Hi,.resident was given 10 units Reg insulin @2015 per sliding scale for BS over 500. A review of Random Resident's 16 Glucose and O2 report for 07/18/11, had Random Resident's 16 blood sugar levels of 331 at 11:00 A.M., 450 at 4:00 P.M., 600 at 11:23 P.M. No where in Random Resident 16's record was how much insulin Random Resident 16 received for these high blood sugar levels. On 07/23/11, Random Resident 16 was admitted to the nearby hospital where she expired on 07/25/11. Random Resident 16 was given incorrect doses or no insulin or there was no documentation to show follow up with the resident's care or that the physician was notified of the significant glucose results. c Record review for Resident 14 revealed that the resident had [DIAGNOSES REDACTED]. Review of the Resident's physician's orders [REDACTED]. 8/11/10 - Novolin N 40 units (u) every morning 4/10/09 - Humulin R 10 u every morning 8/10/10 - Novolin N 15 u every evening 4/10/09 - Humulin R 5 u every evening 4/10/09 - Accucheks before each meal and bedtime 4/10/09 - Novolin R Sliding Scale. There was a page with the orders that did not have a date, name, or any identifiers on it. It had only the following sliding scale on it: 65 - 100=0 units 151 - 200=0 units 201 - 250=2 units 251 - 300=4 units 301 - 350=8 units >350=10 units. Review of the Resident's electronic medication sheets for July, August, and September, 2011 (months were not labelled on print outs) revealed that the scheduled doses of insulin and the Accucheks were documented. There was no evidence of the actual sliding scale or of the times when the Resident received it based on his blood glucose levels. Review of the Resident's Glucose and O2 Report sheets for July, August, and September, 2011 evidenced that there was no sliding scale insulin noted as being given, there were no repeat glucose levels when the Resident's blood glucose was low or high, and there were no physician notifications charted. The following examples demonstrate the failure to document information related to the diabetic management (date, time, blood glucose, sliding scale that should have been given based on physician orders, none charted as given): 7/12/11 at 11:34 A.M. - 214, 2 units should have been given, nothing charted. 7/14/11 at 7:22 P.M. - 203, 2 units should have been given, nothing charted. 7/21/11 at 10:54 A.M. - 63, 120 ml boost, no further follow-up (f/u) noted. 7/27/11 at 11:57 A.M. - 60, 120 m boost, no further f/u noted. 7/30/11 at 7:21 P.M. - 211, 2 units should have been given, nothing charted. 8/5/11 at 11:43 A.M. - 59, Asym (asymptomatic), 60 cc Reg Nova (supplement), no f/u. 8/6/11 at 7:44 P.M. - 227, 2 units should have been given, nothing charted. 8/12/11 at 6:52 P.M. - 242, 2 units should have been given,nothing charted. 8/28/11 at 4:20 P.M. - 242, 2 units should have been given, nothing charted. 9/22/11 at 7:46 P.M. - 238, 2 units should have been given, none; next level was noted on 9/23/11 at 12:05 P.M. 9/25/11 at 4:00 P.M. - 66, 8 oz orange juice; next level was noted on 9/26/11 at 6:10 A.M. d. Resident 3's medical record revealed the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's EMAR for 9/11 showed the resident had an elevated blood sugar of 266 on 9/23/11. There was no documentation of sliding scale insulin being administered for the elevated blood sugar. Review of the physician orders [REDACTED]. At approximately 10:40 A.M., on 9/29/11 the day shift LPN was asked how she finds when a PRN insulin was given. She stated she goes to the EMAR Med Sheet and it should show up. The LPN then went to the EMAR and then stated,oh, it didn't. when the PRN insulin did not appear on the EMAR Med Sheet. At approximately 1:35 P.M., the facility's consultant pharmacist stated that he did not look at amounts of PRN insulins given to residents, he just looked at their Hemoglobin A1Cs (a marker for blood glucose stabilization). On 09/29/11 at approximately 3:05 P.M, the DON stated that the LPNs are annotating that the PRN insulin is being given, however one cannot retrieve that information so the LPNs were writing the PRN insulins in free form in electronic medical record charting but that could only be viewed only for 24 hours prior. The DON also stated that the LPNs were not always consistent with their documentation here. The DON continued to state that all diabetics received sliding slide insulin and then provided a list of all diabetics. The list dated 09/29/11 contained 20 residents and included Residents 1, 3, 5, 6, 9, 13, 14, and 18. This list did not include Random Resident 19 who had a sliding scale insulin order per his physician orders. 