Every finding on record at Eatonton Health and Rehabilitation

Based on observations, staff interviews, record review, and review of the facility's policies titled Medication Storage in the Care Center, the facility failed to ensure that medications were properly stored in one of one medication storage rooms. This deficient practice had the potential to increase the risk of residents receiving medications with altered effectiveness. Findings include: Review of the facility policy titled Medication Storage in the Care Center, provided by the facility and dated 2023 stated, .Medications requiring 'refrigeration' or 'temperatures between 2°C (36°) and 8° (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring . During an observation on 6/25/2025 beginning at 5:20 pm, of the medication storage room with Licensed Practical Nurse/Charge Nurse (LPN/CN) 1 and the Assistant Director of Nurses (ADON) confirmed the following medication storage concerns: R1's NovoLog FlexPen was opened on 5/23/2025 with no expiration date. LPN/CN1 confirmed the pen was almost empty. LPN/CN1 further stated that all opened insulin should have the calculated expiration date, so the nurse knows when to stop using the pen. R1 also had a Lantus insulin pen with no first used date and no expiration date. R6 had an unopened Novolog FlexPen 100 units/ml, three-ml pen, dispensed 4/30/2025. The ADON confirmed that R6 remained in the facility and was still taking the medication. The ADON stated that she was unsure why the insulin was not in the refrigerator and that it would have to be discarded because it had not been refrigerated. The ADON confirmed that R6 started on Novolog on 5/12/2023, and stated the medication should have been kept refrigerated until opened. The pharmacy label indicated that the medication should be refrigerated until opened. R47 had one unopened Insulin Aspart 100 units/ml vial, not refrigerated, dispensed 5/3/2025. The ADON confirmed the start date of 4/22/2025, and the order remained active and should have been kept refrigerated until opened. The pharmacy label indicated that the medication should be refrigerated until opened. R54 had one unopened Novolin R 100 units/ml pen, unrefrigerated with a dispensed date of 4/23/2025. The ADON stated that the resident was still in the facility, and the medication should have been kept refrigerated until opened. The pharmacy label indicated that the medication should be refrigerated until opened. During an interview on 6/25/2025 at 5:15 pm, LPN/CN 1 stated that Humalog and Lantus should be discarded 28 days after opening. During an interview on 6/25/2025 at 6:05 pm, the ADON stated that it was the facility's expectation that, upon delivery of medications, any medications requiring refrigeration, such as insulin, should be refrigerated. The ADON confirmed that the medications were improperly stored.

Based on staff interviews, record review, and review of the facility's policy titled Documentation in the Medical Record, the facility failed to maintain an accurate medical record for one of 17 sampled residents (R) (R29). Specifically, the facility failed to ensure the staff member delivering care was also the staff member who documented the care related to Activities of Daily Living (ADLs) and showers. Finding include Review of the facility's policy titled Documentation in the Medical Record, dated 12/27/2024, indicated, . Pertinent observations, medications, services performed, etc., should be recorded in the patient's medical record. Review of R29's Face Sheet, found under the Face Sheet tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, unspecified. Review of R29's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/28/2025 indicated R29 had a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment) and needed substantial/maximal assistance with bathing. Review of the ADL Plan of Care, provided by the facility, under Self-Care Deficit revealed the resident had an intervention of assist with ADLS as needed, female Certified Nursing Assistants [CNA] only while showering initiated on 5/14/2025. Review of the ADL Sheet, found under the ADL Tab of the EMR, revealed that for the month of June, on 6/23/2025, the resident's shower was performed by CNA2. Interview on 6/25/2025 at 12:26 pm, Licensed Practical Nurse/Charge Nurse (LPN/CN) 1 was asked where the resident's shower preferences were located. LPN/CN1 stated in the chart. When asked how staff would know if a resident preferred not to have a male CNA perform care, she stated we only have one male CNA, and he typically bathes the male residents. When asked where the care was documented, LPNCN1 stated in the EMR. LPN/CN1 stated that when it was signed with that person's name, it was that person who completed the care. During an interview on 6/25/2025 at 2:58 pm, R29 confirmed that a female CNA gave her a bath. In an interview on 6/25/2025 at 2:59 pm, CNA2 stated he just goes through the resident's record and sees the resident's preferences related to ADL care. CNA2 stated some residents do not want a male CNA to bathe them, and if that is the case, CNA3 will work with me. In an interview on 6/25/2025 at 3:03 pm, CNA3 was asked, How do you know a resident's ADL preferences, for instance, showers? CNA3 stated the information was in the EMR. CNA3 stated some women do not want men to do their bath, so I do their bath. When asked if she bathed R29 on 6/23/2025, CNA3 stated, Yes. When asked how the staff code that care was completed. CNA3 stated, I sign for it as care being given. CNA3 stated that R29 would not let a male CNA bathe her, so I bathed her. The ADL Sheet was shown to CNA3, which indicated CNA2 signed as delivering the care, and CNA3 agreed it was not CNA2 who bathed the resident. CNA2 was shown the assignments in the EMR, and R29 was not listed as their resident. CNA3 stated that since R29 was not assigned to her, she could not code that she gave her a bath. In an interview on 6/26/2025 at 11:17 am, the Assistant Director of Nursing (ADON) confirmed that if a CNA is not assigned to a resident, they cannot document care delivered. The staff member would have to notify the assigned person that the care was delivered, and they would notate it in the medical record.

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Self-Administration of Drugs, the facility failed to ensure two of 17 sampled residents (R) (R29 and R48) were assessed for medication self-administration before allowing unsecured medications to be kept at the bedside. This deficient practice had the potential to place R29 and R48 at risk of unauthorized use of medication, inaccurate medication dosing, and a diminished quality of life. Findings include: Review of the facility's policy titled Self-Administration of Drugs reviewed 12/27/2024, indicated, Intent- It is the intent to promote safe medication practices for patients that choose to self-administer medication. Guideline- To permit patients to self-administer their drugs and medication unless such practice for the patient is deemed unsafe. Procedure- Should the patient wish to self-administer his or her own drugs or medications, the patient should be permitted to do so. Drugs and medication should be stored in a safe and secure place designated by the Director of Nursing Services. The care planning team should assess each patient's mental, physical, and visual ability to determine if the patient is capable of self-administration of drugs and medications. Should the care planning team determine that the patient is unable to carry out this responsibility, due to safety concerns, the patient should not be permitted to self-administer his or her drugs or medication. Appropriate documentation as to whether or not the patient made a choice about self-administration of drugs should be in the patients' medical record. Statements intent of governing self-administration of drugs are outlined in the Pharmacy Services Manual. Inquiries concerning self-administration of drugs should be referred to the Director of Nursing Services. 1. Review of R29's Face Sheet, found under the Face Sheet tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's disease, unspecified, psychotic disorder with delusions due to known physiological condition and dysphagia following cerebral infarction. Review of R29's Care Plan, found under the Care Plan tab of the EMR, found that there was no care plan for self-administration of medication. Review of R29's EMR revealed no assessment for medication self-administration. Observation on 6/23/2025 at 9:12 am revealed R29 was asleep in her bed, and a medication cup that contained eight pills was on her overbed table. Observation on 6/23/2025 at 9:42 am revealed the medication cup with the eight medications was no longer in her room. In an interview on 6/23/2025 at 9:42 am, Certified Medication Aid (CMA)1 stated that R29 did not take her medication immediately. CMA1 confirmed the medications were on the side table and stated she had taken them away. CMA1 stated that the normal routine was for R29 to wake up and take the medication; if not, she would take it back. She further stated that sometimes, she may put the medications down and go to the next room, and if the resident did not take the medication, she would come back and take it back to the medication cart. In an interview on 6/25/2025 at 10:20 am, the Director of Nursing (DON) confirmed that R29 did not have a self-administration of medication assessment completed. 2. Review of R48's Care Plan, under the care plan tab of the EMR, revealed there was no documentation in the care plan of the resident being able to administer his own medication. Review of R29's EMR revealed no assessment for medication self-administration. During an observation and interview on 6/23/2025 at 9:22 am, in R48's room, a container of eye drops labeled azelastine 0.05 percent (a prescription medication used to treat itching of the eye) was observed on the overbed table. R48 stated the eye drops were his and that he administered them once a day by himself. R48 further stated that the nursing staff come and check on them. Further observation revealed a cup of antacid medication on the bedside table. R48 stated he took them when he needed them. In an interview on 6/23/2025 at 9:45 am, CMA1 confirmed that R48 randomly consumes the antacid tablets and stated he eats them like candy. CMA1 confirmed the eye drops should not have been left in the resident's room. In an interview on 6/25/2025 at 10:21 am, the DON stated that R48 was not appropriate to self-administer medication. The DON stated that R48 is unable to tell you what the medication was for. The DON confirmed that R48 does not have a self-administration assessment. In an interview on 6/25/2025 at 11:02 am, the Regional Nurse Consultant confirmed R48 did not have an order for the antacid tablets and stated that the family brought them to the resident.

Based on resident and staff interviews, record review, and review of the facility's policy titled Grievance/Concern Guidelines for Patients, the facility failed to document resident grievances and failed to provide a resolution for the grievance for one of 17 sample residents (R) (R6). This deficient practice had the potential to place R6 at risk of unresolved grievances. Findings include: Review of the facility's policy titled Grievance/Concern Guidelines for Patients, dated 12/27/2024, revealed the intent of the facility was to assist, encourage, and educate the residents to file grievances or concerns and to assure the resident that after receiving a concern/grievance, the facility would actively seek a resolution and keep the resident apprised of their progress towards a resolution. The policy also stipulated that the Social Worker (SW) was responsible for entering the concern/grievance into the tracking system, with the investigation and appropriate action recorded. Review of R6's Face Sheet, found under the Face Sheet tab of the electronic medical record (EMR), revealed R6 was admitted to the facility on [DATE]. Review of R6's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/2025 indicated R6 needed minimal assistance with activities of daily living (ADL's) and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact. During an interview on 6/23/2025 at 10:12 am, R6 stated that he had previously reported to multiple staff members that he was not receiving palatable food and never knew what he was going to be served each day because he was not provided with a menu of weekly meals and was not provided with a list of alternate food items. He stated that he had previously filed a grievance about the food with the kitchen lady, the SW, the Director of Nursing (DON), and the Administrator a few months ago. He stated that the four named staff members met with him in his room to discuss the food service. He further stated that he was not given a written grievance form and did not receive a written response or resolution to his reported grievance. Review of the facility-provided Grievance Log, dated from 7/1/2024 through 6/25/2025, revealed no grievances were documented as reported by R6 regarding food service. During an interview on 6/23/2025 at 11:32 am, the SW stated that she was the grievance coordinator for the facility and was aware of the grievance reported by R6 regarding the food service, and validated that the previous Dietary Manager (DM), the SW, the DON, and the Administrator, had visited R6 in his room (date unknown) to discuss his grievance regarding food service. She stated that the normal process for reporting and documenting a resident grievance was to complete a grievance form when the grievance was reported. The SW stated that within three days of the grievance report, she would document the resolution to the grievance and then provide a written grievance form to the resident who reported the grievance. She stated that she did not document R6's grievance regarding food service and did not provide R6 with a resolution of his grievance. During an interview on 6/26/2025 3:46 pm, the Administrator stated his expectation for a resident-reported grievance was that it should be documented by the SW with a documented response and/or resolution provided to the resident within three days of filing the grievance.

Based on staff interviews, record review, and review of the facility's policy titled Bed Hold During Hospital Stays and Therapeutic Leaves, the facility failed to ensure one of four residents (R) (R8) reviewed for hospitalizations, or their Resident Representative (RR), received written notice that specified the duration of the bed hold policy. Specifically, the facility failed to include the current rate for the reserve bed payment in the event the resident did not return within seven days. This failure had the potential to place R8 at risk of denial of re-admission and loss of their room following hospitalization. Findings include: Review of the facility's policy titled Bed Hold During Hospital Stays and Therapeutic Leaves, dated 12/27/2024 indicated, .the intent of this nursing center to offer all residents and/or his/her designee the choice of either paying the appropriate amount to hold the bed when the resident goes to the hospital .the Financial Controller, or the Administrator's designee, should prepare a bed hold letter to be sent to the resident and/or his/her designee .This letter should specify the amount to be paid per day on private bed hold . Review of R8's Face Sheet, in the Electronic Medical Record (EMR) under the Resident tab, indicated she was initially admitted to the facility on [DATE] with a primary diagnosis of hereditary and idiopathic neuropathy. Review of R8's Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/2024 indicated the resident was discharged to a short-term general hospital. Review of R8's Discharge MDS with an ARD of 12/16/2024 indicated the resident had been discharged to a short-term general hospital. Review of R8's Resident/Patient Transfer Form, dated 8/28/2024, and provided by the facility indicated R8 was sent to the hospital with altered mental status (AMS). Review of R8's Resident/Patient Transfer Form, dated 12/16/2024, and provided by the facility indicated R8 was sent to the hospital with altered mental status (AMS). Review of R8's Notice of Transfer or Discharge dated 8/30/2024 and 12/16/2024, provided by the facility, indicated R8 was sent to the local hospital. The form had information regarding the Bed-hold policy - Medicaid Payor Source When a nursing home resident is admitted to a hospital, Medicaid will pay to hold the nursing home bed for seven (7) days. In the event that hospitalization is required for more than seven (7) days, you have the choice to either discharge from the nursing home or assume responsibility for payment to the nursing home to hold the bed. If you choose to hold the bed, you will be billed at the facility's approved daily state per diem rate In the next few days, you will be receiving a telephone call or a letter informing you of the daily rate needed to maintain a bed hold and the date the bed hold will begin . The form did not include the daily bed-hold rate. During an interview on 6/26/2025 at 2:16 pm, Licensed Practical Nurse Wound Care (LPNWC) stated that when a resident was sent to the hospital, the nurse completed a Transfer Form that indicated the reason for the transfer, and that no paperwork was sent by the charge nurse to the family. She stated she thought that either the Director of Nursing (DON) or Assistant DON (ADON) sent the bed hold/transfer notification to R8's Power of Attorney. During an interview on 6/26/2025 at 2:40 pm, the DON stated that the facility's policy was to mail the bed hold/transfer notification to the responsible party and was not aware if the form included the specific bed hold amount or where the Social Worker (SW) documented that the Bed Hold form was mailed to the POA. During an interview on 6/26/2025 at 2:40 pm, the SW stated that she used to document when she sent a Bed Hold notification to the POA, but she no longer did that. She stated her practice was to mail the Bed Hold to the POA, and she was not aware it should be documented. She further stated she was unaware that the document needed to include the specific charge of the reserve bed payment.

Based on resident, resident Power of Attorney (POA), and staff interviews and record review, the facility failed to ensure three of three dependent residents (R) (R29, R8, and R64) from a sample of 17 residents received showers according to the schedule. This failure had the potential to place the residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues. Findings include: 1. Review of R29's Face Sheet, found under the Face Sheet tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R29's Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/28/2025 indicated R29 needed substantial/maximal assistance with bathing. Further review revealed R29 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. Review of R29's ADL [Activities of Daily Living] Sheet, found under the ADL tab of the EMR, revealed that for the month of June 2025, R29 only received a bath/shower on 6/4/2025 and 6/23/2025. Review of R29's ADL Plan of Care, provided by the facility, for Self-Care Deficit revealed the resident had an intervention of assistance with ADLs as needed. In an interview on 6/23/2025 at 4:06 pm, R29 stated she missed her baths. She stated she was supposed to get her bath on Monday, Wednesday, and Friday, but she did not get them all of the time. In an interview on 6/25/2025 at 12:26 pm, Licensed Practical Nurse/Charge Nurse (LPN/CN) 1 referred to a sign which indicated shower schedules and confirmed R29 was scheduled for showers on Mondays, Wednesdays, and Fridays, during the second shift, because she likes to sleep late in the mornings. When asked where the care is documented, LPN/CN1 stated in the EMR. LPN/CN1 stated it is signed with that person's name, who completed the care. In an interview on 6/26/2025 at 11:17 am, the Director of Nursing (DON) stated that showers should be documented when given. The DON confirmed they did not have a policy related to showering and ADL care. 2. Review of R8's Face Sheet, located in the EMR under the Face sheet tab, indicated she was admitted to the facility on [DATE] with a primary diagnosis of hereditary and idiopathic neuropathy. Review of R8's Quarterly MDS located in the EMR with an ARD of 3/21/2025 included a BIMS score of 10 out of 15, indicating moderate cognitive impairment. R8 required partial to moderate assistance with bathing. Review of R8's Care Plan, located in the EMR under the Care Plan tab, initiated 1/19/2024 included assistance with activities of daily living (ADLs) as needed. Review of R8's Shower Documentation, provided by the facility, for January 2025 indicated that she received seven showers and refused bathing once; February 2025 indicated that she received two showers and refused bathing once; March 2025 indicated that she received one shower and refused bathing once; April 2025 indicated that she received five showers with no refusals; May 2025 indicated that she received three showers with no refusals; and June 2025 indicated that she received two showers with no refusals. During an interview on 6/23/2025 at 12:20 pm, R8 stated that she was supposed to get a shower three times a week on Mondays, Wednesdays, and Fridays, but that did not always happen. R8's POA1 was present during the interview and stated that R8 did not always receive her showers and that the facility staff would say that she refused, which was not true. R8 admitted to declining one shower in the past six months and stated that she would frequently ask for her shower on the scheduled days, but that the staff would not show up to bathe her. 3. Review of R64's Face Sheet, located in the EMR under the Face sheet tab, indicated that she was admitted to the facility on [DATE] with a primary diagnosis of chronic atrial fibrillation. Review of R64's Quarterly MDS located in the EMR with an ARD of 4/9/2025 included a BIMS score of nine out of 15, indicating moderate cognitive impairment. R64 required substantial to maximum assistance with bathing and had impairment on one side of one upper extremity. Review of R64's Care Plan, located in the EMR under the Care Plan tab, revised 4/18/2025, included assistance with ADLs as needed. Review of R64's Shower Documentation, provided by the facility, for April 2025 indicated that she received one shower and refused bathing zero times. May 2025 indicated that she received zero showers and refused bathing zero times. June 2025 indicated that she received zero showers and refused bathing zero times. During an interview on 6/25/2025 at 11:43 am, R64 stated that she didn't know her bathing schedule and did not recall having her hair washed since she was admitted to the facility. R64 stated that she had not refused any showers and loved getting bathed. Additionally, she stated that she had not been showered very often but rather would receive bed baths. During an interview on 6/25/2025 at 11:53 am, R64's POA2 stated that he was not aware of her bathing schedule and could not verify that the resident was being bathed three times a week per facility schedule. R64's hair looked oily, and POA2 stated that he was taking her to have her hair washed and trimmed on 6/26/2025. During an interview on 6/26/2025 at 3:27 pm, Certified Nurse Aide (CNA)5 stated that when the CNAs bathed/showered a resident, the policy was for them to document the activity in the computer. If a resident refused a shower, that was to be documented in the EMR. If nothing is documented in the EMR, that would mean the activity wasn't performed. CNA5 stated they were not aware of R8 or R64 having a history of refusing to bathe or shower. During an interview on 6/26/2025 at 4:00 pm, the DON confirmed that there was no documentation for R8 and R64 to confirm whether showers had been completed or not. The DON stated that she had provided education to the CNAs on the importance of offering the resident a bath or shower on their scheduled day and documenting the refusal accordingly.