2. On 09/27/11, the facility stated that all residents received standing orders from their primary care physician. The standing orders included 5 pages of as needed medications for 18 different ailments plus routine laboratory orders and what the sliding scale insulin should be if ordered (there was a space for a check mark to mean an order). For fever, the standing orders stated, Acetaminophen (also known as Tylenol) 325 mg (2 tablets) for oral temperature greater than 100 degrees. For headache/minor pain, the standing order read, Acetaminophen 325 mg (two tablets), monitor response. As written, these orders had no parameters as to how much acetaminophen these residents could receive. A review of Random Resident 19's and 21's EMAR Med Sheet for August 2011 and September 2011, both had routine orders for Acetaminophen. Random Resident 19 had an order that stated Tylenol 650 mg po TID for pain (total 1950 mg or 1.95 g a day) and Random Resident 20 had an order that stated Tylenol 650 mg po QID (four times a day) for pain. (total 2600 mg or 2.6 g a day) According to the drug reference Lexi-comp Drug Information Handbook, under acetaminophen, dosage, it listed, do not exceed 4 g (grams) a day. On 09/29/11 at approximately 3:05 P.M, the DON could not produce documentation to indicate if these residents received their PRN doses of acetaminophen, or if the dosage exceeded over 4 grams per day. On 09/29/11 at approximately 10:00 A.M., the MDS coordinator stated that the reason why the PRN medications were not showing up on the EMAR Med Sheets was due a glitch in the system since October 2010 when MDS 3.0 went into effect. An immediate jeopardy was declared on 09/29/11 at 3:20 P.M. due to the failure to provide pharmaceutical services by not effectively communicating all as needed (prn) medications to ensure the accurate administration of all drugs and biologicals to residents and not having that information in a readily retrievable media for all clinical staff for effective monitoring. The immediate jeopardy was abated on 09/30/11 at 9:50 A.M. with an acceptable plan of correction that included a paper system that documents the as needed medications until the software technician can come and fix the electronic medical record. The facility demonstrated that all clinical staff had been trained on the new paper system. 4. On 9/29/11 at 5:32 P.M., during the observation of a medication pass with LS, she prepared to administer medication to Resident 24. The Resident's electronic Medication Record listed Calcium 600 mg (milligrams) Vitamin D 400 u (units). The LS took a Calcium 600 mg Vitamin D 200 u tablet from the resident's medication card and cut it into two pieces. Once the LS was ready to leave the medication cart to administer the Resident's medication, the surveyor stopped the LS. The surveyor asked about the dosage of the Calcium and Vitamin D. The nurse confirmed that the dosage that she had prepared was not correct. She was unable to find the correct dosage and held the medication. Review of the Resident's medication card evidenced that 13 tablets had been used from the current card. The Director of Nursing (DON) was asked many times if the pharmacy had filled that prescription. She was unable to provide that information. On 13 occasions, Resident 24 had received the incorrect dose.

Based on observation, interview and record review, the facility failed to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable for one of 15 sampled residents. Resident 5 failed to receive specialized rehabilitation to ambulate after a recent left [MEDICAL CONDITION] that stopped her progress in recovery from the [MEDICAL CONDITION] and increased the risk of complications in ambulating in the future. Findings include: 1. Resident 5 was an [AGE] year old female admitted [DATE]following repair of a left trochanteric fracture and a rehabilitation stay in another nursing home. The resident reported in an interview conducted with an interpreter on 9/29/11 at 1 P.M. that she was walking prior to a fall that occurred 8/6/11. During this survey week, the resident was observed to be wheelchair bound and was not observed walking at any tme. The resident's record contained a Discharge Summary from another nursing home dated 9/9/11 which described the resident as able to Stand amb (ambulate) 9/6-25 ft (feet) without pain and with FWW (front wheel walker) so far. Needs further PT for WBAT (weight bearing as tolerated) and gait training. The resident did not receive a physical therapy evaluation from admission to 9/30/11, the last day the surveyor was onsite at this nursing home. The resident was evaluated by a PT aide on 9/21/11 who reported on 9/29/11 at about 11 A.M. that she had the resident walk with assistance thru parallel bars, but that she stopped the resident from walking further because she heard crunching sounds that she was concerned about. She reported the resident continued with therapy, but only in a wheelchair and only for upper body strengthening. The Mobility Assessment report dated 9/21/11 stated: STOP, will wait until PE/PT evaluation is completed, now pending for both. The surveyor discovered a consult from the resident's orthopedic surgeon dated 9/6/11 (6:34 P.M.) and under Impression & Plan Summary, the following was noted along with the impression the resident had suffered a fx closed trochanteric NOS (Left) - new. Recommendation: This patient has a left trochanteric fracture. This appear stable. I recommended weightbearing as tolerated ambulation with a walker. She can do therapy for this. She should followup in another 6 weeks. We'll repeat x-rays AP lateral left hip. On this consult note was a hand written note indicating the facility reviewed the information on 9/27/11 at 4:20 P.M, more than 2 weeks after the resident's admission. The facility failed to order and obtain an evaluation from a physical therapist and failed to include this information in the resident's admission orders [REDACTED] 2.The resident was observed to be in the bathroom on 9/29/11 at 12:30 P.M. and there was no staff around to assist her. After the surveyor waited about 5 minutes and no assistance was received, a CNA was notified who went to this resident's bathroom to check on the resident. The CNA came out of the bathroom and stated the resident was fine and did not need/want assistance. The resident's care plan stated that she would receive one person assistsance for all transfers. 3. In an interview conducted on 9/29/11 at 1 P.M., the resident stated she has waited too long for assistance to the bathroom more than once in the early morning, resulting in accidents where she wet herself. The resident's care plan for Activities of Daily Living (ADL) states: Resident is able to bear weight for transfer. Please assist. The lack of specialized rehabilitation evaluation and clear guidance for therapy assistants and staff, as well as oversight of the work of the therapy staff, limited Resident 5's recovery and progress to be able to walk again. The lack of assistance during transfers caused her to have embarrassing accidents and increased her risk of injury from a fall.

Based on observation, record review, and staff interview, that the facility failed to provide adequate supervison to prevent accidents and to ensure that the environment was as free of accident hazards as possible placing 2 of 15 sampled residents (Residents 2 and 10) at greater risk for falls. Findings include: FALLS 1. Record review for Resident 2 revealed that the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Resident's 9/17/11 annual Minimum Data Set (MDS) assessment evidenced that the resident was assessed to require limited assistance with toilet use and personal hygiene; supervision with transfer, locomotion on and off the unit, and dressing; had not walked in the room or corridor; and was independent with bed mobility and eating. The Resident was assessed to use a walker and wheelchair and had impairment on one side in the lower extremity. He was coded as having had no falls since the prior assessment. Review of the Resident's incident report dated 11/14/10 revealed that the Resident experienced a fall outside of the building when he could not go through the main hallway since it had been mopped. This Resident in his wheelchair and an ambulatory resident went out into the backyard (courtyard) to get around the blocked section of the hallway. The Resident's wheelchair tipped backwards on the uneven concrete sidewalk where there were dips for water runoff and drainage. He was found lying on his back with a large hematoma to the back of his head (occipital) and was transported to the hospital. Review of the Resident's chart evidenced that he was hospitalized from [DATE] to 11/18/10 due to the head injury and seizure activity. Review of the facility report which was submitted to the Regional Office evidenced that the facility developed the following suggestion/recommendations after investigating and reviewing their findings: 1. Maintenance staff to install sensor alarm monitors to all exit doors. 2. Re Evalluate (sic) all wheel chairs for rear anti=tip bars by I.H.S. PT staff. 3. Maintenance staff to cover the water runoff canals in the courtyard of facility. 4. Housekeeping Manager to in-service to the residents and employees on the yellow wet sign precautions when in use. Review of the Housekeeping policies provided to the surveyor did not address the use of caution signs or mopping part of the hallway so that residents still have access. No Housekeeping staff inservice information was provided to surveyor. On 9/29/11 at 11:50 A.M., an observation made from the A unit nurses station evidenced that the entire width of the hallway leading to the exit door was wet from mopping. Two signs were placed to the right side of the hallway. People were observed entering and exiting over the wet floor. 