Based on observations, resident, resident Power of Attorney ([NAME]), and staff interviews, record review, and review of the facility policy titled Restorative, the facility failed to ensure splint application was provided for one of one resident (R) (R64) sampled for Restorative Nursing from a sample of 17. This failure had the potential to place R64 at risk for increased contractures and decreased range of motion. Findings include: Review of the facility's policy titled Restorative, provided by the facility dated 12/27/2024 stated, .This center promotes nursing interventions that assist the patient in his/her ability to adapt and adjust to living conditions .may be captured in a formalized restorative nursing care plan overseen by Nursing Supervisor(s) .The plan of care will be outlined in electronic medical record (EMR) and will be followed by staff trained in restorative care .Documentation of minutes of care provided will be documented in the EMR by staff providing restorative services. Review of R64's Face Sheet, located in the EMR under the Face sheet tab, indicated that she was admitted to the facility on [DATE] with a primary diagnosis of chronic atrial fibrillation and comorbidities including cerebral infarction due to thrombosis of the right middle cerebral artery. Review of R64's Quarterly Minimum Data Set (MDS) located in the EMR with an Assessment Reference Date (ARD) of 4/9/2025 included a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. The MDS indicated R64 had impairment of one side of one upper extremity. Review of R64's Care Plan, located in the EMR under the Care Plan tab, revised 4/15/2025 included limited mobility with interventions including See Restorative Program. Review of R64's Restorative Care Plan, initiated 4/7/2025, included splint/brace application once daily for six days per week. The goal was patient will maintain current ROM [range of motion] of joint with use of splint to decrease risk of developing or worsening of contracture with no signs or symptoms of compromised skin integrity through the review period. Interventions included, gentle stretching of affected joint with .apply the following splint to affected joint for the stated time period: palmar grip splint on her L [left] hand for 2-4 [two to four] hours, assist patient with verbal and physical guidance and direction to teach how to apply, manipulate, and care with the following splint . Review of R64's Restorative Program documentation provided by the facility indicated that on 4/7/2025 and 4/29/2025 the splint was applied for 15 minutes; 5/7/2025 and 5/10/2025 the splint was applied for 45 minutes; 5/13/2025 the splint was applied for 15 minutes; 5/16/2025 and 5/20/2025 the splint was applied for 45 minutes; 5/23/2025 the splint was applied for 15 minutes; 5/29/2025 the splint was applied for five minutes; 5/31/2025 the splint was applied for 15 minutes; 6/16/2025 the splint was applied for 45 minutes; 6/20/2025, 6/24/2025 to 6/26/2025 for 15 minutes; and on 6/23/2025 the splint was applied for 45 minutes. Review of R64's Occupational Therapy Daily Note provided by the facility dated 2/17/2025 stated, .Pt [patient] demonstrated more difficulty performing digit extension today compared to previous sessions .Pt's personal hand splint was donned . for one hour .tolerated palmar grip splint for greater than two hours .Pt was educated on importance of using her palmar grip splint when supine in bed to help prevent digit contracture in flexion .staff were educated on the importance of continuing to wear her palmar grip splint later on in the day to prevent contracture and less stiffness in the morning . Review of R64's Occupational Therapy Daily Note provided by the facility dated 3/10/2025 stated, Pt demonstrated increased stiffness this morning .Pt tolerated PROM [passive range of motion] prior to donning palmar grip splint for three hours (3) .Pt is continuing to be educated on the importance of using her palmar grip splint when supine in bed to help prevent digit contracture in flexion in order to be able to don her resting hand splint. Pt and staff continue to be educated on continuing to wear her palmar grip splint later on in the day to prevent contracture . Review of R64's Occupational Therapy Daily Note provided by the facility dated 3/21/2025 stated, Pt tolerated PROM prior to donning palmar grip splint. Pt demonstrated less digit extension this morning . During an observation on 6/23/2025 at 10:33 am, R64 had a contracture noted to the left hand and was not wearing a splint. During an interview on 6/23/2025 at 10:33 am, Certified Nursing Assistant (CNA)4 confirmed that R64 was not wearing a hand splint at that time and was not aware of the need for the splint. During an observation on 6/25/2025 at 11:48 am, R64 was wearing a splint on the left wrist/hand. During an observation on 6/26/2025 at 2:14 pm, R64 was wearing her splint on the left hand/wrist. During an interview on 6/25/2025 at 11:48 am, R64 stated that before yesterday, she had not had a splint applied to her left hand and wrist on a consistent basis and was not sure when the splint was scheduled to be worn. R64 was able to confirm that she had a stroke in the past that caused paralysis to her left upper extremity. During an interview on 6/25/2025 at 11:53 am, R64's POA2 stated that R64 sustained a stroke in November 2024 that caused paralysis to the left upper extremity. He had previously brought two splints from home for her to use while at the facility to aid in opening her hand up (contracture prior to facility admission). The facility had put it on R64's left hand and wrist in the past, but it was very inconsistent. POA2 stated that he was not aware of a splint schedule and that he had never seen her with it in place, and he visited almost daily. He stated he had mentioned this concern in the past, and he had given up because he feared retaliation. During an interview on 6/26/2025 at 3:27 pm, CNA4 confirmed that R64's splint was included in her plan of care and that if the staff applied the splint, it should have been documented. She did not recall seeing the splint on R64's left hand and wrist until today. During an interview on 6/26/2025 at 4:38 pm, Registered Nurse (RN)1 stated that she had seen R64 wearing a splint off and on, but not daily. During an interview on 6/26/2025 at 5:00 pm, the Director of Rehabilitation (DOR) stated that R64 received occupational therapy from 1/9/2025 to 4/4/2025 and physical therapy from 1/14/2025 to 4/14/2025. Additionally, she stated that all nursing staff were in-serviced for application of splints and that it was the restorative nursing program's responsibility to apply the splints; however, sometimes she would do it even though it was not populated for her to document on the service. During an interview on 6/26/2025 at 5:22 pm, the Director of Nursing (DON) stated that the Certified Medication Aides (CMAs) used to apply the splints and did not recall when this task was switched over for the CNAs to perform. The DON stated that she was not aware that R64 was not receiving splint application or range of motion exercises. The DON stated the MDS nurse was responsible for running the restorative program and ensuring documentation was being completed for all residents with splints. The DON's expectation was for nursing staff to apply the splints as indicated on the Restorative Care Plan.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Destruction: Collection Receptacle All Medications (Non-Controlled and Controlled), the facility failed to ensure discontinued medications were stored in a manner to maintain control and accountability for five of 17 sampled residents (R) (R2, R8, R54, R59, and R273). This failure had the potential to increase the risk for drug diversion or misappropriation of medications. Findings include: Review of the facility policy titled Medication Destruction: Collection Receptacle All Medications (Non-Controlled and Controlled), provided by the facility and dated [DATE] indicated, .When medications (non-controlled and controlled substance medications) are expired, discontinued from use, or the patient for whom they were ordered is no longer a patient, the drugs should be promptly removed from the active stock and inventoried by two licensed nurses (either Registered Nurse (RN) or Licensed Practical Nurse (LPN) .The medication is destroyed by two nurses disposing of the medication in an authorized collection receptacle and completing, signing, and dating the Certificate of Inventory and Destruction (CID). Medications should be disposed of into the Collection Receptacle within 3 business days from discontinuation of use. Review or R2's Physician Orders provided by the facility dated [DATE] included nystatin 100,000 units/gram topical ointment to be applied twice daily until [DATE] for candidiasis of skin and nails. Review of R8's Physician Orders provided by the facility dated [DATE] for Nystop 100,000 unit/gram topical powder to be applied once daily for 14 days under the bilateral breasts for candidiasis of skin and nails. Review of R54's Physician Orders provided by the facility dated [DATE] with a stop date of [DATE] for Novolin Flexpen 100 units/milliliter (ml) (three ml) subcutaneous insulin pen per sliding scale for diabetes mellitus. Review of R59's Physician Orders provided by the facility dated [DATE] for Nystop 100,000 unit/gram topical powder to be applied twice daily to an unspecified site with a stop date of [DATE] for candidiasis of skin and nails. Review of R273's Physician Orders provided by the facility dated [DATE] for Klor-Con 10 mEq (milliequivalent) tablet, extended release (ER), give one tablet by mouth once daily for chronic kidney disease and metformin 500 mg tablet dated [DATE], give one tablet by mouth twice daily for type two diabetes mellitus without complications. During an observation on [DATE] at 5:20 pm, Licensed Practical Nurse/Charge Nurse (LPN/CN)1 opened the medication storage room for the facility, which contained a drawer in the lower left side of the room, including a plastic bag with multiple residents' medications. At 6:01 pm, the Assistant Director of Nurses (ADON) entered the medication room to relieve LPN/CN 1 and confirmed the following medication storage concerns: R2 had two tubes of nystatin ointment USP 100,000 units/gram dispensed [DATE] and [DATE]. The ADON confirmed during an interview on [DATE] at 6:04 pm, the start date was [DATE], and the discontinued date of [DATE]. R8 had Nystop powder 100,000 units/gram dispensed [DATE], unknown when opened or first used. The ADON confirmed during an interview on [DATE] at 6:04 pm that the medication was started on [DATE] and discontinued on [DATE]. R54 had one Novolin R 100 unit/ml pen, unopened, unrefrigerated, dispensed on [DATE]. Interview on [DATE] at 6:04 pm, the ADON stated that the resident was still here and that the order was started on [DATE] and discontinued [DATE]. R59 had Nystop powder 100,000 units/gram bottle dispensed [DATE], unknown when opened or first used. The ADON confirmed during an interview on [DATE] at 6:04 pm that the medication start date was [DATE] and was discontinued on [DATE]. R273's Klor-Con tablets dispensed on [DATE], originally dispensed 90 tablets, 42 tablets remaining. The ADON stated during an interview on [DATE] at 6:04 pm, that the medication was filled at a local pharmacy. The resident was admitted on [DATE] and passed away on [DATE]. The medication should have been sent home with the family upon admission. R273's metformin 500 mg tablets were dispensed on [DATE], dispensed 180 tablets, 88 tablets remaining. The ADON confirmed during an interview on [DATE] at 6:04 pm that the resident was deceased and the medication started on [DATE] and was discontinued on [DATE] when the resident passed away unexpectedly. During an interview on [DATE] at 5:15 pm, LPN/CN 1 confirmed that discontinued medications were not properly discarded/disposed of for R2, R8, R54, R59, and R273. LPN/CC 1 stated that all medications that are discontinued for disuse or upon death should be recorded, and two nurses should witness and sign off on the medications being disposed of in the authorized, secured medication collection receptacle. During an interview on [DATE] at 6:05 pm, the ADON stated that all discontinued residents' medications that the resident has been discharged or passed away should be recorded on the CID medication log and properly disposed of in the authorized, secured medication collection receptacle. The ADON confirmed that the medications that were improperly stored were not listed on the medication log.

Based on observations and staff interviews the facility failed to remove ice build-up from cases of food items in the stand-up freezer to prevent contamination. This deficient practice had the potential to affect 51 of 53 residents receiving an oral diet. Findings include: Observation on 1/27/2024 at 8:30 am of the two-door stand-up freezer located by the back exterior entrance of the kitchen revealed ice build-up on three cases of food products with extension to the top of a case of a nutritional supplement. Observation on 1/28/2024 at 9:15 am of the two-door stand-up freezer near the back exterior entrance revealed the ice on the three cases of food product remained. During an interview on 1/28/2024 at 9:15 am the Dining and Nutritional Services Manager (DNSM) confirmed that there was ice build-up on the cases of food products in the stand-up freezer. The DNSM confirmed that the ice had covered part of the top lid of the case of nutritional supplement. The DNSM revealed that she had not seen ice build-up occur in the freezer before and she expected the Dietary Staff to have notified her that there was ice forming on the cases of food. During an interview on 1/28/2024 at 9:20 am the Maintenance Director (MD) confirmed that there was ice build-up on several cases of food in the stand-up freezer. The MD revealed that this was the first time that this freezer had this type of issue.

Based on staff interviews, record review, and review of the facility policy titled Antibiotic Stewardship, the facility failed to identify trends in antibiotic use, maintain documentation for clinical indication of use for antibiotics, implement systematic protocols to monitor, decrease use, and measure the effectiveness of antibiotics, and failed to create an action plan to lower the use of antibiotics that did not meet criteria for one of 28 sampled residents (R) (R28). Findings include: A review of the policy titled Antibiotic Stewardship reviewed 12/20/2022, indicated the main components of the facility's antimicrobial stewardship program (ASP) include: Formulary restriction. Prospective audit and feedback by pharmacy and feedback to physicians. Staff and physician education. Parenteral to oral conversion protocol. Dose optimization/automatic dose adjustment. Streamlining/de-escalation of therapy. Indication clarification required in patient record. Infectious disease consults when necessary. Reporting on stewardship is an essential component of the quarterly Quality Assurance Performance Improvement (QAPI) program. The Director of Nursing (DON) or designee works to educate departments of the facility whether they are involved directly or indirectly with patient care about stewardship. Antimicrobial stewardship is a continuing process improvement program based on the CDC Core Elements of Antibiotic Stewardship. A review of an undated document provided by the facility titled Ready 365 Infection Prevention-Antibiotic Stewardship, indicated F-881, the facility must establish an Infection Prevention and Control Program that must include, at a minimum, an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. The program should describe how the program will be implemented and how antibiotic use will be monitored, must be incorporated into the overall infection prevention and control program, be reviewed on an annual basis, and as needed, contain a system of reports related to monitoring antibiotic usage and resistance data, incorporate monitoring and frequency of monitoring review, assess patients with standardized tools and criteria, include mode and frequency education for prescribing practitioner and nursing staff on antibiotic use and protocol. A review of the McGreer's Criteria Worksheet, titled Surveillance Definitions for Urinary Tract Infection (UTIs), copyright 2012, revealed residents with an indwelling urinary catheter, both criteria 1 and 2 must be present, signs or symptoms sub-criteria and urinary catheter specimen culture collected. A review of 12 months of surveillance data revealed the monthly infection rate ranged from 5.0 - 13.0 % (percent), including UTIs for residents with and without catheters. Further review of the surveillance data revealed that 10 of the past 12 months indicated that one to three residents per month did not meet the criteria for antibiotic use, yet they were prescribed antibiotics, per the Infection Preventionist (IP). A review of the clinical record revealed that R28 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), urinary tract infection (UTI), and type 2 diabetes. A review of the January 2024 Physician Orders, revealed an order dated 11/22/2023, for nitrofurantoin macrocrystal (an antibiotic used to treat urinary tract infections) 100 milligram (mg) capsule by mouth one time per day for 190 days. There was no evidence of documented symptomology to support the use of an antibiotic or evidence that a specimen was obtained. In an interview on 1/27/2024 at 11:39 am, Regional Nurse Consultant EE stated that she was unable to locate any documentation to validate the reason R28 was ordered an antibiotic for 190 days. She stated the resident has a history of recurring UTIs. In an interview on 1/28/2024 at 12:51 pm, the IP stated residents with urinary catheters are placed on enhanced barrier precautions as a prophylactic measure. She stated that she uses the McGreer's Criteria Worksheet as guidance for an infection control assessment tool but confirms that she does not fill out the worksheet, or document in the resident medical record the symptomology for the use of the prescribed antibiotic. She stated that she questioned herself about the physician's order for R28 to be prescribed an antibiotic for 190 days, without the presence of symptoms or a specimen to confirm an active infection. During further interview, she stated she talked to the Hospice nurse about R28's antibiotic order written on 11/22/2023, and the Hospice Nurse stated that it is their policy to not obtain specimens from Hospice residents. She confirmed there was no written rationale as to why the physician had ordered the antibiotic, without symptomology or a lab result identifying a micro-organism. In an interview on 1/28/2024 at 3:02 pm, the IP stated she has not provided any education to the nursing staff or physician regarding the antibiotic stewardship program, and she hasn't provided any education training related to the increase in UTIs.

Based on observations, staff interviews, a review of the facility document titled Personal Items, and a review of the facility policy titled Laundry Services, the facility failed to ensure resident personal care items and 12 clean mop heads were stored in a manner to prevent cross-contamination. These failures had the potential to expose residents to infections due to cross-contamination. Findings include: 1. A review of an undated facility document titled Personal Items, revealed the following: Patient personal items should be labeled with room number. Washbasins should be discarded after patient use. If the patient uses it daily, then should be changed out weekly. Items should be stored in such a way to prevent cross-contamination. Washbasins and bedpans must be stored clean and dry. They do not have to be placed in plastic bags and covered. Observations on 1/26/2024 revealed: at 9:33 am in the shared bathroom for rooms [ROOM NUMBERS] a wash basin was unbagged, not labeled, and on the floor. There also was a toothbrush that was not covered or labeled and located on top of the paper towel holder; at 9:50 am in the shared bathroom of rooms [ROOM NUMBERS], there was one pink wash basin and one gray wash basin unlabeled and nested on the floor in the bathroom; at 10:50 am the shared bathroom for rooms [ROOM NUMBERS] revealed one pink wash basin on the floor that was not labeled or bagged. During an environmental tour, which included observations and interviews, on 1/28/2024 at 11:02 am with the Housekeeping Supervisor, Maintenance Supervisor, and the Assistant Director of Nursing (ADON) the following was confirmed: 1. In the shared bathroom for rooms [ROOM NUMBERS] at 11:05 am there was a toothbrush that remained uncovered and unlabeled on top of the paper towel holder. 2. In the shared bathroom of rooms [ROOM NUMBERS] at 11:13 am there was one pink wash basin and one gray wash basin nested on the floor in the bathroom and the wash basins were not labeled. 3. In the shared bathroom for rooms [ROOM NUMBERS] at 11:23 am there was one pink wash basin on the floor that was not labeled or bagged. The ADON reported that resident toothbrushes should be kept at the bedside but sometimes residents may want to keep the toothbrush in the bathroom, but she acknowledged that toothbrushes should be covered. The ADON also reported that wash basins could be stored on the floor, but she thought that they should be discarded after each use. During an interview with the ADON on 1/28/2024 at 11:41 am she revealed that she had spoken with her consultant and the facility does not have a policy related to storage of wash basins and toothbrushes. 38988 2. A review of the facility policy titled Laundry Services, copyright 2020, revealed the Guideline section stated: Separating clean from dirty in the laundry. In the laundry, dirty linen should be moved from the dirtiest to the cleanest areas as it is being processed; dirty linen should be clearly separated from areas where clean linen is handled. Observation on 1/27/2024 at 12:45 pm in the laundry room, located in a separate building outside of the facility, revealed inside the front entrance, which was identified as the dirty side, was a linen buggy/cart that had unidentified items stored in the bottom. There was a sheet spread across the buggy, and 12 laundered blue mop heads were spread out across the sheet, to air dry, in the dirty side of the laundry room. In an interview on 1/27/2024 at 12:59 pm, Housekeeping/Laundry Aide DD stated she gets the laundry items from the nursing units every two hours. She stated she pushes the soiled linen carts into the dirty side of the laundry, where she sorts the laundry and loads it into the washing machines. She stated she placed the wet mop heads across the linen cart in the dirty side of the laundry room, as she pulled them from the washer, so they could air dry. She stated no one told her she had to place them on the clean side of the laundry to dry. In an interview on 1/27/2024 at 1:14 pm, the Housekeeping/Laundry Supervisor stated she had one laundry aide out on medical leave and stated Housekeeping/Laundry Aide DD was cross trained to work in the laundry. She stated that she would re-educate her about the dirty and clean side of the laundry room and remind her that when the mop heads are taken out of the washer, she should place them on the clean side to air dry.