2. Resident 10 is [AGE] years old with a medical history of [REDACTED]. A review of Resident 10's record revealed on 02/13/11 at 12:30A.M, Resident 10 fell as she self transferred from her wheelchair to her bed. A review of Resident 10's annual MDS dated [DATE] under G 0300 balance during transitions and walking for A. Moving from seated to standing position, B. Walking (with assistive device if used), C. Turning around and facing the opposite direction while walking, D. Moving on and off toilet, and E. Surface-to-surface transfer (transfer between bed and chair or wheelchair) were all coded as 2 meaning, Not steady, only able to stabilize with human assistance. A review of Resident 10's records regarding her falls revealed Resident 10 fell on [DATE] at 01:36A.M. where she slip (sic) off the wheelchair. The record continued to state CN (charge nurse)did an overall assessment that revealed no injuries. Furthermore, under Measure(s) to be implemented to prevent future similiar problem(s) : . apply w/c (wheelchair) and bed alarm to alert staff. The record also revealed Resident 10 fell on [DATE] at 12:15P.M. when she rolled off bed and onto floor. A review of Medication and /or [DIAGNOSES REDACTED]. Furthermore, the record stated, Measure(s) to be implemented to prevent future similar problem(s): . apply w/c and bed alarm to alert staff. On 09/29/11, the CNA that was assisting Resident 10 the early morning of 02/13/11 was interviewed. The CNA stated that Resident 10 had a history of [REDACTED]. Furthermore, the CNA had stated that night Resident had A and D ointment applied to her feet since they were dry. A review of Resident's 10 record notes regarding the 02/13/11 fall stated, Immediate corrective action taken by charge nurse at time of resident's fall. apply alarm to bed to monitor/ wheelchair to monitor / alert staff of resident's independent transfer attempts. Resident 10 failed to receive fall prevention measures as noted in plans designed to address her history of falls. A review of the fall investigation conducted by the facility after the fall that occurred on 2/23/11 revealed Resident 10 was transferred to Hospital A where after an x-ray was diagnosed with [REDACTED]. 3. During the environmental tour on 9/29/11 at 2:00 P.M. with the Maintenance Director the outside center courtyard to the facility was checked. The area was fenced in and had a gazebo area which the resident could access. There was a sidewalk area that ran along the build between the A wing and B wing of the facility. The doors accessing this sidewalk from both A wing and B wing were not alarmed. The sidewalk was noted to have four dips in the sidewalk which were dips in the cement for water/rain runoff from the building which presented a trip hazard. These areas were specifically checked due to a resident having a fall from a wheelchair from this sidewalk. The facilities plan of action to prevent further accidents from this hazard was to alarm the two doors leading to this sidewalk and correct the dips in the cement walkway. However these actions had not been completed and the hazards were still present and confirmed by the Maintenance Direct. Additionally the second sidewalk joining the A wing and B wing to the gazebo was noted to have areas with a drop off from the sidewalk. The Maintenance Direct reported he had planned to level to ground at the edge of the sidewalk but had not completed the project. He confirmed that residents did use the area and it presented a hazard for residents either walking or in wheelchairs. ELECTRICAL HAZARDS: 4. During the initial tour on 9/27/11 from 8:00 A.M. to 9:30 A.M. with LS noted the following electrical hazard. The observation of room 2A revealed the call light for bed three had loose wiring. The end of the call light used by the resident was frayed and not working. The air mattress for room 3A bed 1 had exposed wiring where the plug went into the wall electrical socket. During the environmental tour on 9/29/11 at 2:00 P.M. with the Maintenance Director the electrical hazard were checked. The Maintenance Director confirmed the above issues and reported he had not been notified of the frayed wiring. 5. On 9/27/11, starting at 8:05 AM, during the initial facility tour of the B unit in the presence of CNA, the right arm rest on Resident 1's wheelchair observed to be torn. This created a potential for skin tears. 6. On 9/27/11 at 3:45 PM, during an observation of one of the shower rooms located at the nurses' station on the B unit, there was a razor lying on the sink in the toilet room. No staff or residents were present at the time of the observation. 7. On 9/28/11 and 9/29/11, a cart containing supplies was sitting in the hall at the nurses' station on B unit. The cart was left there unattended and not in use or placed in the unlocked shower rooms. The cart contained razors and cleaning supplies for peri-care. 8. On 9/28/11 at 8:25 P.M., a CNA was observed taking Resident 14 to a shower room on the B unit. The Resident used the handrail in this area to pull to a standing position. When the Resident's leg dressing was removed by the CNA and LS, the LS bumped the handrail. The handrail was pulled out of the wall at the end, making the handrail loose. The LS attempted to fix it but it was still loose. On 9/29/11 at 8:10 A.M., the surveyor reported the concern about the loose handrail to the Maintenance Supervisor. He was not aware of the loose handrail in that shower room.