Based on observation, staff interviews, record review, and review of the facility document titled Call Light Guidelines, the facility failed to ensure the call light was within reach for one resident (R) (R24). The facility census was 53 residents. Findings include: A review of the facility's undated document titled Call Light Guidelines, revealed that staff was to monitor and ensure that call lights were within reach of the residents every two hours and as needed. A review of the Minimum Data Set (MDS) OBRA Quarterly assessment dated [DATE], revealed that R24 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A further review revealed that R24 was dependent on staff for all hygiene and mobility needs. An observation of R24 on 1/26/2024 at 9:07 am revealed the resident's call light was on the wall and out of reach of the resident. An observation of R24 on 1/26/2024 at 10:00 am revealed the resident's call light was on the wall and out of reach of the resident. During an interview with R24 on 1/26/2024 at 10:05 am, the resident stated she did not know where her call light was. An observation of R24 on 1/26/2024 at 1:30 pm revealed the resident's call light was on the wall and out of reach of the resident. An observation of R24 on 1/27/2024 at 8:00 am revealed Certified Medication Tech (CMT) AA administered R24 medications. After CMT AA left the room, the resident's call light remained on the wall and out of reach of the resident. During an interview with Licensed Practical Nurse (LPN) BB, on 1/27/2024 at 8:05 am, LPN BB acknowledged that R24's call light was on the wall, and she stated she did not know why it was not with the resident. LPN BB explained the call light was supposed to be clipped near the resident, so it was within reach. During an interview with the Director of Nursing (DON) on 1/27/2024 at 8:10 am, the DON acknowledged the resident's call light was on the wall and not within reach. The DON explained that all staff should round every two hours to ensure the call lights were within the residents' reach. The DON said R24s should not have been clipped to the wall and should have been secured near the resident. During an interview with CMT AA on 1/27/2024 at 8:16 am, she acknowledged that she entered R24's room on 1/26/2024 at approximately 8:40 am and 1/27/2024 at 8:00 am to administer medications to the resident, and stated she did not check to ensure the call light was within reach of the resident. Cross-reference F656

Based on staff interviews, record review, and review of facility policy titled Baseline Care Plans, the facility failed to develop a baseline care plan for two residents (R) (R20 and R55) of six newly admitted residents in the past 30 days. Specifically, the facility failed to develop a baseline care plan related to dementia care and antipsychotic medication use for R20 and failed to develop a baseline care plan for R55. Findings include: A review of facility policy titled Baseline Care Plan, review date 12/30/2022 revealed the Procedure section to state: Admitting nurses, review the care plan for each patient, after completing the admission assessment to individualize patient care needs. Baseline care plans will address, at a minimum, the patient's initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, if applicable, and completed within 48 hours of admission. The Interdisciplinary team will collaborate with nursing to address specific patient needs. 1. Clinical record review revealed that R20 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia with other behavioral disturbances, psychosis, depression, and anxiety disorder. A review of R20's physician orders revealed an order dated 12/23/2023 for quetiapine 100 milligrams (mg) (an antipsychotic medication used to treat mental or mood disorders) twice a day. A review of the medical record revealed a document titled Baseline Care Plan Summary, dated 12/15/2023 that documented R20 was admitted to the facility for dementia and anxiety. Continued review of the document revealed dementia and antipsychotic medication were not addressed and there were no interventions for staff to provide care related to dementia or anxiety. During an interview on 1/27/2024 at 1:30 pm the Resident Assessment Instrument (RAI) Coordinator revealed she was responsible for developing the baseline care plans for newly admitted residents. She confirmed that R20 did not have a baseline care plan for the admission diagnosis of dementia or the antipsychotic medication. The RAI Coordinator revealed the baseline care plan should have included dementia and antipsychotic medication use but it was not developed. An interview on 1/27/2024 at 1:50 pm with the Director of Nursing (DON) and the Corporate Nurse Consultant revealed they expected a baseline care plan to include dementia care and antipsychotic medication. The Corporate Nurse Consultant revealed that the RAI Coordinator is responsible for developing baseline care plans and it is encouraged to include resident-specific care such as dementia and antipsychotic medication. 36200 2. A review of the electronic medical record (EMR) revealed R55 was admitted to the facility on [DATE] and had diagnoses that included, but not limited to, type 2 diabetes mellitus without complications, gout, depression, insomnia, benign prostatic hyperplasia without lower urinary tract symptoms, unspecified dementia, epilepsy not intractable without status epilepticus, unspecified atrial fibrillation, and essential (primary) hypertension. Further review of the EMR did not reveal a baseline care plan for R55. During an interview on 1/27/2024 at 9:36 am with the RAI Coordinator it was reported that she does not see a baseline care plan completed for R55. She reported that the comprehensive care plan was completed on 1/22/2024. She reported that she was responsible for completing the baseline care plan for this resident. It was further reported that the baseline care plan should have been completed within 72 hrs. An interview was conducted on 1/28/2024 at 2:31 pm with the Administrator who reported that he was unaware of any issues with the completion of baseline care plans being completed before this survey. It was further reported that his expectation is for baseline care plans to be completed in a timely manner.

Based on observation, staff interviews, record review, and review of the facility policy titled Patient's Plan of Care, the facility failed to implement the care plan for two residents (R) related to ensuring the call light was within reach (R24) and providing a therapeutic diet (R13). Additionally, the facility failed to develop a person-centered care plan for R20 and R55 related to dementia care and antipsychotic medications. The sample size was 28. Findings include: A review of the facility policy titled Patient's Plan of Care, reviewed 12/30/2022, revealed the Guideline section stated: Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals and address the patient's medical, physical, mental, and psychological needs. 1. A review of R24's comprehensive care plan revealed a care area/problem for Communication and Speech dated 12/12/2023 which included an intervention to keep the call light within reach of the resident. Observations on 1/26/2024 at 8:40 am, 9:07 am, 10:00 am, 1:30 pm, and 1/27/2024 at 8:00 am revealed that R24's call light was on the wall and not within her reach. 33548 2. A review of R13's Quarterly MDS assessment dated [DATE] revealed: Section K - Swallowing and Nutritional Status: Received a mechanically altered and therapeutic diet while in the facility. A review of the physician orders for R13 revealed an order dated 5/18/2023 for a renal diet and an order dated 5/30/2023 for a puree diet. A review of the comprehensive care plan revealed a care area/problem for altered nutrition as evidenced by a therapeutic diet and mechanically altered diet. Interventions included providing a diet as prescribed. Observation on 1/28/2024 at 12:30 pm revealed R13 was served pureed lasagna instead of a pureed beef patty that the facility document titled Diet Spreadsheet indicated to be provided for a renal diet, in place of the lasagna. During an interview on 1/28/2024 at 12:50 pm, the Corporate Nurse Consultant revealed that she expects R13 to be served the correct food items on a renal diet. 3. A review of R20's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed: Section C - Cognition: Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Section N - Medications: Received an antipsychotic and an antidepressant while in the facility. Section V - Care Area Assessment Summary: indicated cognitive loss/dementia care area was triggered and to be addressed in the care plan. The psychotropic drug use care area was triggered and is to be addressed in the care plan. A review of the comprehensive care plan revealed there was not a care area/problem developed to address dementia care or antipsychotic medication use. During an interview on 1/27/2024 at 1:30 pm the Resident Assessment Instrument (RAI) Coordinator revealed she was responsible for developing resident comprehensive care plans. The RAI Coordinator confirmed that there was not a care plan developed for R20 for dementia care or antipsychotic medication use. She stated that it was overlooked, and a care plan should have been developed for both areas. During an interview on 1/27/2024 at 1:50 pm the DON and the Corporate Nurse Consultant stated they expected the RAI Coordinator to develop a comprehensive care plan for a resident that included resident care areas such as dementia care and antipsychotic medication. 36200 4. A review of R55's Admission MDS assessment dated [DATE] revealed: Section N - Medications: Received an antipsychotic and an antidepressant medication during the last seven days. Section V - Care Area Assessment Summary: indicated a triggered area that consisted of psychotropic drug use. A review of the comprehensive care plan did not include the use of psychotropic drugs. During an observation and interview on 1/27/2024 at 9:36 am with the RAI Coordinator it was reported that the comprehensive care plan was completed for R55. The RAI Coordinator reviewed the comprehensive care plan for R55 but was unable to find a care plan specific to psychotropic medications. The RAI Coordinator reported that the care plan is partially populated on admission, but she is responsible for making sure that everything else is added to complete the comprehensive care plan.

Based on observation, staff interviews, and record review, the facility failed to serve a proper renal diet for one resident (R) (R13) of one resident ordered to receive a renal diet. The deficient practice had the potential to adversely affect R13's nutritional intake. Findings include: Clinical record review revealed that R13 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, acute pyelonephritis. A review of the Physician orders for R13 revealed an order dated 5/18/2023 for a renal diet and an order dated 5/30/2023 for a puree diet. Observation on 1/28/2024 at 12:30 pm of R13 revealed she was sitting in the main dining room eating lunch. Continued observation revealed she was served pureed lasagna, pureed lettuce salad, pureed bread, and chocolate pudding on her lunch plate. R13 had eaten several bites of the puree lasagna and continued eating the lasagna. A review of the Resident Dietary Menu for week 5 for the 1/28/2024 lunch meal revealed that lasagna with meat sauce was to be served to residents. A review of the facility document titled Diet Spreadsheet dated 1/28/2024 revealed residents receiving a renal diet were to receive a beef patty in place of the lasagna. During an interview on 1/28/2024 at 12:30 pm, the Dining and Nutrition Services Manager (DNSM) confirmed that R13's diet order was puree, renal diet. The DNSM confirmed that R13 was served and was eating pureed lasagna. The DNSM revealed that R13 should have received a plain puree beef patty instead of the lasagna. A continued interview with the DNSM revealed that she does not provide a production sheet for the Dietary Cook regarding what food items need to be prepared for each meal. The DNSM stated that the Dietary Cook is to review the menu and the diet spreadsheet to determine what food items should be prepared. The DNSM revealed that there is a whiteboard hung on the wall in the kitchen that alerts the dietary staff to how many residents receive certain therapeutic diets, such as renal, as well as the number of residents on altered consistency diets. The DNSM stated that R13 was the only resident in the facility who received a renal diet. Cross-reference F656

Based on observations and staff interviews, the facility failed to ensure that the daily nurse staffing information was posted daily and was readily accessible to residents and visitors on three of three survey dates, 1/26/2024, 1/27/2024, and 1/28/2024. The facility census was 53 residents. Findings include: Observation on 1/26/2024 at 8:34 am during the initial tour of the facility revealed that the required daily nurse staffing assignment sheet was located behind the nurse's station on the desk and not accessible to residents or visitors. Observation on 1/27/2024 at 8:55 am revealed the required daily nurse staffing assignment sheet was located behind the nurse's station on the desk and not accessible to residents or visitors. Observation on 1/28/2024 at 9:13 am revealed the required daily nurse staffing assignment sheet was located behind the nurse's station on the desk and not accessible to residents or visitors. During an interview on 1/28/2024 at 11:25 am, the Director of Nurses (DON) stated she concurred that the daily nurse staffing assignment sheet was not located in a place accessible for viewing by residents or visitors. The DON stated she would have it moved.

Based on record review, staff interviews, and review of facility policy Skilled Inpatient Services-Elopement and Skilled Inpatient Services-Wandering, the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R) (#1) from a sample of 18 residents identified by the facility to be at risk for elopement. The facility failed to ensure an area remained locked and inaccessible to wandering residents. Findings include: Review of the undated facility policy titled Skilled Inpatient Services-Elopement revealed 'Intent: To ensure patients are provided an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each patient to prevent avoidable accidents. This includes: identifying hazards and risks; evaluating and analyzing hazards and risks; and monitoring for effectiveness and modifying interventions as necessary. The implementation of mechanisms and procedures for monitoring and managing patients at risk for elopement can help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision.' Review of the undated facility policy titled 'Skilled Inpatient Services-Wandering' revealed 'Intent: It is the intent of this center to identify wandering behavior of a patient and to address the behavior appropriately. Guidelines: 3. The center may have a door alarm system. If any patient were to exit one of these doors when the alarm is on, the alarm should sound, Staff members are trained to respond to the alarm signal for patient's safety.' Record review revealed R#1 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease, Dementia with behavioral disturbances, and generalized anxiety disorder. Review of R#1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Section E (behaviors) indicated no behaviors and wandering not exhibited. Review of R#1's care plan updated 10/25/21 revealed elopement/risk for elopement evidence by aimless wandering and/or exit seeking behavior, with appropriate interventions. Review of R#1's medical record revealed on 10/23/21 at 7:30 p.m., a citizen stopped by and informed staff there was a patient walking . Staff got into private vehicle of citizen and went to return resident to facility. Staff took a wheelchair to meet them so he can be pushed back to facility. Resident was across from a building. During an interview on 10/27/21 at 11:41 a.m. with Maintenance Director revealed the door at the end of the A hall has a magnetic lock that was not working. He revealed this is how resident left the facility. Observation on 10/27/21 at 11:45 a.m. revealed a door to the kitchen pantry leading into the kitchen and an unlocked exit door that would be accessible to wandering residents. Interview on 10/27/21 at 12:11 a.m. with the Administrator confirmed the resident exited from the facility through the A hall exit door that was not locking properly. The resident made it off the property and was found by a member of the community.

Based on interview, observation, review of in-services, and review of policy titled Storage Area the facility failed to discard expired items, failed to label and date items, and failed to keep personal food separate from resident food in the kitchen. The census was 79 residents. Findings include: Observation on [DATE] at 1:50 pm. during a brief kitchen tour with Aide/Cook BB revealed the following: 1. In the reach in refrigerator #4 there was a to go plate in a plastic bag that did not have a name or a date. 2. In refrigerator #6 there was a pack of hot dog buns with a use by date of [DATE] on the package. There was a container with onions with a prepare date of [DATE] and a discard date of [DATE]; there were two stalks of celery with a prepare date of [DATE] and a use by date of [DATE]. One of the stalks of celery had begun to turn yellow; bell peppers prepared on [DATE] and discard on [DATE]; carrots with a prepare date of [DATE] and discard date of [DATE]; container with lemons with a prepare date of [DATE] and a discard date of [DATE]. 3. In a plastic storage container in the kitchen there was a package of country style gravy that had been opened but it did not have an open date or an expiration date. During the second kitchen tour on [DATE] at 11:35 a.m. the following was observed: 1. In refrigerator #6 there was a pack of hotdog buns with a use by date of [DATE]. Regional Certified Dietary Manager (CDM) confirmed items expired and removed the buns from the refrigerator. An interview with Aide/Cook BB on [DATE] at 1:55 p.m. revealed that she was not aware of who the to go plate belonged to but confirmed that the plate should not have been stored in the refrigerator. An interview on [DATE] at 12:52 p.m. with the Regional Certified Dietary Manager (CDM) and Registered Dietitian (RD) regarding to kitchen findings on [DATE] revealed that staff's personal food should not be kept in the refrigerator in the kitchen. An interview on [DATE] at 12 p.m. with the Regional CDM, RD, and CDM revealed that the CDM does routine audits related to checking the refrigerator for expired items. Regional CDM further reported that the cooks are responsible to assure temperature and sanitation audits are performed. Regional CDM reported that the items probably were out of place because the CDM was out on leave. The RD reported that whenever the CDM is on leave she is on call and available to dietary staff if there are concerns. The CDM reported that her expectation is that items in the refrigerator are checked daily for expiration dates. An interview with the Regional CDM and CDM on [DATE] at 11:47 a.m. revealed that sanitation audits include checking the pantry refrigerators for expired foods and checking for temperature logs on the refrigerators and freezers. The CDM reported that the cook is responsible for performing these audits when she is not in the building. Policy: Storage area Intent: It is the intent of this center to store food that maintains quality and safety. 1. All items will be inspected for quality and temperature control upon receipt. a. Items will be covered, sealed, labeled, and dated appropriately. Labeling and dating in-service dated [DATE] revealed the following: 1. Only patient food should be stored in kitchen and nurse pantry storage area. Employee food should always be stored separately and away from patient food.

Based on record review and interviews, the facility failed to implement care plan interventions for one resident (R #9) related to assuring that hearing device interventions were in place. Findings include: Review of R#9 medical record noted a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated the resident has moderated difficulty with hearing. Review of R#9 care plan for hearing highly impaired contained the following interventions: Be aware of patient's frustration with communication, come back later or get other staff member if necessary, check hearing aid batteries and change as needed, Encourage patient to sit close to front of speaker during activity, refer to audiologist as indicated, use alternative forms of communication to enhance understanding. Additionally, according to resident Activities of Daily Living (ADL) task list provides evidence that R#9 should have been monitored for hearing aid placement. Further review of the (ADL) task list indicated that R#9 was not being monitored for hearing aid placement or batteries. An interview on 07/01/2019 at 10:00 a.m with R#9 who stated he's been having a hard time hearing without his hearing aid. He was able to communicate that staff lost his hearing aid device but could not express the time or date they went missing. Additionally, he stated he would like new hearing aids. An interview on 07/02/2019 at 11:27 a.m. with the Resident Care Coordinator (RCC) revealed that she could not identify when the resident was sent out for his evaluation for hearing but after reviewing her schedule, she confirmed that the resident has an appointment for (MONTH) 24, 2019. She further revealed that the Certified Nursing Assistants (CNA's) are responsible for carrying out duties of monitoring of his hearing aid placement and confirmed that the monitoring of his hearing aids had not been done as stated in the resident plan of care.

Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management policy, corporate, physician, and staff interview, it was determined that the facility failed to revise the care plan after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for two residents (R) (#56, #45, ). A total of six residents were reviewed for falls, and the sample size was 28 residents. In addition, the facility failed to revise the care plan to reflect ongoing significant weight loss and any new interventions to address it for one resident #56. Review of the facility Resident Census and Condition of Residents Form CMS-672 revealed that the current facility census was 72 residents, and 37 residents were identified by the facility as being high risk for falls. On 6/16/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/16/17 at 8:21 p.m. The facility's Interim Administrator, Director of Nursing Services (DNS) and the Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 11/24/16. The immediate jeopardy continued through 6/18/17, and was removed on 6/19/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 6/17/17. The immediate jeopardy is outlined as follows: IJ was determined to exist as of 11/24/16, when resident (R) #56 had a fall that resulted in a cervical fracture and [MEDICAL CONDITION] and the facility failed to determine the cause of the fall and failed to determine if current interventions were in place at the time of the fall so that their effectiveness and/or appropriateness could be evaluated to prevent further falls. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J) A Credible Allegation of Compliance related to CFR 483.25 (F323 S/S: J), CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J) was received on 6/17/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/19/17. The facility remained out of compliance at a lower scope and severity at F280 S/S: D, F323 S/S: D, F490 S/S: D and F520 S/S: D, while the facility continued management level staff oversight of resident fall assessments and procedures to ensure the safety of residents who are at high risk for falls. This oversight process also includes analysis of facility staff's conformance with the facility's Policies and Procedures related to falls, and while the facility develops and implements the Plan of Correction (POC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents' safety from falls. Resident records were reviewed to ensure that resident assessments were current and accurate and that appropriate interventions were developed and implemented after each fall to prevent further falls. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines revised 5/1/17 included the following: Each patient's risk for falls is evaluated by the interdisciplinary team. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. When a fall occurs: Implement interventions to prevent recurrence and maintain patient safety. Implement any new orders received and update plan of care. 1. Review of R #56's clinical record revealed that he was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that R #56 had one fall with major injury since prior assessment. Review of the Quarterly MDS dated [DATE] revealed that he had a Brief Interview for Mental Status Score (BIMS) of 0 (a score of 0 to 7 indicates severe cognitive impairment); and that he wandered 4 to 6 days of the assessment period; that he needed extensive assist by one staff for bed mobility and transfers; walking did not occur; the resident needed supervision with no physical help from staff for locomotion in his wheelchair; and that the resident had one fall with a non-major injury since the prior assessment. Review of a risk for falls and risk for an injury with a fall care plan that was originated on 1/21/15 revealed that R #56 was at risk due to a decline in lower extremity function; decline in functional mobility; weakness; and decreased safety awareness. Review of an intervention dated 1/21/15 revealed to See FIP (Falls Intervention Plan). Review of additional interventions on this falls care plan, dated 1/21/15, included: 5/24/17: Low bed 5/31/17: Assisted into W/C (wheelchair) and to day room for closer observation 6/7/17: Therapy screen for Broda chair Review of the FIP revealed the following interventions with the date implemented: 1/25/15: Winged mattress 9/4/15: Educate patient on how to use the call light, consider cognition 11/8/15: Wheelchair automatic brakes 12/29/15: Place bedside table within reach 1/24/16: Keep bed in low position 2/2/16: Fall mat at bedside on one side 11/25/16: Fall mat X 1 12/8/16: Pressure sensitive alarm on bed 4/8/17: Environmental factors, remove clutter, lighting, hazards 5/24/17: Low bed 6/7/17: Therapy screen for Broda chair Review of an Admission and Readmission Care Plan dated 2/16/16 and 11/18/16 documented an intervention for a fall mat. Review of an Acute Care Plan for falls dated 4/8/17 revealed a handwritten intervention for fall mat placed beside bed on floor night table (sic). Review of an Situation-Background- Appearance-Review SBAR and a Report of Resident Fall (RoRF (incident report) ) dated 11/24/16 revealed that on 11/24/16, R #56 was found on the floor in his room with a pool of blood around his head and a small laceration, skin tear, and hematoma to his right forehead. Review of a hospital Discharge Summary dated 11/25/16 documented an acute [MEDICAL CONDITION] (seventh cervical vertebrae). Review of the FIP revealed that the only intervention added was for a fall mat X 1, but this was already entered as an intervention on the FIP on 2/2/16 and on an Admission and Readmission Care Plan on 11/18/16. Review of an SBAR dated 12/8/16 revealed that R #56 was observed on the floor beside his bed with an abrasion to the left upper shoulder, his feet were at the head of the bed and his upper body was on the floor between the bed and wall. Review of a PAR (Patient at Risk) Review note dated 12/8/16 revealed that according to staff the resident's bed was unlocked at the time of the fall and staff were educated to make sure the bed was kept locked, but the care plan was not updated to reflect this intervention. Review of an SBAR dated 3/10/17 revealed that the resident fell on the floor when trying to get out of bed, and reopened a skin tear to his right forearm and top of head. Review of the care plans revealed that they were not updated to include this fall, nor updated with any new interventions to prevent a future fall. Review of an Interdisciplinary Progress Note (IPN) dated 3/31/17 revealed that R #56 was observed lying in the doorway of his room at 3:45 p.m., and was assisted back to his wheelchair. Further review of the IPN revealed that at 3:50 p.m., five minutes after the earlier fall, R #56 was observed, again laying on the floor in the doorway of his room, and this time he had sustained skin tears to his right elbow, right hand, and left hand with bleeding from these areas. Review of the care plans revealed no evidence that they were updated to include these two falls. Review of an IPN dated 4/8/17 at 10:00 p.m. revealed that the resident was observed on the floor beside his bed, with a small skin tear noted to his left elbow, but no documentation of how the fall and injury occurred. Review of the FIP revealed an intervention dated 4/8/17 for Environmental factors, remove clutter, lighting, hazards, but it did not specify what environmental interventions were implemented. Review of an Acute Care Plan dated 4/8/17 revealed a handwritten intervention for *fall mat placed beside bed on floor night table (sic). During interview with the Corporate Vice President (VP) PP on 6/19/17 at 11:43 a.m., revealed that the night stand was removed from R #56's bedside as it was a possible cause of the skin tear on 4/8/17. During an interview with the Corporate Clinical Consultant OO at this time, confirmed that the FIP did not specify that, and that only the general notation of environmental factors was listed as the intervention. Review of a Comprehensive Falls assessment dated [DATE] and 10/27/16 revealed interventions including a low bed, but review of the FIP revealed that this was not included as an intervention until 5/24/17. During interview with Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) CC on 6/15/17 at 2:20 p.m., she stated that the nurse on duty at the time of a fall assessed the resident and the environment, for things such as water on the floor or if non-skid socks were on. She further stated that the nurse then completed the SBAR, and put an immediate intervention in place, then created an incident report in the computer, as well as a more detailed nurse's note, and would also update the falls care plan. She stated that falls were discussed in morning meetings as well as weekly PAR meetings, and falls interventions were reviewed and additional interventions suggested as necessary. She further stated that she usually updated the care plan as needed during these meetings. LPN CC verified that there was no documentation on the FIP or falls care plan related to the fall on 3/10/17, nor the two falls on 3/31/17, and there were no new interventions listed. During further interview, LPN CC revealed that she did not know what the intervention on the FIP dated 4/8/17 for environmental factors meant, nor what the acute care plan intervention for fall mat placed beside bed on floor night table meant. During an interview with the Director of Nursing Services (DNS) on 6/16/17 at 12:19 p.m., she verified that the intervention on the FIP after the fall on 11/24/16 was for a fall mat, but that intervention had already been put in place. During further interview, she verified that there was no documentation on the FIP related to ensuring that the wheels on R #56's bed were locked after the fall on 12/8/16, and the DNS stated she really didn't consider it necessary as that was just something that should always be done. During an interview with the Registered Nurse (RN) Resident Assessment Instrument (RAI) Director GG on 6/16/17 at 1:37 p.m., revealed that the nurse on duty at the time of the fall updated the care plan. Cross-refer to F 323. 2. Review of the Quarterly Minimum Data Set (MDS), for R#56, dated 3/22/17 revealed that he had a non-physician prescribed weight loss of 5% or more in the past month or 10% or more in the last six months. Review of the June 2017 physician's orders [REDACTED].#56 was on a mechanical soft diet with ground meats, and nutritional supplement orders included house supplement 90 milliliters (mL) three times a day, a frozen nutritious treat with lunch and supper, and Prostat (a protein supplement) 30 mL twice a day. Review of a weight loss and at risk for further weight loss due to resident not eating and picks at food care plan originated on 8/25/15 revealed that the last time that it was reviewed was on 10/25/16, with no new interventions since 8/25/15. Review of a care plan for mechanical soft diet with ground meats care plan that originated on 1/25/16 and last reviewed on 3/23/17 documented the last intervention added was on 1/12/17, to monitor weights and report any significant continued loss to the physician. Review of the facility's Registered Dietician (RD) dietary assessment, for R #56, dated 6/8/17 revealed the following: Current weight 105 pounds, which is a 2.78% loss in one month, a 17.32% significant weight loss (SWL) in 90 days, and a 17.32% SWL in 180 days. Increase caloric and nutrient needs related to significant weight loss and wounds. Continue to provide diet and supplements as ordered and close monitoring per protocol. Goals: improved PO (by mouth) intake, weight gain/no more unintended weight loss; improve skin integrity. Review of a Facility Detail Weight Report for R #56 revealed a weight of 138 pounds on 11/22/16, and a weight of 105 pounds on 6/17/17 (a 23.91% loss in seven months). During observation at breakfast on 6/15/17 at 7:50 a.m., R #56 was observed feeding himself, and had stopped after consuming almost all of the ground meat, all of the scrambled eggs, toast, juice and milk, and approximately 25% of the grits. Further observation of R #56 at this time revealed that he pulled the tablemate's plate of food toward him, and started eating the other resident's toast, and staff was observed to pull the plate of food away from R #56 and disposed of it. R #56 then grabbed his tablemate's glass of milk and it was again taken away by staff, who did not ask him if he wanted anything else. A second dining observation of R #56 was done on 6/15/17 beginning at 12:14 p.m., and the Director of Nursing Services (DNS) was observed feeding the resident his lunch. The resident only consumed approximately 25% to 50% of his entree and vegetables and bread, but ate 100% of the frozen nutritious treat and two small bowls of ice cream that were obtained after he stopped eating the food served to him. During interview with Dietary Manager (DM) SS on 6/17/17 at 3:29 p.m., she stated that she obtained R #56's food likes and dislikes when he was first admitted , but that was the last one she did for him (the resident was admitted on [DATE]). During an interview with Clinical Dietary Manager (CDM) TT on 6/19/17 at 8:57 a.m., she stated that about the only thing that R #56 would always eat was ice cream. Interview with the Corporate Director of Nutrition on 6/19/17 at 9:36 a.m., revealed that the facility did not have a policy on weight loss, but used guidelines which everyone at the facility had access to. Review of the Nutritional Intervention Tool that she provided dated 11/2016, revealed that relevant findings, concerns and referrals as well as response to interventions should be documented, and the care plan should be reviewed and updated. During interview with the facility's Resident Assessment Instrument (RAI) Coordinator GG on 6/19/17 at 11:13 a.m., she stated that continued weight loss should be reflected on the weight loss care plan, and verified that the weight loss care plan had not been updated since 8/25/15, and did not know why this had not been done. During further interview, she stated that they went over each individual care plan problem and revised the care plan as needed at R #56's last care plan meeting on 4/16/17, but that they didn't have the resident's weights at that meeting. Cross-refer to F 325. 3. Resident #45 (R45) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] revealed activities revealed that the resident required extensive assistance. Review of the Care plan dated 2/17/17 documents that on admission the bed was placed against the wall and a fall mat was to be placed to open side of the bed. The care plan was observed to be updated on 3/22/17 for pressure sensitive chair alarm added for resident getting up out of chair without assistance. The care plan was updated on 4/25/17 after a fall with the intervention of hip pads to prevent injury. Updated after a fall on 5/1/17 elbow pads to prevent injury. Further review revealed that the care plan was not updated after the resident had a fall on 4/13/17. Medical record review for R45 revealed that the resident has had four (4) falls recorded since being admitted , two of which have no interventions put in place and that there were not any interventions put in place to prevent any further falls. Review of the Interdisciplinary Progress Note dated 4/13/17 documents: resident observed sitting on the floor in the day room in front of the chair that she was sitting in. Further review revealed that there was not any evidence of a Situation, Background, Assessment, Recommendation (SBAR) Communication Form documented for this fall and that there were not any interventions documented for this fall. Review of an SBAR dated 5/12/17 documents: resident observed lying on her back on the floor, laceration to back, left side of her head. Neuro checks started, family and physician notified. Sent to ER for evaluation, returned and neuro checks continued. Further review revealed that there were not any new interventions documented. Interview with LPN NN on 6/16/17 at 11:22 a.m. revealed that she said the resident was admitted with a history of falls. LPN NN reviewed residents chart stated that the interventions should be on the care plan and confirmed that they were not. Interview with the DON on 6/16/16 at 4:57 p.m. confirmed that the care plan, for R#45, was not updated with each fall and also said that the interventions were not put in place to prevent any further falls. Interview with LPN CC on 6/17/17 at 11:13 a.m. revealed that the nurse on duty at the time of an incident was responsible for putting an intervention on the care plan. When asked about the interventions that were put in place, the hipsters and elbow pads, she stated that they were put into place to prevent injury. LPN CC reviewed the chart and confirmed that the resident didn't have interventions for each fall. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Beginning 6/16/17, residents (R) #50, #45, #80 and #56 were reassessed to determine risk factors placing them at high risk for falls. 2. The environment was assessed and corrected for hazards to ensure immediate safety for the four residents by the Regional Nurse and Director of Nursing (DON). 3. Each fall was thoroughly investigated by the Regional Nurse and DON to determine the root cause of the fall. 4. The residents' care plans were reviewed and updated to reflect current and appropriate interventions as indicated. 5. Changes in interventions for the four residents were communicated verbally to the staff providing care to the residents. 6. Physician and resident representatives were notified of any change after the four residents were reassessed. 7. Direct care staff to conduct hourly rounds for these four residents to ensure safety for 72 hours starting on 6/16/17 at 9:30 p.m. and concluding on 6/18/17 at 9:30 p.m. 8. All residents at high risk for falls with a fall risk assessment score between 7 and 18 were identified and their fall risk assessments and care plans were reviewed with no further occurrence of adverse events. 9. On 6/16/17 at 10:00 p.m., 80% of LPNs and RNs were educated via in-service by the Regional Nurse Consultant on the fall management program which includes the fall risk assessment, the care plan and interventions. Education included conducting a head to toe assessment to identify any injuries or changes in condition, observation and interview of the resident or witnesses to determine the possible cause of the fall, implementation of interventions to prevent recurrence and maintain patient safety, completion of the Event Manager Report to capture the investigation of the fall and assessment of the resident, notification of the physician and resident representative, documentation of the occurrence in the medical record, communication of the fall with other care providers, review of the falls with the interdisciplinary team (IDCPT) in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete, and reviewing the event and resident status at the next Patient at Risk (PAR) meeting. Education also included the importance of using the falls risk assessment to determine risk factors that place the patient at increased risk for falls and ensuring that appropriate interventions are in place to address the root cause of the fall. The remaining 20% of LPNs and RNs will be in-serviced by 6/19/17. 10. Licensed nurses and Certified Nursing Assistants (CNAS) will be re-educated on the fall management program to include assessment, the care plan and safety interventions, how to report and investigate a fall and notification of the physician and resident representative by the Director of Nursing (DON)/designee. 11. The interdisciplinary team (IDCPT) was re-educated via in-service to review the fall risk assessment and include safety interventions in the preparation of the care plan; that the Resident Care Coordinator (RCC)/designee will update the care plan at the time of a fall to reflect an appropriate intervention to ensure patient safety; to have the care plans reviewed by the IDCPT within 24 hours post fall to ensure that an appropriate intervention has been implemented; and to review care plans at least quarterly and changes made as appropriate. 12. An audit was conducted by LPNs and RNs on fall assessments, care plans and interventions for residents identified to be at high risk for falls. 13. Opportunities for process improvement related to falls management and patient safety were identified by the Regional Consultant after review of the medical records for R#50, #45, #80 and #56 and reviewed with the Administrator and IDCPT. 14. On 6/17/17 at 9:30 a.m. the Regional Vice President provided education to the Administrator on job description, roles and responsibilities and duty to ensure processes are in place to ensure patient safety. 15. On 6/17/17 at 9:30 a.m. an in-service was provided to facility staff by the Administrator on the QAPI process and the role and function of the QAPI committee. 16. An ad hoc QAPI committee meeting was held on 6/17/17 at 9:30 a.m. to review compliance with the fall risk assessments, fall care plan interventions, in-service education on the Fall Management Program including investigation and follow-up for each fall incident and opportunities for process improvements related to patient safety and falls management. The ad hoc committee members included the Administrator, DON, Assistant Director of Nursing (ADON), Social Services Director, Activities Director, Maintenance Director, Wound Care Nurse, Minimum Data Set (MDS) Coordinator, Housekeeping Coordinator and Food Services Manager. The Medical Director was notified by the DON on 6/17/17 at 9:00 a.m. 17. A performance Improvement Plan (PIP) has been developed by the Administrator and DON to address patient safety and falls management. 18. The Administrator will oversee the Falls Management Program to ensure that all residents upon admission, quarterly, annually and with significant change in condition will have a falls risk assessment completed by a licensed nurse; all residents sustaining a fall will have an appropriate intervention placed at the time of the fall to reduce risk for repeat fall and injury; all falls are reviewed by the Administrator and DON to ensure that the falls are thoroughly investigated as outlined in the falls management guidelines; all LPNs and RNs will be educated on fall risk assessment, fall interventions, fall investigation and care plan interventions and revisions by 6/19/17; and that proper follow-up to falls is completed and any opportunities for process improvement are addressed through the Quality Assessment and Performance Improvement (QAPI) process. 19. Results of all reviews and audits will be incorporated into the Quality Assessment and Performance Improvement (QAPI) process to ensure compliance is achieved and sustained. 20. Daily safety compliance rounds will be completed by the Maintenance Director/designee to determine any potential safety risks and the results reported to the QAPI committee for further evaluation as indicated. 21. QAPI meetings will be held monthly under the direction of the Administrator. The Administrator/designee will review all actual and potential fall concerns and the QAPI committee will review the findings and follow-up with revised action plans as indicated. The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the medical records for R#50, #45, #80 and #56 revealed that staff had completed Fall Risk Assessments for all four residents between 6/16/17 and 6/17/17 and had determined the risk factors that placed each resident at high risk for falls (fall risk score between 7 to 18). 2. Review of the Interdisciplinary (IDP) Notes for R#50, #45, #80 and #56 revealed that each resident room was assessed by the Regional Nurse Consultant and DON for any potential fall hazards. Review of the IDP notes revealed that there were no hazards identified. 3. Review of the medical records for R#50, #45, #80 and #56 revealed that there had been no resident falls since 6/16/17 so the SSA requested staff to review any resident falls in the last 30 days. Review of the medical records for R#50 and #45 revealed no falls since 5/18/17. Review of the medical record for R#80 revealed that staff determined the root cause of the two falls on 6/2/17 and that appropriate interventions were in place. Review of the medical record for R#56 revealed that staff determined the root cause of the falls on 5/22/17, 5/31/17 and 6/7/17 and that appropriate interventions were in place. 4. Review of the care plans for R#50, #45, #80 and #56 revealed that staff had reviewed and revised the care plans to include current and appropriate interventions. 5. Interviews with Certified Nursing Assistants (CNAs) revealed that they were told by the nurses of any new interventions to prevent falls for R#50, #45, #80 and #56. Continued interviews revealed that interventions to prevent falls included bed/chair alarms, fall mats, low beds, non-skid footwear and placing residents at the Nurses' Station for closer observation. Continued interview revealed that new interventions to prevent falls were also entered into the kiosk to which the CNAs could refer. Further interviews revealed that if a resident has a fall, the CNAs notify the nurse, obtain vital signs and assist the resident to the bed/chair after the resident is assessed by the nurse for injuries. Interviews were conducted with the following certified nursing staff who worked the 6:00 a.m. to 2:00 p.m. shift : CNA UU on 6/18/17 at 10:04 a.m., CNA VV on 6/18/17 at 10:10 a.m., Restorative Aide FF on 6/18/17 at 10:15 a.m. and CNA WW on 6/18/17 at 10:20 a.m. Interviews were conducted with the following certified nursing staff who worked the 2:00 p.m. to 10:00 p.m. shift: CNA KKK on 6/17/17 at 4:00 p.m., CNACCC on 6/17/17 at 4:00 p.m. and CNA GGG on 6/18/17 at 5:45 p.m. Interviews were conducted with the following certified nursing staff who worked the 10:00 p.m. to 6:00 a.m. shift: CNA EEE on 6/19/17 at 10:15 a.m. via phone interview, CNA FFF on 6/19/17 at 10:15 a.m. via phone interview, CNA AAA on 6/19/17 at 10:15 a.m. and CNA BBB on 6/19 /17 at 10:20 a.m. 6. Review of medical records for R#50, #45, #80 and #56 revealed that the physician and resident representatives were notified of the results of the Fall Risk Assessments that were completed on 6/16/17 and 6/17/17. 7. Review of the Fall Audit Observation sheets revealed that staff performed rounds every hour to ensure safety from falls for on all 37 at high risk for fall residents from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. Continued review revealed that none of the residents had a fall during that time. 8. Observation sheets revealed that staff performed rounds every hour to ensure safety from falls for on all 37 at high risk for fall residents from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. Continued review revealed that none of the residents had a fall during that time. 9. Staff identified 37 residents in the facility (R#46, 3, 65, 11, 5, 21, 84, 26, 12, 78, 23, 71, 10, 37, 59, 70, 25, 35, 6, 81, 115, 116, 112, 113, 114, 87, 1, 79, 52, 86, 49, 17 and R S, including R#50, #45, #80 and #56, who had a fall risk score between 7 and 18 on the Fall Risk Assessment indicating that they were at high risk for falls. The IDP Notes for all 37 residents were reviewed for any falls in the last 30 days (since 5/18/17). R#3 had a fall since 5/18/17 but, was currently in the hospital unrelated to a fall event and staff would reassess his fall when he returned from the hospital. R#113, R#56 and R#80 had falls within the last 30 days and review of their medical records revealed that staff had investigated the falls on 6/17/17 through 6/18/17 to determine the root cause of each fall and had revised the care plans to reflect appropriate interventions to address each fall to prevent further falls. The physician and responsible parties were notified. Observation of R#113 on 6/19/17 at 12:46 p.m. revealed that staff had implemented interventions as care planned. Interview with CNA UU on 6/19/17 at 2:10 p.m. revealed that she was aware of all the interventions in place to prevent falls for R#113. 10. Review of the sign-in sheet for the in-service conducted on 6/16/17 at 10:00 p.m. was compared with the employee roster and revealed that 7 of 7 RN's, 12 of 15 LPN's, and 26 of 32 CNA's, a total of 87% of the staff receiving in-services. LPNs and RNs were provided in-services by the Regional Nurse Consultant on the Fall Management Program. Education included conducting a head to toe assessment to identify any injuries or changes in condition, interviews with the resident (if able) and any witnesses to the fall to determine the root cause of the fall, implementation of immediate appropriate interventions to prevent further falls, notification of the physician and resident representative of the fall and any injuries, documentation of the fall incident in the resident's medical record, completion of the Event Manager Report in the computer to indicate that the resident was assessed and the fall investigated for tracking purposes, communication of the fall and new interventions placed to other care providers, and review of the all falls in the last 24 hours by the IDCPT in the morning meeting to ensure that a root cause for each fall could be determined, that interventions are appropriate and documentation about the falls were complete, and that the fall and resident status would be reviewed in the next Patient at Risk (PAR) meeting. Education also included the importance of using the Fall Risk Assessment to determined risk factors and ensuring that appropriate intervention

Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management policy, corporate, physician, and staff interview, it was determined that the facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) meetings per facility policy so that the cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for three residents (R) (#56, #45, #50). In addition, the facility failed to revise the care plan after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for two residents (#56 and #45). A total of six residents were reviewed for falls, and the sample size was 28 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 revealed that the current facility census was 72 residents, and 37 residents were identified by the facility as being high risk for falls. On 6/16/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/16/17 at 8:21 p.m. The facility's Interim Administrator, Director of Nursing Services (DNS) and the Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 11/24/16. The immediate jeopardy continued through 6/18/17, and was removed on 6/19/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 6/17/17. The immediate jeopardy is outlined as follows: IJ was determined to exist as of 11/24/16, when resident (R) #56 had a fall that resulted in a cervical fracture and head laceration and the facility failed to determine the cause of the fall and failed to determine if current interventions were in place at the time of the fall so that their effectiveness and/or appropriateness could be evaluated to prevent further falls. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J) A Credible Allegation of Compliance related to CFR 483.25 (F323 S/S: J), CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J) was received on 6/17/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/19/17. The facility remained out of compliance at a lower scope and severity at F280 S/S: D, F323 S/S: D, F490 S/S: D and F520 S/S: D, while the facility continued management level staff oversight of resident fall assessments and procedures to ensure the safety of residents who are at high risk for falls. This oversight process also includes analysis of facility staff's conformance with the facility's Policies and Procedures related to falls, and while the facility develops and implements the Plan of Correction (POC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents' safety from falls. Resident records were reviewed to ensure that resident assessments were current and accurate and that appropriate interventions were developed and implemented after each fall to prevent further falls. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines revised 5/1/17 included the following: Each patient's risk for falls is evaluated by the interdisciplinary team. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. When a patient is found on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. All patients will be reassessed for risk at least quarterly, annually, and with significant change in condition. Patients experiencing falls should be reviewed in the morning meeting. Patients should be reviewed in the Patient at Risk (PAR) or UR (Utilization Review) meeting as indicated. When a fall occurs: Implement intervention/s to prevent recurrence and maintain patient safety. Implement any new orders received and update plan of care. Review falls with the IDT in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete (including Event Management Report). Review the event and patient status at the next scheduled PAR and/or UR meeting as indicated. 1. Review of R #56's clinical record revealed that he was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the Annual Minimum Data Set, for R#56, ((MDS) dated [DATE] revealed that R #56 had one fall with major injury since the prior assessment. Review of the Quarterly MDS dated [DATE] revealed that he had a Brief Interview for Mental Status Score (BIMS) of 0 (a score of 0 to 7 indicates severe cognitive impairment); wandered 4 to 6 days of the assessment period; needed extensive assist by one staff for bed mobility and transfers; walking did not occur; needed supervision with no physical help from staff for locomotion in his wheelchair; and had one fall with a non-major injury since the prior assessment. Review of a Nurse Practitioner's History and Physical dated 1/4/17 revealed that R #56 had fallen a total of three times this past year, and one of them resulted in injury. Review of a risk for falls and risk for an injury with a fall care plan, for R#56, originated on 1/21/15 revealed that R #56 was at risk due to a decline in lower extremity function; decline in functional mobility; weakness; and decreased safety awareness. Review of an intervention dated 1/21/15 revealed to See FIP (Falls Intervention Plan). Review of additional interventions on this falls care plan included: 5/24/17: Low bed 5/31/17: Assisted into W/C (wheelchair) and to day room for closer observation 6/7/17: Therapy screen for Broda chair Review of the FIP revealed the following interventions with date implemented: 1/25/15: Winged mattress 9/4/15: Educate patient on how to use the call light, consider cognition 11/8/15: Wheelchair automatic brakes 12/29/15: Place bedside table within reach 1/24/16: Keep bed in low position 2/2/16: Fall mat at bedside on one side 11/25/16: Fall mat X 1 12/8/16: Pressure sensitive alarm on bed 4/8/17: Environmental factors, remove clutter, lighting, hazards 5/24/17: Low bed 6/7/17: Therapy screen for Broda chair Review of an Admission and Readmission Care Plan, for R#56, dated 2/16/16 and 11/18/16 noted an intervention for a fall mat. Review of an Acute Care Plan for falls dated 4/8/17 noted a handwritten intervention for fall mat placed beside bed on floor night table (sic). Review of a Comprehensive Falls Assessment, for R#56, dated 9/13/16 revealed interventions including a low bed. Review of a Comprehensive Falls assessment dated [DATE] noted that interventions included a low bed and fall mat. Review of a Comprehensive Falls Assessments dated 12/8/16 and 1/4/17 revealed that R #56 continued to be at risk for falls related to a history of falls, poor safety awareness, frequent periods of combativeness and agitation with staff, and refusals of care at times. He has a fall mat at bedside X 1, bed against wall, his nightstand has been moved away from the bed, and a bed alarm has been placed on his bed. He is also at a room close to the nurses' station. Further review of the clinical record revealed that no other Falls Assessments were documented after the Fall Assessment completed on 1/4/17. Review of the Event Log by Resident report, which was obtained from the facility's computerized system that tracked falls, revealed the following falls for R #56 from 6/1/16 through 6/15/17: 11/24/16 at 5:15 a.m. 3/10/17 at 1:00 a.m. 3/31/17 at 3:45 p.m. 3/31/17 at 3:50 p.m. 5/22/17 at 10:15 a.m. 5/31/17 at 3:40 p.m. 6/7/17 at 8:55 a.m. In addition to the above falls, two other falls were found in the clinical record that had not been entered into the falls tracking system: 12/8/16: Unknown time, physician was notified of the fall at 8:20 a.m. 4/8/17: Unknown time. Review of SBARs (Situation-Background-Appearance-Review), the Interdisciplinary Progress Notes (IPN), Report of Resident Fall (RoRF), and any PAR (Patient at Risk) Reviews for the above falls revealed the following information: 11/24/16: SBAR: Called to the room by a CNA (Certified Nursing Assistant). Resident, (R#56) noted on right side on floor with pool of blood around head. Pressure applied to stop bleeding. Assisted to bed by four staff members. Small laceration to right forehead. EMS (Emergency Medical Services) notified, sent to the ER (emergency room ). IPN: 11/24/15 (sic) at 5:35 a.m. EMS at facility and transported resident to ER. (No other information related to the circumstances of the fall in the IPN). Review of an IPN dated 11/25/16 at 7:10 p.m. after R #56 was readmitted to the facility noted that he had a fall mat in place and bed alarm will be applied. Bed remains in low position, call light in reach. RoRF: 11/24/16 at 5:15 a.m. Resident noted on floor beside his bed. Small laceration noted to right forehead and small skin tear to right hand. Attempting to get into bed unattended. Skin tear and laceration to right forehead with hematoma. (The RoRF does not note if a fall mat was in place, and this was an intervention on the FIP dated 2/2/16). Review of a hospital Discharge Summary dated 11/25/16 noted an acute fracture of the C7 (seventh cervical vertebrae) involving posterior elements of C7 with anterior displacement of C6 on C7. 12/8/16 (this fall was not on the Event Log): SBAR: Observed on floor beside bed with abrasion to left upper shoulder. Observed with feet at HOB (head of bed) with upper body on floor between bed and wall. (No time noted of the fall, but the physician was notified at 8:20 a.m.). IPN: No nurse's notes seen related to this fall. RoRF: There was no incident report done for this fall. PAR: 12/8/16: Resident (R#56) status reviewed by IDCP (Interdisciplinary Care Plan) team related to recent falls on 11/24/16 and 12/8/16. Fall on 11/24/16 resulted in a fracture to C7 of spine. Resident was sent to hospital overnight and returned with a cervical collar which he will not wear. A fall mat was placed beside bed and his bed is against the wall. On 12/8/16 fall occurred when resident fell between bed and wall, his bed was unlocked according to staff. Staff educated to make sure bed is kept locked and bed alarm placed on bed. 3/10/17: SBAR: Resident (R#56) trying to get OOB (out of bed), and fell on floor. Reopen skin tear to RFA (right forearm) and had a skin tear to top of head. Bed in low position. IPN: No nurse's notes seen related to this fall. RoRF: 3/10/17 at 1:00 a.m. Unwitnessed fall to floor beside his bed. Last known location in his bed. Attempting to get out of bed unattended. Skin tear to right forearm. If a bed or a chair alarm was in use at the time of the fall, did it work properly? N/A. (This RoRF does not note if a fall mat was in place or if the bed alarm was on and sounding at the time of the fall). PAR: no evidence found that this fall was discussed in a PAR meeting. 3/31/17 at 3:45 p.m.: SBAR: Things that make the condition or symptom worse are being unsupervised. Things that make the condition or symptom better are sitting in day room where staff can observe. Resident lying in doorway on right side arm under his body. IPN: Resident (R#56) observed lying in doorway of his room on his right side at 3:45 p.m. Staff assisted resident back in the wheelchair. At 3:50 p.m. resident was observed again laying on his right side on the floor in the doorway of his room. Skin tear to his right elbow and right hand and also small skin tear on left hand. Resident was bleeding from these areas. Resident was helped into bed to rest. RoRF: 3/31/17 at 3:45 p.m. Staff observed resident lying on floor in the doorway of his room. Assisted back into wheelchair by staff. Last known location sitting in hallway in his W/C. Bed or chair alarm?: N/A. PAR: no evidence found that this fall was discussed in a PAR meeting. 3/31/17 at 3:50 p.m. (Five minutes after the last fall): SBAR: Things that make the condition or symptom worse are being unattended. Things that make the condition or symptom better are sitting in the day room so he can be observed by staff. S/T (skin tear) to right hand and S/T to right elbow and S/T to left hand. Resident found lying on the floor on his right side. Right elbow and hand under his body. Interventions: closer observation by staff. IPN: See IPN notes above on 3/31/17 at 3:45 p.m. RoRF: 3/31/17 at 3:50 p.m. Staff observed resident laying on the floor in the doorway of his room. Blood noted on top of resident's right hand and on right elbow. Skin tear to top of right hand and right elbow. Bed or chair alarm?: N/A. PAR: no evidence found that this fall was discussed in a PAR meeting. 4/8/17 (this fall was not on the Event Log): SBAR: Resident (R#56) observed lying on floor beside his bed on left side with legs extended. S/T noted to left elbow. IPN: 4/8/17 at 10:00 p.m. When writer passed by resident's room after completing evening med pass, resident was observed lying on floor beside bed on left side with legs extended in front of him. Small S/T noted to left elbow lateral aspect. RoRF: there was no incident report completed for this fall. PAR: no evidence found that this fall was discussed in a PAR meeting. 5/22/17: SBAR: Resident (R#56) rolled off bed onto floor, noted lying on back. Scant redness noted to back of head with skin intact. IPN: No nurse's notes seen for this fall. RoRF: 5/22/17 at 10:15 a.m. Resident rolled off bed onto floor and was noted lying on back. No apparent injuries observed. Back of head with some redness noted with skin intact. The Preventative measures section only had bed in low position checked (this RoRF does not note if the bed alarm, an intervention since 12/8/16, was on the bed and/or if it was alarming, nor did it note if the fall mat was in place, an intervention since 2/2/16). If a bed or a chair alarm was in use at the time of the fall, did it work properly?: N/A. PAR 5/25/17: Fall occurred on 5/22/17 when the resident rolled OOB. Resident was placed in a low bed after the fall. (There was no evidence of a discussion if the current interventions were in place, such as the fall mat and bed alarm). 5/31/17: SBAR: Resident (R#56) attempting to open door and slid out of W/C onto right side. Staff assisted resident off floor back into W/C. IPN: No nurse's notes seen for this fall. RoRF: 5/31/17 at 3:40 p.m. Resident attempting to open door (to his room) and slid out of wheelchair onto floor onto right side-no apparent injuries noted-no new discoloration noted-staff assisted off floor back to wheelchair. Bed or chair alarm?: N/A. PAR 6/2/17: Resident slid out of his wheelchair 5/31/17. Care plan already addresses his fall/injury risk. (there is no evidence of any discussion of any new interventions). 6/7/17: SBAR: Staff observed resident try to get up from his wheelchair and fell on to his right side. Resident (R#56) got skin tear on right wrist and right hand from hitting side of wheelchair, small amount of blood. IPN: No documentation of how the fall occurred, only that a therapy screen for a Broda chair would be put in. RoRF: 6/7/17 at 8:55 a.m. Staff observed resident try to get up from his wheelchair in his room and fell on to his right side. Resident got skin tear on right wrist from hitting side of wheelchair. Bed or chair alarm?: N/A. PAR 6/9/17: Staff observed resident attempt to get up from wheelchair and fall onto his right side. Resident got S/T on his right wrist and right hand from hitting the side of wheelchair. Resident has a pressure sensitive alarm on bed, has low bed, has fall mat at bedside, has winged mattress. On 6/7/17 resident has therapy screen for Broda chair. (there was no evidence of any discussion of what the resident may have been trying to do, such as get a drink). Interview 6/15/17 at 2:20 p.m., with Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) CC revealed that the nurse on duty at the time of a fall assessed the resident and the environment, for things such as water on the floor or if non-skid socks were on. She further stated that the nurse then completed the SBAR, and put an immediate intervention in place, such as a low bed or fall mat, or put a frequent faller in an area where they could be monitored more closely. LPN CC further stated that the nurse then created an incident report in the computer, as well as a more detailed nurse's note, and would also update the falls care plan. She stated that they had recently been instructed not to use the FIP anymore, and all falls interventions and the dates of the falls should be on the comprehensive falls care plan. She stated that they had weekly meetings where all falls were discussed, either in the Utilization Review (UR) meeting if the resident was receiving skilled services, or in the PAR meetings. LPN CC stated that falls were on the 24-hour report, and were discussed in morning meetings, and falls interventions were reviewed and additional interventions suggested as necessary. She further stated that she usually updated the care plan as needed. LPN CC added that someone was assigned to PAR the falls (document the fall and discussion of the fall), but the falls were discussed as an interdisciplinary team. She further stated that she completed the Falls Risk Assessments quarterly, and did not know why one was not done for R #56 after 1/4/17. The following falls were discussed with LPN CC at this time: 3/10/17: LPN CC verified that there was not any documentation on the FIP or falls care plan related to this fall, and that there were not any new interventions listed. She verified that there was not a PAR note for the week of this fall. 3/31/17 at 3:45 p.m. and 3:50 p.m.: LPN CC stated that the immediate intervention when R#56 was found on the floor at 3:45 p.m. was to put him back in his wheelchair, and he fell again five minutes later before they could come back to the room to assess him. She verified that neither the FIP or falls care plan were updated to reflect the falls, nor that there was no PAR meeting notes in the chart for that week, and did not know why his falls weren't discussed in PAR. 4/8/17: LPN CC did not know specifically what the environmental factors, remove clutter, lighting, hazards intervention referred to on the FIP. LPN CC also stated that she did not know what the intervention for fall mat placed beside bed on floor night table meant on the acute falls care plan dated 4/8/17. 5/31/17: LPN CC stated that this fall was discussed in PAR on 6/2/17, but she did not see that any new interventions were discussed. She verified that the intervention on the care plan to take the resident to the day room was just an immediate intervention for closer observation. Interview on 6/16/17 at 12:19 p.m., with the Director of Nursing Services (DNS) revealed that they reviewed the 24-hour report in morning meetings including falls, and had a round-table discussion on what caused the fall and interventions to address it. Review of a Daily Morning Meeting record dated 11/28/16 revealed Resident #56 was listed as having a fall, but there was no documentation of a discussion of what caused the fall. The DNS further stated that LPN CC was responsible for the falls program, but that she (the DNS) was ultimately responsible for monitoring falls. The DNS stated that the SBAR was generally the most complete documentation in most cases of what was observed at the time of a fall. She verified that neither the incident report (RoRF), PAR Review note, IPN or SBAR contained documentation of how R #56 fell on [DATE]. She stated that if the nurse on duty at the time of the fall did not complete the computerized incident report (RoRF), that she (the DNS) would fill it out. She further stated that she did not think that what she entered in the RoRF on 11/24/16 was accurate regarding the resident was attempting to get in the bed unattended when the fall occurred, as he was last seen in the bed. She verified that she completed this form on 12/2/16, eight days after the fall occurred. The DNS stated that her expectation for documentation of a fall was that it contained enough information to assess and determine what caused the fall, to help prevent a future fall. She stated was it spelled out how he fell on [DATE]? No. She stated that the intervention after the fall with fracture on 11/24/16 was for a fall mat, but verified that an intervention for a fall mat was already in place, and that there was not any evidence that a fall mat was in place at the time of this fall. The DNS verified that the FIP was not updated to include an intervention to ensure the wheels on the bed were locked after the fall on 12/8/16, and stated she really didn't consider it necessary to do so as keeping the wheels locked was just something that should always be done. Interview on 6/16/17 at 3:39 p.m., with LPN LL revealed that the best he could recall, that R #56's bed was in low position at the time of the fall on 11/24/16, but he could not recall with certainty if there was a fall mat on the floor. During interview with Certified Nursing Assistant MM on 6/16/17 at 5:30 p.m., she stated that the CNAs did not have anything in writing such as a CNA care plan that told them what fall interventions were used for a resident, but they relied on the nurse to tell them what interventions to use. During interview with LPN NN on 6/16/17 at 5:37 p.m., she stated that after a fall, the nurse puts an immediate intervention in place, and their documentation included how the resident fell . During interview with R #56's attending physician and the facility's Medical Director, he stated that because of the resident's cognition, it would be difficult to keep him from falling, but that they just had to keep trying different things. During interview with the DNS on 6/17/17 at 11:20 a.m., she stated that she did not have any incident reports for R #56's falls on 12/8/16 and 4/8/17, and verified these two falls were not listed on the Event Log report that tracked the number of falls. During interview with the Corporate VP (Vice President) of Clinical Practice PP on 6/18/17 at 11:26 a.m., she verified that the intervention after the fall on 4/8/17 was for a fall mat, and verified that the PAR Review note dated 12/8/16 noted that a fall mat was placed beside the bed, and that there were previous interventions for a fall mat on the FIP on 2/2/16 and 11/25/16, and on the Admission Care Plan on 11/18/16. During further interview, she stated that they planned on having training for the facility staff on how to determine the root cause of a fall, including documentation of what was in place at the time of the fall, such as a fall mat or low bed. During interview with Corporate VP PP on 6/19/17 at 11:43 a.m., she stated that the night stand was removed from R #56's bedside as it was a possible cause of the skin tear on 4/8/17. During interview with Corporate Clinical Consultant OO at this time, she verified that the FIP did not specify that, and that only the general notation of environmental factors was listed as the intervention. Further interview with Corporate VP PP revealed that there was no evidence that the height of the bed at the time of the fall on 5/22/17 was discussed in the PAR meeting on 5/25/17, and that it would be prudent to assume that the bed was not in its lowest position if the intervention at the time of the fall was to place the resident in a low bed. She further stated that staff did not know why they were documenting the bed alarm as being N/A on the RoRF reports, and she verified that there was not any evidence that it was discussed in PAR what interventions were in place at the time of the falls. During interview with LPN KK on 6/19/17 at 2:27 p.m., she stated that when R #56 fell out of bed on 5/22/17, that there was no alarm sounding, and that she didn't think that a bed alarm was an intervention at that time. 2. Resident #45 (R45) was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented that the resident requires extensive assistance and the Care Area Assessment (CAA) Summary triggered for falls. Review of the care plan, for R#45, dated 2/17/17 documents that on admission that the bed was placed against the wall and the fall mat was to be placed to open side of bed. Updated 3/22/17 for pressure sensitive chair alarm added for resident getting up out of chair without assistance. 4/25/17 updated after a fall with the intervention of hip pads to prevent injury. Updated after a fall on 5/1/17 elbow pads to prevent injury. No update noted after the fall on 5/12/17. Medical record review for R45 documented: Fall Risk Evaluation from 5/16/17 documented previous history of falls, unsafe behavior. Comprehensive Falls Assessment documented resident is at risk for falls related to history of falls, restless and agitated behavior with attempts to crawl out of bed. Resident has had four (4) falls recorded since being admitted , two of which have no interventions put in place and the other two have inappropriate interventions. Review of an Interdisciplinary Progress Note dated 4/13/17 documented that the resident was observed sitting on the floor in the day room in front of the chair that she was sitting in. Further review revealed that there was not a Situation, Background, Assessment, Recommendations (SBAR) Communication Form documented for this fall, and that there were not any interventions documented for this fall. Review of an SBAR dated 5/12/17 documented that the resident was observed lying on her back on the floor, laceration to back, left side of her head. Neuro checks started, family and physician notified. Sent to ER for evaluation, returned and neuro checks continued. Further review revealed that there were not any new interventions documented for this resident. Interview on 6/16/17 at 11:22 a.m. with LPN NN revealed that the resident was admitted with a history of falls and that staff try to redirect the resident. LPN NN revealed that R#45 will stand up unassisted often when she is in her wheel chair, also the resident will get out of bed unassisted and will stand and walk unassisted. LPN NN revealed that the resident has a chair alarm and that has helped. LPN NN reviewed the chart for R#45 and confirmed that there are no patient at risk (PAR) notes on the chart. Further interview with LPN NN revealed that the interventions, for R#45, should be on the care plan but confirmed that they were not. Interview on 6/16/16 at 4:57 p.m. with the DON revealed that if a PAR note is not on the chart that it wasn't completed. The DON also revealed that PAR notes are not kept anywhere else. When asked specifically about this resident, the DON stated, I don't remember discussing her in PAR. The DON confirmed that the care plan was not updated with each fall. Interview on 6/17/17 at 11:13 a.m. with LPN CC revealed that the nurse on duty at the time of an incident was responsible for putting an intervention on the care plan. When asked about the interventions that were put in place, the hipsters and elbow pads, she stated that they were put into place to prevent injury. LPN CC reviewed the chart, for R#45 and confirmed that there were not any PAR notes on the chart and that she does not remember discussing this resident in the meetings. LPN CC also confirmed that the resident didn't have interventions for each fall. 3. R# 50 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of 15 indicating that she was alert and oriented, was independent with ambulation and had no falls since the last MDS assessment on 12/21/16. Review of the care plan dated 10/22/15 and reviewed 10/18/16, 12/27/16 and 3/21/17 revealed that the resident was at risk for falls related to her age and frequent pacing with interventions for staff to keep the call light within reach. Review of the resident ' s medical record revealed that she received Klonopin 0.5 milligrams (mgs.) three times a day for anxiety since 9/14/16, Depakote ER 2000 mgs. every bedtime for bipolar disorder since 10/13/15, Trazadone 50 mgs. Every bedtime for sleep since 10/13/15 and Geodon 80 mgs. twice a day for schizophrenia since 9/14/15. Review of the Comprehensive Falls assessment dated [DATE] revealed that the resident was at risk for falls related to frequent pacing, poor safety awareness, unsteady gait and weakness to bilateral legs. Continued review revealed that the resident sometimes wore flip flops and would not use her walker at other times. Review of the Interdisciplinary Progress (IDP) Notes revealed that the resident ambulated with the use of a Rollator (walker) and did not have any falls from 6/2016 to 4/10/2017. Continued review revealed that she complained frequently of left knee pain and was treated with Acetaminophen 650 mgs. twice a day and every eight (8) hours as needed. Voltaren gel was applied to her left knee four times a day. Review of the X-ray dated 3/1/17 revealed that she had mild osteoarthritis. The physician ordered Lortab 5/325 mgs. every four (4) hours as needed for pain on 3/11/17. Further review of the medical record revealed that the resident received Physical Therapy (PT) from 3/7/17 to 4/14/17 and was discharged to restorative services on 4/14/17 for Active Range of Motion (AROM)

Based on observation, record review, staff interview and review of the document Job Title: Administrator the facility failed to be administered in a manner to ensure there was an effective falls program that determined the cause of falls, failed to monitor the implementation and effectiveness of interventions to keep residents safe from falls, failed to update care plans to include appropriate interventions and dates of falls for staff to follow and failed to ensure the facility's falls policy was fully implemented and discussed in patient at risk (PAR) meetings. The facility census was 72 residents. On 6/16/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/16/17 at 8:21 p.m. The facility's Interim Administrator, Director of Nursing Services (DNS) and the Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 11/24/16. The immediate jeopardy continued through 6/18/17, and was removed on 6/19/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 6/17/17. The immediate jeopardy is outlined as follows: IJ was determined to exist as of 11/24/16, when resident (R) #56 had a fall that resulted in a cervical fracture and [MEDICAL CONDITION] and the facility failed to determine the cause of the fall and failed to determine if current interventions were in place at the time of the fall so that their effectiveness and/or appropriateness could be evaluated to prevent further falls. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J) A Credible Allegation of Compliance related to CFR 483.25 (F323 S/S: J), CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J) was received on 6/17/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/19/17. The facility remained out of compliance at a lower scope and severity at F280 S/S: D, F323 S/S: D, F490 S/S: D and F520 S/S: D, while the facility continued management level staff oversight of resident fall assessments and procedures to ensure the safety of residents who are at high risk for falls. This oversight process also includes analysis of facility staff's conformance with the facility's Policies and Procedures related to falls, and while the facility develops and implements the Plan of Correction (POC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents' safety from falls. Resident records were reviewed to ensure that resident assessments were current and accurate and that appropriate interventions were developed and implemented after each fall to prevent further falls. Findings include: Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/13/17 through 6/19/17. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F280: The facility failed to revise the care plan after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for two residents (R) (#56 and #45). Cross reference to F323 The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) meetings per facility policy so that the cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for three residents (R) (#56, #45, #50). In addition, the facility failed to revise the care plan after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for two residents (#56 and #45). Cross reference to F490 The facility failed to be administered in a manner to ensure there was an effective falls program that determined the root cause of falls, failed to monitor the implementation and effectiveness of interventions to keep residents safe from falls, failed to update care plans to include appropriate interventions and dates of falls for staff to follow and failed to ensure the facility's falls policy was fully implemented and discussed in patient at risk (PAR) meetings. Cross reference to F520 The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents that sustained multiple falls. The QAA committee also failed to identify that their established policies for accidents were not being fully operationalized, and therefore failed to implement effective corrective actions to address the problems A facility provided job description for the Administrator documents that the responsibilities of the Administrator are: to direct the day-to-day functions of the Nursing Center in accordance with current federal, state and local regulations that govern long term care centers, and as may be directed by the Regional Vice President, to provide appropriate care for our patients. During a phone interview with the previous Administrator on 6/19/17 at 1:10 p.m., she revealed that she believed that falls were identified about three months ago and was discussed in the last QA meeting. Continued discussion revealed that she did not remember exactly what was discussed and the actions that were being taken concerning the falls. During an interview with the Interim Administrator on 6/19/17 at 3:00 p.m., he stated that when he started the new position at the facility last week and discovered there was an issue with falls he addressed the issue by talking with the Director of Nursing (DON) and Regional Nurse Consultant and created a performance improvement plan (PIP) to be worked by staff. He further stated that staff informed him that the previous administrator didn't put plans on paper but verbally communicated her plans. The (QA) Committee met on 6/17/17 to review the deficiencies cited including F224, F280, F323, F490 and F520 and plans to correct the cited deficiencies. During the meeting, they discussed the facility policy and procedures in regards to falls, investigation of root causes of falls, and implementation of fall interventions. He further stated the QA Committee would continue to meet on a monthly basis to review/discuss the currently cited deficiencies to ensure the Plan of Correction was effective. Additional Interview on 6/19/2017 at 4:07 p.m. with the Interim Administrator revealed that he believes that the previous Administrator was handling things more in house and not putting issues in PIP or on paper and that things had been falling through the cracks. The Interim Administrator revealed that he uses this process: identify the issue, gather information, PIP the issue and start working the PIP immediately. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Beginning 6/16/17, residents (R) #50, #45, #80 and #56 were reassessed to determine risk factors placing them at high risk for falls. 2. The environment was assessed and corrected for hazards to ensure immediate safety for the four residents by the Regional Nurse and Director of Nursing (DON). 3. Each fall was thoroughly investigated by the Regional Nurse and DON to determine the root cause of the fall. 4. The residents' care plans were reviewed and updated to reflect current and appropriate interventions as indicated. 5. Changes in interventions for the four residents were communicated verbally to the staff providing care to the residents. 6. Physician and resident representatives were notified of any change after the four residents were reassessed. 7. Direct care staff to conduct hourly rounds for these four residents to ensure safety for 72 hours starting on 6/16/17 at 9:30 p.m. and concluding on 6/18/17 at 9:30 p.m. 8. All residents at high risk for falls with a fall risk assessment score between 7 and 18 were identified and their fall risk assessments and care plans were reviewed with no further occurrence of adverse events. 9. On 6/16/17 at 10:00 p.m., 80% of LPNs and RNs were educated via in-service by the Regional Nurse Consultant on the fall management program which includes the fall risk assessment, the care plan and interventions. Education included conducting a head to toe assessment to identify any injuries or changes in condition, observation and interview of the resident or witnesses to determine the possible cause of the fall, implementation of interventions to prevent recurrence and maintain patient safety, completion of the Event Manager Report to capture the investigation of the fall and assessment of the resident, notification of the physician and resident representative, documentation of the occurrence in the medical record, communication of the fall with other care providers, review of the falls with the interdisciplinary team (IDCPT) in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete, and reviewing the event and resident status at the next Patient at Risk (PAR) meeting. Education also included the importance of using the falls risk assessment to determine risk factors that place the patient at increased risk for falls and ensuring that appropriate interventions are in place to address the root cause of the fall. The remaining 20% of LPNs and RNs will be in-serviced by 6/19/17. 10. Licensed nurses and Certified Nursing Assistants (CNAS) will be re-educated on the fall management program to include assessment, the care plan and safety interventions, how to report and investigate a fall and notification of the physician and resident representative by the Director of Nursing (DON)/designee. 11. The interdisciplinary team (IDCPT) was re-educated via in-service to review the fall risk assessment and include safety interventions in the preparation of the care plan; that the Resident Care Coordinator (RCC)/designee will update the care plan at the time of a fall to reflect an appropriate intervention to ensure patient safety; to have the care plans reviewed by the IDCPT within 24 hours post fall to ensure that an appropriate intervention has been implemented; and to review care plans at least quarterly and changes made as appropriate. 12. An audit was conducted by LPNs and RNs on fall assessments, care plans and interventions for residents identified to be at high risk for falls. 13. Opportunities for process improvement related to falls management and patient safety were identified by the Regional Consultant after review of the medical records for R#50, #45, #80 and #56 and reviewed with the Administrator and IDCPT. 14. On 6/17/17 at 9:30 a.m. the Regional Vice President provided education to the Administrator on job description, roles and responsibilities and duty to ensure processes are in place to ensure patient safety. 15. On 6/17/17 at 9:30 a.m. an in-service was provided to facility staff by the Administrator on the QAPI process and the role and function of the QAPI committee. 16. An ad hoc QAPI committee meeting was held on 6/17/17 at 9:30 a.m. to review compliance with the fall risk assessments, fall care plan interventions, in-service education on the Fall Management Program including investigation and follow-up for each fall incident and opportunities for process improvements related to patient safety and falls management. The ad hoc committee members included the Administrator, DON, Assistant Director of Nursing (ADON), Social Services Director, Activities Director, Maintenance Director, Wound Care Nurse, Minimum Data Set (MDS) Coordinator, Housekeeping Coordinator and Food Services Manager. The Medical Director was notified by the DON on 6/17/17 at 9:00 a.m. 17. A performance Improvement Plan (PIP) has been developed by the Administrator and DON to address patient safety and falls management. 18. The Administrator will oversee the Falls Management Program to ensure that all residents upon admission, quarterly, annually and with significant change in condition will have a falls risk assessment completed by a licensed nurse; all residents sustaining a fall will have an appropriate intervention placed at the time of the fall to reduce risk for repeat fall and injury; all falls are reviewed by the Administrator and DON to ensure that the falls are thoroughly investigated as outlined in the falls management guidelines; all LPNs and RNs will be educated on fall risk assessment, fall interventions, fall investigation and care plan interventions and revisions by 6/19/17; and that proper follow-up to falls is completed and any opportunities for process improvement are addressed through the Quality Assessment and Performance Improvement (QAPI) process. 19. Results of all reviews and audits will be incorporated into the Quality Assessment and Performance Improvement (QAPI) process to ensure compliance is achieved and sustained. 20. Daily safety compliance rounds will be completed by the Maintenance Director/designee to determine any potential safety risks and the results reported to the QAPI committee for further evaluation as indicated. 21. QAPI meetings will be held monthly under the direction of the Administrator. The Administrator/designee will review all actual and potential fall concerns and the QAPI committee will review the findings and follow-up with revised action plans as indicated. The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the medical records for R#50, #45, #80 and #56 revealed that staff had completed Fall Risk Assessments for all four residents between 6/16/17 and 6/17/17 and had determined the risk factors that placed each resident at high risk for falls (fall risk score between 7 to 18). 2. Review of the Interdisciplinary (IDP) Notes for R#50, #45, #80 and #56 revealed that each resident room was assessed by the Regional Nurse Consultant and DON for any potential fall hazards. Review of the IDP notes revealed that there were no hazards identified. 3. Review of the medical records for R#50, #45, #80 and #56 revealed that there had been no resident falls since 6/16/17 so the SSA requested staff to review any resident falls in the last 30 days. Review of the medical records for R#50 and #45 revealed no falls since 5/18/17. Review of the medical record for R#80 revealed that staff determined the root cause of the two falls on 6/2/17 and that appropriate interventions were in place. Review of the medical record for R#56 revealed that staff determined the root cause of the falls on 5/22/17, 5/31/17 and 6/7/17 and that appropriate interventions were in place. 4. Review of the care plans for R#50, #45, #80 and #56 revealed that staff had reviewed and revised the care plans to include current and appropriate interventions. 5. Interviews with Certified Nursing Assistants (CNAs) revealed that they were told by the nurses of any new interventions to prevent falls for R#50, #45, #80 and #56. Continued interviews revealed that interventions to prevent falls included bed/chair alarms, fall mats, low beds, non-skid footwear and placing residents at the Nurses' Station for closer observation. Continued interview revealed that new interventions to prevent falls were also entered into the kiosk to which the CNAs could refer. Further interviews revealed that if a resident has a fall, the CNAs notify the nurse, obtain vital signs and assist the resident to the bed/chair after the resident is assessed by the nurse for injuries. Interviews were conducted with the following certified nursing staff who worked the 6:00 a.m. to 2:00 p.m. shift : CNA UU on 6/18/17 at 10:04 a.m., CNA VV on 6/18/17 at 10:10 a.m., Restorative Aide FF on 6/18/17 at 10:15 a.m. and CNA WW on 6/18/17 at 10:20 a.m. Interviews were conducted with the following certified nursing staff who worked the 2:00 p.m. to 10:00 p.m. shift: CNA KKK on 6/17/17 at 4:00 p.m., CNACCC on 6/17/17 at 4:00 p.m. and CNA GGG on 6/18/17 at 5:45 p.m. Interviews were conducted with the following certified nursing staff who worked the 10:00 p.m. to 6:00 a.m. shift: CNA EEE on 6/19/17 at 10:15 a.m. via phone interview, CNA FFF on 6/19/17 at 10:15 a.m. via phone interview, CNA AAA on 6/19/17 at 10:15 a.m. and CNA BBB on 6/19 /17 at 10:20 a.m. 6. Review of medical records for R#50, #45, #80 and #56 revealed that the physician and resident representatives were notified of the results of the Fall Risk Assessments that were completed on 6/16/17 and 6/17/17. 7. Review of the Fall Audit Observation sheets revealed that staff performed rounds every hour to ensure safety from falls for on all 37 at high risk for fall residents from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. Continued review revealed that none of the residents had a fall during that time. 8. Observation sheets revealed that staff performed rounds every hour to ensure safety from falls for on all 37 at high risk for fall residents from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. Continued review revealed that none of the residents had a fall during that time. 9. Staff identified 37 residents in the facility (R#46, 3, 65, 11, 5, 21, 84, 26, 12, 78, 23, 71, 10, 37, 59, 70, 25, 35, 6, 81, 115, 116, 112, 113, 114, 87, 1, 79, 52, 86, 49, 17 and R S, including R#50, #45, #80 and #56, who had a fall risk score between 7 and 18 on the Fall Risk Assessment indicating that they were at high risk for falls. The IDP Notes for all 37 residents were reviewed for any falls in the last 30 days (since 5/18/17). R#3 had a fall since 5/18/17 but, was currently in the hospital unrelated to a fall event and staff would reassess his fall when he returned from the hospital. R#113, R#56 and R#80 had falls within the last 30 days and review of their medical records revealed that staff had investigated the falls on 6/17/17 through 6/18/17 to determine the root cause of each fall and had revised the care plans to reflect appropriate interventions to address each fall to prevent further falls. The physician and responsible parties were notified. Observation of R#113 on 6/19/17 at 12:46 p.m. revealed that staff had implemented interventions as care planned. Interview with CNA UU on 6/19/17 at 2:10 p.m. revealed that she was aware of all the interventions in place to prevent falls for R#113. 10. Review of the sign-in sheet for the in-service conducted on 6/16/17 at 10:00 p.m. was compared with the employee roster and revealed that 7 of 7 RN's, 12 of 15 LPN's, and 26 of 32 CNA's, a total of 87% of the staff receiving in-services. LPNs and RNs were provided in-services by the Regional Nurse Consultant on the Fall Management Program. Education included conducting a head to toe assessment to identify any injuries or changes in condition, interviews with the resident (if able) and any witnesses to the fall to determine the root cause of the fall, implementation of immediate appropriate interventions to prevent further falls, notification of the physician and resident representative of the fall and any injuries, documentation of the fall incident in the resident's medical record, completion of the Event Manager Report in the computer to indicate that the resident was assessed and the fall investigated for tracking purposes, communication of the fall and new interventions placed to other care providers, and review of the all falls in the last 24 hours by the IDCPT in the morning meeting to ensure that a root cause for each fall could be determined, that interventions are appropriate and documentation about the falls were complete, and that the fall and resident status would be reviewed in the next Patient at Risk (PAR) meeting. Education also included the importance of using the Fall Risk Assessment to determined risk factors and ensuring that appropriate interventions were in place to address the root cause of the fall. Review of the in-services conducted 6/19/17 revealed that the remaining 20% of LPNs and RNs were in-serviced on 6/19/17. The DON planned an in-service for 6/19/17 for the remaining staff that had not been in-serviced. These staff were not to work before receiving in-service training. 11. Multidisciplinary staff members were interviewed on the Falls Management Program. All staff stated they had attended in-services related to the fall management program on 6/18/17 and 6/19/17 provided by the Director of Health Services (DHS) and Regional Nursing Staff. The Licensed Nurses were able to verbalize how to complete a Falls Risk Assessment, how to assess a resident who has had a fall, how to update the care plan with an appropriate intervention after a fall, how to investigate a fall, how to report a fall and to notify the physician and responsible party after each fall. Interviews were conducted with the following Licensed Nurses on the 7:00 a.m. to 7 p.m. shift: LPN MMM on 6/17/17 at 3:05 p.m., LPN LLL on 6/17/17 at 3:40 p.m. and LPN DDD on 6/17/17 at 4:00 p.m., LPN PPP on 6/17/17 at 5:40p.m., MDS RN on 6/17/17 at 2:00p.m., DON on 6/17/17 at 2:00 p.m, RN II 6/17/17 at 3:00p.m., 7 PM - 7AM: LPN ZZ 6/19/17 at 9:40 a.m., LPN AAA on 6/19/17 at 9:50 a.m., Interviews with Certified Nursing Assistants (CNAs) revealed that they were provided in-services on fall prevention. Continued interviews revealed that interventions to prevent falls included bed/chair alarms, fall mats, low beds, non-skid footwear and placing residents at the Nurses' Station for closer observation. Continued interview revealed that new interventions to prevent falls were verbally communicated by the nurse to certified nursing staff and also entered into the kiosk to which the CNAs could refer. Further interviews revealed that if a resident has a fall, the CNAs notify the nurse, obtain vital signs and assist the resident to the bed/chair after the resident is assessed by the nurse for injuries. Interviews were conducted with the following certified nursing staff who worked the 6:00 a.m. to 2:00 p.m. shift : CNA UU on 6/18/17 at 10:04 a.m., CNA VV on 6/18/17 at 10:10 a.m., Restorative Aide FF on 6/18/17 at 10:15 a.m. and CNA WW on 6/18/17 at 10:20 a.m. Interviews were conducted with the following certified nursing staff who worked the 2:00 p.m. to 10:00 p.m. shift: CNA KKK on 6/17/17 at 4:00 p.m., CNACCC on 6/17/17 at 4:00 p.m. and CNA GGG on 6/18/17 at 5:45 p.m. Interviews were conducted with the following certified nursing staff who worked the 10:00 p.m. to 6:00 a.m. shift: CNA EEE on 6/19/17 at 10:15 a.m. via phone interview, CNA FFF on 6/19/17 at 10:15 a.m. via phone interview, CNA AAA on 6/19/17 at 10:15 a.m., CNA BBB on 6/19 /17 at 10:20 a.m. and CNA ZZZ on 6/19/17 at 2:10 p.m. 12. A group interview was conducted with the Interdisciplinary Team (IDCPT) on 6/18/17 at 1:55 p.m. Members of the team interviewed included the Administrator, DON, ADON, LPN/Minimum Data Set (MDS) Coordinator, LPN/Resident Care Coordinator (RCC), Social Services Director (SSD), Medical Records, RN/MDS Coordinator, Activity Director, Financial Controller, LPN/Wound Care Nurse and Physical Therapist. All members stated that they had a separate in-service from other staff that was provided by the Reginal Nurse Consultant. LPN/RCC stated at that time that a head to toe assessment should be performed on any resident who has a fall. The root cause of the fall should be determined and an immediate appropriate intervention placed by the nurse on duty. The resident's care plan was updated with the new intervention by the nurse on duty. The nurses were responsible for communicating verbally any changes in a resident's care plan to the CNAS. Continued interview revealed that staff were supposed to bring the medical records of residents who have had a fall in the last 24 hours to the morning meeting so that the fall can be discussed, the root cause of the fall determined and the new intervention evaluated for appropriateness. The medical record was reviewed for completion of documentation. The ADON stated that a Fall Risk Assessment was completed for a resident by a licensed nurse on admission, annually, quarterly, and after a significant change in the resident's condition. Continued interview revealed that the RCC, DON and ADON reviewed that the assessments were completed. Continued interview revealed that IDCPT also attended the Patient at Risk (PAR) meetings. Further interview revealed that the IDCPT was also provided an in-service on the Quality Assessment and Performance Improvement (QAPI) process and the role of the QAPI committee to address concerns, develop action plans and revise plans as indicated. Interview with the RN/MDS Coordinator on 6/19/17 at 9:10 a.m. revealed that none of the residents had an admission, quarterly, annual or significant change assessment since 6/17/17 but, staff had completed Fall Risk Assessments on all the residents in the facility. 13. Review of the audit conducted by the LPNs/RNs for the 37 residents identified at high risk for falls revealed no falls for any of the 37 residents since 6/16/17. 14. Review of the audit completed by the Regional Nurse Consultant revealed that the medical records for R#50, #45, #80 and #56 were reviewed and that opportunities for process improvement related to falls management was identified and reviewed with the Administrator and IDCPT. 15. Interview with the Administrator on 6/18/17 at 2:10 p.m. and 6/19/17 at 3:07 p.m. revealed that he became Administrator one week prior to the survey. He stated that his responsibility is to oversee the Falls Management Program to ensure resident safety and he will accomplish that by holding morning meetings with the rest of the IDCPT to review residents who had falls in the previous 24 hours. The medical records for residents who are newly admitted in the last 24 hours will also be brought to morning meetings to ensure that a Falls Risk Assessment has been completed. If the nurse on duty fails to complete a Falls Risk Assessment on a newly admitted resident then the Falls Risk Assessment will be completed and the nurse re-educated. He will oversee that the IDCPT reviews each fall to determine the cause of the fall and to evaluate the appropriateness of the intervention that was placed immediately after the fall to prevent further falls. Current interventions will also be reassessed for effectiveness. The medical records will be reviewed to ensure documentation regarding the fall is complete and accurate, physician/family notified and that interventions are entered into AccuNurse and verbally communicated to the CNAs by the nurse. Continued interview with the Administrator revealed that staff had failed to determine the root cause of some of the resident falls and that it was necessary to determine the root cause of the fall in order to develop and implement appropriate interventions. Continued interview revealed that all residents at high risk for falls will be reviewed in the weekly PAR meetings as well to determine that the root cause of falls has been identified and appropriate interventions in place. Continued interview with the Administrator revealed that he had reviewed the Quality Measurements (QM) when he became Administrator of the facility and identified that the facility had a high percentage of falls and weight loss. He stated that he had initiated a Performance Improvement Plan (PIP) for each when he arrived to the facility. Further interview revealed that he believed that the previous Administration was aware of the increase in falls but, had not initiated a PIP. Further interview revealed that initiating a formal PIP brought falls immediately to the forefront so that falls could be addressed. 16. Review of the In-service provided by the Administrator on 6/17/17 revealed Administrator, DON, ADON, SSD, AD, MD, WCN, MDS Coordinator, Housekeeping Coordinator and Food Services Manager were in-serviced on the QAPI process and the role and function of the QAPI (Robin-did you validate this? How many staff signed-in?)committee. Interviews on 6/18/17 at 1:55 p.m. with the IDCPT revealed that they were also provided an in-service on the Quality Assessment and Performance Improvement (QAPI) process and the role of the QAPI committee to address concerns, develop action plans and revise plans as indicated. 17. Review of the ad hoc QAPI committee meeting held 6/17/17 revealed the Administrator, DON, ADON, SSD, AD, MD, WCN, MDS Coordinator, Housekeeping Coordinator and Food Services Manager met to review the Fall Management Program. Interview with the Administrator on 6/19/17 at 3:13 pm revealed that the Medical Director was not present at the meeting but, had been informed about the Immediate Jeopardy related to falls and had requested assurance that particular interventions were in place. 18. Review of the Performance Improvement Project (PIP) form dated 6/7/17 revealed that falls with major injuries, representing 42% of all falls, was identified as a concern. Continued review revealed that the goal was to decrease the number of falls with injuries over the next 30 days. Continued review revealed that staff would evaluate the fall risk of a resident upon admission, re-evaluate interventions, conduct a thorough investigation of falls, conduct huddles with staff and re-educate staff on fall prevention with a target date of 6/19/17. Further review revealed that data sources used to monitor for improvement included the falls tracking system, care plans and documentation. Interview with the Administrator on 6/19/17 at 3:13 p.m. revealed that the PIP was developed mid-week before the survey team entered the facility but, that the facility had not had a chance to implement it. 19. Refer to Validation #8, #9, #11, #14 and #15. 20. Interview on 6/19/17 at 3:07 p.m. with the Administrator, Regional Nurse Consultant and Vice President of Clinical Practice revealed that the QAA committee meets monthly. Each department identifies issues via frequent rounds, chart audits, staff/resident/family interviews and morning meetings and brings concerns to the monthly QAPI meeting. Quality Measures (QMs) are also reviewed monthly to determine any increases in falls. The Vice President of Clinical Practice stated at that time that review of the QMs for falls revealed that falls had fluctuated in the last six months but, her review of falls for that time period revealed no trends. Continued interview revealed that she believed that the roles/responsibilities of staff reviewing falls had changed and that those staff were not knowledgeable about how to conduct an analysis for the root cause of falls. Further interview revealed that the RNs and LPNs will be given actual scenarios to educate them on how to analyze falls and determine the root cause of each fall. 21. Review of the safety compliance rounds performed by the Maintenance Director from revealed that the Maintenance Director conducted rounds for all 37 residents. No safety concerns were identified. Refer to Validation#15, #16, and #19

Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents that sustained multiple falls. The QAA committee also failed to identify that their established policies for accidents were not being fully operationalized, and therefore failed to implement effective corrective actions to address the problems. Additionally, the QA Committee failed to address inaccurate weights. The facility census was 72 residents and the sample size was 28 residents. On 6/16/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 6/16/17 at 8:21 p.m. The facility's Interim Administrator, Director of Nursing Services (DNS) and the Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 11/24/16. The immediate jeopardy continued through 6/18/17, and was removed on 6/19/17. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on 6/17/17. The immediate jeopardy is outlined as follows: IJ was determined to exist as of 11/24/16, when resident (R) #56 had a fall that resulted in a cervical fracture and [MEDICAL CONDITION] and the facility failed to determine the cause of the fall and failed to determine if current interventions were in place at the time of the fall so that their effectiveness and/or appropriateness could be evaluated to prevent further falls. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25 Quality of Care (F 323 Scope and Severity (S/S): J) A Credible Allegation of Compliance related to CFR 483.25 (F323 S/S: J), CFR 483.20 Resident Assessment (F 280 S/S: J), CFR 483.75 Administration (F 490 S/S: J), and CFR 483.75(o) (1) QAA (F520 S/S: J) was received on 6/17/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AOC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 6/19/17. The facility remained out of compliance at a lower scope and severity at F280 S/S: D, F323 S/S: D, F490 S/S: D and F520 S/S: D, while the facility continued management level staff oversight of resident fall assessments and procedures to ensure the safety of residents who are at high risk for falls. This oversight process also includes analysis of facility staff's conformance with the facility's Policies and Procedures related to falls, and while the facility develops and implements the Plan of Correction (POC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing residents' safety from falls. Resident records were reviewed to ensure that resident assessments were current and accurate and that appropriate interventions were developed and implemented after each fall to prevent further falls. Findings include: The Quality Assessment and Assurance (QAA) committee failed to identify, develop, and implement corrective action plans for residents that sustained multiple falls. The QAA committee also failed to identify that their established policies for accidents were not being fully operationalized, and therefore failed to implement effective corrective actions to address the problems. 1. During interview with the facility's Medical Director on 6/16/17 at 6:20 p.m., he stated that he had been coming to the facility for [AGE] years, and there had been discussions about falls during this whole time. He further stated that falls had been discussed in QA (Quality Assessment and Assurance) lately, and there was currently a plan in place to address falls. During a phone interview with the previous administrator on 6/19/17 at 1:10 p.m., she said that she believed that falls were identified about three months ago and discussed in the last QA meeting, says she doesn't remember exactly what was discussed and the actions that were being taken. During interview with the Administrator on 6/19/17 at 3:13 p.m., he stated that he had been the Administrator at the facility for only a week before the survey started, and could not say how long the center had known about problems with falls. He further stated that a Performance Improvement Program (PIP) was put in place to address falls the week he started. He stated during further interview that it wasn't that the facility had not put any falls interventions into place, but that it was his job to ensure the interventions were put through in a more urgent manner. During continued interview, the Administrator stated that to his knowledge, a PIP had not previously been developed for falls, and that he felt the staff was trying, but better results could be obtained if things were put down in writing. He further stated that he could see that staff were not drilling down to the cause of falls when he was reviewing the falls documentation. During further interview, he stated that he did not see the nurses bring the residents' charts when falls were discussed in the morning meetings, and that they needed to drill down to the cause of the falls to make their residents safer. The Administrator added that if they didn't know where the resident fell from, that they could not develop a plan to address the fall. During interview with the corporate Vice President (VP) of Clinical Practice PP, at this same, time, she stated that the center (facility) was looking at falls informally, but did not have a formal PIP in place to her knowledge. During continued interview, she stated that she thought facility staffs' roles and responsibilities had changed, and there was additional support and education needed so that the staff knew what to look for when determining the root cause of falls. Cross-refer to F 323. 2. Review of the facility's Registered Dietician (RD) dietary assessment for R #56 dated 6/8/17 revealed the following: Current weight 105 pounds, which is a 2.78% loss in one month, a 17.32% significant weight loss (SWL) in 90 days, and a 17.32% SWL in 180 days. Review of a Facility Detail Weight Report (printed from Dietary's computerized system) revealed the following weights: 11/22/16: 138 (pounds) 12/7/16: 127 (this was a 7.97% weight loss since the previous weight 15 days ago) 12/26/16: 127 1/2/17: 140 (this was a 10.23% weight gain since the previous weight seven days ago) 3/1/17: 140 3/13/17: 127 (this was a 9.28% weight loss since the previous weight 12 days ago) 4/10/17: 138 4/17/17: 111 (this was a 19.56% weight loss since the previous weight seven days ago) During interview with the RD on 6/15/17 at 1:32 p.m., she stated that she was given a weight report that already had any SWL calculated, and she used that information as well as talking to the staff about the resident's food and supplement consumption to determine what nutritional recommendations to make. During interview with the Director of Nursing Services (DNS) on 6/16/17 at 1:16 p.m., she stated that either Licensed Practical Nurse (LPN) Resident Care Coordinator (RCC) CC or the Clinical Dietary Manager (CDM) would be responsible for following up for questionable weights such as for R #56 from 138 pounds on 4/10/17 to 111 pounds on 4/17/17. She further stated that these weights were a mistake, and that they had identified that weights were not accurate. The DNS stated during continued interview that the restorative CNAs (RCNA) obtained the weights, and that training had been done with them to make sure they were calibrating the scales and obtaining weights accurately. She further stated that this had been discussed with the RD, and they considered doing a PIP (Performance Improvement Project) to address the inaccurate weights. During interview with Restorative Certified Nursing Assistant (RCNA) BB on 6/16/17 at 1:24 p.m., she stated that the Certified Nursing Assistants (CNA) had training on doing weights back in January, because they had problems with big changes in the weights that were possibly inaccurate. During interview with the DNS on 6/18/17 at 10:47 a.m., she stated that to improve the accuracy of weights, they increased the schedule for calibrating the scales, and had considered locating the scale in a location where it would not have to be moved. The DNS stated that they had developed a PIP for the accuracy of weights somewhere around March of 2016, and that it was still in QA (Quality Assessment) and they have had ongoing discussion about why the weights remained inaccurate. She further stated that the PIP had not been revised. During interview with CDM TT on 6/19/17 at 8:57 a.m., she stated that they had discussed the out of range weights and that there was something happening with weights approximately eight months ago, and discussion included the many different staff doing the weights as well as the accuracy of the scale. She further stated that to improve the accuracy of the weights, they had contracted with a scale company to come on a routine basis to inspect the scale, but verified the weights remained inaccurate. During interview with the corporate VP of Clinical Practice PP on 6/19/17 at 3:13 p.m., she stated that they had a PIP in place for an increase in weight loss per the quality measures report, but it did not necessarily address the accuracy of weights. Cross-refer to F 325. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Beginning 6/16/17, residents (R) #50, #45, #80 and #56 were reassessed to determine risk factors placing them at high risk for falls. 2. The environment was assessed and corrected for hazards to ensure immediate safety for the four residents by the Regional Nurse and Director of Nursing (DON). 3. Each fall was thoroughly investigated by the Regional Nurse and DON to determine the root cause of the fall. 4. The residents' care plans were reviewed and updated to reflect current and appropriate interventions as indicated. 5. Changes in interventions for the four residents were communicated verbally to the staff providing care to the residents. 6. Physician and resident representatives were notified of any change after the four residents were reassessed. 7. Direct care staff to conduct hourly rounds for these four residents to ensure safety for 72 hours starting on 6/16/17 at 9:30 p.m. and concluding on 6/18/17 at 9:30 p.m. 8. All residents at high risk for falls with a fall risk assessment score between 7 and 18 were identified and their fall risk assessments and care plans were reviewed with no further occurrence of adverse events. 9. On 6/16/17 at 10:00 p.m., 80% of LPNs and RNs were educated via in-service by the Regional Nurse Consultant on the fall management program which includes the fall risk assessment, the care plan and interventions. Education included conducting a head to toe assessment to identify any injuries or changes in condition, observation and interview of the resident or witnesses to determine the possible cause of the fall, implementation of interventions to prevent recurrence and maintain patient safety, completion of the Event Manager Report to capture the investigation of the fall and assessment of the resident, notification of the physician and resident representative, documentation of the occurrence in the medical record, communication of the fall with other care providers, review of the falls with the interdisciplinary team (IDCPT) in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete, and reviewing the event and resident status at the next Patient at Risk (PAR) meeting. Education also included the importance of using the falls risk assessment to determine risk factors that place the patient at increased risk for falls and ensuring that appropriate interventions are in place to address the root cause of the fall. The remaining 20% of LPNs and RNs will be in-serviced by 6/19/17. 10. Licensed nurses and Certified Nursing Assistants (CNAS) will be re-educated on the fall management program to include assessment, the care plan and safety interventions, how to report and investigate a fall and notification of the physician and resident representative by the Director of Nursing (DON)/designee. 11. The interdisciplinary team (IDCPT) was re-educated via in-service to review the fall risk assessment and include safety interventions in the preparation of the care plan; that the Resident Care Coordinator (RCC)/designee will update the care plan at the time of a fall to reflect an appropriate intervention to ensure patient safety; to have the care plans reviewed by the IDCPT within 24 hours post fall to ensure that an appropriate intervention has been implemented; and to review care plans at least quarterly and changes made as appropriate. 12. An audit was conducted by LPNs and RNs on fall assessments, care plans and interventions for residents identified to be at high risk for falls. 13. Opportunities for process improvement related to falls management and patient safety were identified by the Regional Consultant after review of the medical records for R#50, #45, #80 and #56 and reviewed with the Administrator and IDCPT. 14. On 6/17/17 at 9:30 a.m. the Regional Vice President provided education to the Administrator on job description, roles and responsibilities and duty to ensure processes are in place to ensure patient safety. 15. On 6/17/17 at 9:30 a.m. an in-service was provided to facility staff by the Administrator on the QAPI process and the role and function of the QAPI committee. 16. An ad hoc QAPI committee meeting was held on 6/17/17 at 9:30 a.m. to review compliance with the fall risk assessments, fall care plan interventions, in-service education on the Fall Management Program including investigation and follow-up for each fall incident and opportunities for process improvements related to patient safety and falls management. The ad hoc committee members included the Administrator, DON, Assistant Director of Nursing (ADON), Social Services Director, Activities Director, Maintenance Director, Wound Care Nurse, Minimum Data Set (MDS) Coordinator, Housekeeping Coordinator and Food Services Manager. The Medical Director was notified by the DON on 6/17/17 at 9:00 a.m. 17. A performance Improvement Plan (PIP) has been developed by the Administrator and DON to address patient safety and falls management. 18. The Administrator will oversee the Falls Management Program to ensure that all residents upon admission, quarterly, annually and with significant change in condition will have a falls risk assessment completed by a licensed nurse; all residents sustaining a fall will have an appropriate intervention placed at the time of the fall to reduce risk for repeat fall and injury; all falls are reviewed by the Administrator and DON to ensure that the falls are thoroughly investigated as outlined in the falls management guidelines; all LPNs and RNs will be educated on fall risk assessment, fall interventions, fall investigation and care plan interventions and revisions by 6/19/17; and that proper follow-up to falls is completed and any opportunities for process improvement are addressed through the Quality Assessment and Performance Improvement (QAPI) process. 19. Results of all reviews and audits will be incorporated into the Quality Assessment and Performance Improvement (QAPI) process to ensure compliance is achieved and sustained. 20. Daily safety compliance rounds will be completed by the Maintenance Director/designee to determine any potential safety risks and the results reported to the QAPI committee for further evaluation as indicated. 21. QAPI meetings will be held monthly under the direction of the Administrator. The Administrator/designee will review all actual and potential fall concerns and the QAPI committee will review the findings and follow-up with revised action plans as indicated. The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of the medical records for R#50, #45, #80 and #56 revealed that staff had completed Fall Risk Assessments for all four residents between 6/16/17 and 6/17/17 and had determined the risk factors that placed each resident at high risk for falls (fall risk score between 7 to 18). 2. Review of the Interdisciplinary (IDP) Notes for R#50, #45, #80 and #56 revealed that each resident room was assessed by the Regional Nurse Consultant and DON for any potential fall hazards. Review of the IDP notes revealed that there were no hazards identified. 3. Review of the medical records for R#50, #45, #80 and #56 revealed that there had been no resident falls since 6/16/17 so the SSA requested staff to review any resident falls in the last 30 days. Review of the medical records for R#50 and #45 revealed no falls since 5/18/17. Review of the medical record for R#80 revealed that staff determined the root cause of the two falls on 6/2/17 and that appropriate interventions were in place. Review of the medical record for R#56 revealed that staff determined the root cause of the falls on 5/22/17, 5/31/17 and 6/7/17 and that appropriate interventions were in place. 4. Review of the care plans for R#50, #45, #80 and #56 revealed that staff had reviewed and revised the care plans to include current and appropriate interventions. 5. Interviews with Certified Nursing Assistants (CNAs) revealed that they were told by the nurses of any new interventions to prevent falls for R#50, #45, #80 and #56. Continued interviews revealed that interventions to prevent falls included bed/chair alarms, fall mats, low beds, non-skid footwear and placing residents at the Nurses' Station for closer observation. Continued interview revealed that new interventions to prevent falls were also entered into the kiosk to which the CNAs could refer. Further interviews revealed that if a resident has a fall, the CNAs notify the nurse, obtain vital signs and assist the resident to the bed/chair after the resident is assessed by the nurse for injuries. Interviews were conducted with the following certified nursing staff who worked the 6:00 a.m. to 2:00 p.m. shift : CNA UU on 6/18/17 at 10:04 a.m., CNA VV on 6/18/17 at 10:10 a.m., Restorative Aide FF on 6/18/17 at 10:15 a.m. and CNA WW on 6/18/17 at 10:20 a.m. Interviews were conducted with the following certified nursing staff who worked the 2:00 p.m. to 10:00 p.m. shift: CNA KKK on 6/17/17 at 4:00 p.m., CNACCC on 6/17/17 at 4:00 p.m. and CNA GGG on 6/18/17 at 5:45 p.m. Interviews were conducted with the following certified nursing staff who worked the 10:00 p.m. to 6:00 a.m. shift: CNA EEE on 6/19/17 at 10:15 a.m. via phone interview, CNA FFF on 6/19/17 at 10:15 a.m. via phone interview, CNA AAA on 6/19/17 at 10:15 a.m. and CNA BBB on 6/19 /17 at 10:20 a.m. 6. Review of medical records for R#50, #45, #80 and #56 revealed that the physician and resident representatives were notified of the results of the Fall Risk Assessments that were completed on 6/16/17 and 6/17/17. 7. Review of the Fall Audit Observation sheets revealed that staff performed rounds every hour to ensure safety from falls for on all 37 at high risk for fall residents from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. Continued review revealed that none of the residents had a fall during that time. 8. Observation sheets revealed that staff performed rounds every hour to ensure safety from falls for on all 37 at high risk for fall residents from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. from 6/16/17 at 9:30 p.m. to 6/18/17 at 9:30 p.m. Continued review revealed that none of the residents had a fall during that time. 9. Staff identified 37 residents in the facility (R#46, 3, 65, 11, 5, 21, 84, 26, 12, 78, 23, 71, 10, 37, 59, 70, 25, 35, 6, 81, 115, 116, 112, 113, 114, 87, 1, 79, 52, 86, 49, 17 and R S, including R#50, #45, #80 and #56, who had a fall risk score between 7 and 18 on the Fall Risk Assessment indicating that they were at high risk for falls. The IDP Notes for all 37 residents were reviewed for any falls in the last 30 days (since 5/18/17). R#3 had a fall since 5/18/17 but, was currently in the hospital unrelated to a fall event and staff would reassess his fall when he returned from the hospital. R#113, R#56 and R#80 had falls within the last 30 days and review of their medical records revealed that staff had investigated the falls on 6/17/17 through 6/18/17 to determine the root cause of each fall and had revised the care plans to reflect appropriate interventions to address each fall to prevent further falls. The physician and responsible parties were notified. Observation of R#113 on 6/19/17 at 12:46 p.m. revealed that staff had implemented interventions as care planned. Interview with CNA UU on 6/19/17 at 2:10 p.m. revealed that she was aware of all the interventions in place to prevent falls for R#113. 10. Review of the sign-in sheet for the in-service conducted on 6/16/17 at 10:00 p.m. was compared with the employee roster and revealed that 7 of 7 RN's, 12 of 15 LPN's, and 26 of 32 CNA's, a total of 87% of the staff receiving in-services. LPNs and RNs were provided in-services by the Regional Nurse Consultant on the Fall Management Program. Education included conducting a head to toe assessment to identify any injuries or changes in condition, interviews with the resident (if able) and any witnesses to the fall to determine the root cause of the fall, implementation of immediate appropriate interventions to prevent further falls, notification of the physician and resident representative of the fall and any injuries, documentation of the fall incident in the resident's medical record, completion of the Event Manager Report in the computer to indicate that the resident was assessed and the fall investigated for tracking purposes, communication of the fall and new interventions placed to other care providers, and review of the all falls in the last 24 hours by the IDCPT in the morning meeting to ensure that a root cause for each fall could be determined, that interventions are appropriate and documentation about the falls were complete, and that the fall and resident status would be reviewed in the next Patient at Risk (PAR) meeting. Education also included the importance of using the Fall Risk Assessment to determined risk factors and ensuring that appropriate interventions were in place to address the root cause of the fall. Review of the in-services conducted 6/19/17 revealed that the remaining 20% of LPNs and RNs were in-serviced on 6/19/17. The DON planned an in-service for 6/19/17 for the remaining staff that had not been in-serviced. These staff were not to work before receiving in-service training. 11. Multidisciplinary staff members were interviewed on the Falls Management Program. All staff stated they had attended in-services related to the fall management program on 6/18/17 and 6/19/17 provided by the Director of Health Services (DHS) and Regional Nursing Staff. The Licensed Nurses were able to verbalize how to complete a Falls Risk Assessment, how to assess a resident who has had a fall, how to update the care plan with an appropriate intervention after a fall, how to investigate a fall, how to report a fall and to notify the physician and responsible party after each fall. Interviews were conducted with the following Licensed Nurses on the 7:00 a.m. to 7 p.m. shift: LPN MMM on 6/17/17 at 3:05 p.m., LPN LLL on 6/17/17 at 3:40 p.m. and LPN DDD on 6/17/17 at 4:00 p.m., LPN PPP on 6/17/17 at 5:40p.m., MDS RN on 6/17/17 at 2:00p.m., DON on 6/17/17 at 2:00 p.m, RN II 6/17/17 at 3:00p.m., 7 PM - 7AM: LPN ZZ 6/19/17 at 9:40 a.m., LPN AAA on 6/19/17 at 9:50 a.m., Interviews with Certified Nursing Assistants (CNAs) revealed that they were provided in-services on fall prevention. Continued interviews revealed that interventions to prevent falls included bed/chair alarms, fall mats, low beds, non-skid footwear and placing residents at the Nurses' Station for closer observation. Continued interview revealed that new interventions to prevent falls were verbally communicated by the nurse to certified nursing staff and also entered into the kiosk to which the CNAs could refer. Further interviews revealed that if a resident has a fall, the CNAs notify the nurse, obtain vital signs and assist the resident to the bed/chair after the resident is assessed by the nurse for injuries. Interviews were conducted with the following certified nursing staff who worked the 6:00 a.m. to 2:00 p.m. shift : CNA UU on 6/18/17 at 10:04 a.m., CNA VV on 6/18/17 at 10:10 a.m., Restorative Aide FF on 6/18/17 at 10:15 a.m. and CNA WW on 6/18/17 at 10:20 a.m. Interviews were conducted with the following certified nursing staff who worked the 2:00 p.m. to 10:00 p.m. shift: CNA KKK on 6/17/17 at 4:00 p.m., CNACCC on 6/17/17 at 4:00 p.m. and CNA GGG on 6/18/17 at 5:45 p.m. Interviews were conducted with the following certified nursing staff who worked the 10:00 p.m. to 6:00 a.m. shift: CNA EEE on 6/19/17 at 10:15 a.m. via phone interview, CNA FFF on 6/19/17 at 10:15 a.m. via phone interview, CNA AAA on 6/19/17 at 10:15 a.m., CNA BBB on 6/19 /17 at 10:20 a.m. and CNA ZZZ on 6/19/17 at 2:10 p.m. 12. A group interview was conducted with the Interdisciplinary Team (IDCPT) on 6/18/17 at 1:55 p.m. Members of the team interviewed included the Administrator, DON, ADON, LPN/Minimum Data Set (MDS) Coordinator, LPN/Resident Care Coordinator (RCC), Social Services Director (SSD), Medical Records, RN/MDS Coordinator, Activity Director, Financial Controller, LPN/Wound Care Nurse and Physical Therapist. All members stated that they had a separate in-service from other staff that was provided by the Reginal Nurse Consultant. LPN/RCC stated at that time that a head to toe assessment should be performed on any resident who has a fall. The root cause of the fall should be determined and an immediate appropriate intervention placed by the nurse on duty. The resident's care plan was updated with the new intervention by the nurse on duty. The nurses were responsible for communicating verbally any changes in a resident's care plan to the CNAS. Continued interview revealed that staff were supposed to bring the medical records of residents who have had a fall in the last 24 hours to the morning meeting so that the fall can be discussed, the root cause of the fall determined and the new intervention evaluated for appropriateness. The medical record was reviewed for completion of documentation. The ADON stated that a Fall Risk Assessment was completed for a resident by a licensed nurse on admission, annually, quarterly, and after a significant change in the resident's condition. Continued interview revealed that the RCC, DON and ADON reviewed that the assessments were completed. Continued interview revealed that IDCPT also attended the Patient at Risk (PAR) meetings. Further interview revealed that the IDCPT was also provided an in-service on the Quality Assessment and Performance Improvement (QAPI) process and the role of the QAPI committee to address concerns, develop action plans and revise plans as indicated. Interview with the RN/MDS Coordinator on 6/19/17 at 9:10 a.m. revealed that none of the residents had an admission, quarterly, annual or significant change assessment since 6/17/17 but, staff had completed Fall Risk Assessments on all the residents in the facility. 13. Review of the audit conducted by the LPNs/RNs for the 37 residents identified at high risk for falls revealed no falls for any of the 37 residents since 6/16/17. 14. Review of the audit completed by the Regional Nurse Consultant revealed that the medical records for R#50, #45, #80 and #56 were reviewed and that opportunities for process improvement related to falls management was identified and reviewed with the Administrator and IDCPT. 15. Interview with the Administrator on 6/18/17 at 2:10 p.m. and 6/19/17 at 3:07 p.m. revealed that he became Administrator one week prior to the survey. He stated that his responsibility is to oversee the Falls Management Program to ensure resident safety and he will accomplish that by holding morning meetings with the rest of the IDCPT to review residents who had falls in the previous 24 hours. The medical records for residents who are newly admitted in the last 24 hours will also be brought to morning meetings to ensure that a Falls Risk Assessment has been completed. If the nurse on duty fails to complete a Falls Risk Assessment on a newly admitted resident then the Falls Risk Assessment will be completed and the nurse re-educated. He will oversee that the IDCPT reviews each fall to determine the cause of the fall and to evaluate the appropriateness of the intervention that was placed immediately after the fall to prevent further falls. Current interventions will also be reassessed for effectiveness. The medical records will be reviewed to ensure documentation regarding the fall is complete and accurate, physician/family notified and that interventions are entered into AccuNurse and verbally communicated to the CNAs by the nurse. Continued interview with the Administrator revealed that staff had failed to determine the root cause of some of the resident falls and that it was necessary to determine the root cause of the fall in order to develop and implement appropriate interventions. Continued interview revealed that all residents at high risk for falls will be reviewed in the weekly PAR meetings as well to determine that the root cause of falls has been identified and appropriate interventions in place. Continued interview with the Administrator revealed that he had reviewed the Quality Measurements (QM) when he became Administrator of the facility and identified that the facility had a high percentage of falls and weight loss. He stated that he had initiated a Performance Improvement Plan (PIP) for each when he arrived to the facility. Further interview revealed that he believed that the previous Administration was aware of the increase in falls but, had not initiated a PIP. Further interview revealed that initiating a formal PIP brought falls immediately to the forefront so that falls could be addressed. 16. Review of the In-service provided by the Administrator on 6/17/17 revealed Administrator, DON, ADON, SSD, AD, MD, WCN, MDS Coordinator, Housekeeping Coordinator and Food Services Manager were in-serviced on the QAPI process and the role and function of the QAPI (Robin-did you validate this? How many staff signed-in?)committee. Interviews on 6/18/17 at 1:55 p.m. with the IDCPT revealed that they were also provided an in-service on the Quality Assessment and Performance Improvement (QAPI) process and the role of the QAPI committee to address concerns, develop action plans and revise plans as indicated. 17. Review of the ad hoc QAPI committee meeting held 6/17/17 revealed the Administrator, DON, ADON, SSD, AD, MD, WCN, MDS Coordinator, Housekeeping Coordinator and Food Services Manager met to review the Fall Management Program. Interview with the Administrator on 6/19/17 at 3:13 pm revealed that the Medical Director was not present at the meeting but, had been informed about the Immediate Jeopardy related to falls and had requested assurance that particular interventions were in place. 18. Review of the Performance