Every finding on record at Falls Run Nursing and Rehabilitation

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 37 residents in the survey sample, Residents #32 and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to offer non-pharmacological interventions and assess for the location of a resident's pain prior to administering an as needed pain medication on multiple occasions in March 2023. A review of R32's physician orders revealed the following order dated 1/17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. A review of R32's March 2023 MAR (medication administration record) revealed the resident received the Oxycodone-Acetaminophen as ordered on 3/2/23, 3/4/23, 3/6/23, 3/11/23, 3/12/23, and 3/14/23. Further review of the clinical record revealed no evidence that non-pharmacological interventions were offered to R32 prior to the administration of Oxycodone-Acetaminophen on all six of these dates in March 2023. The record revealed no evidence that the resident's pain location was assessed or documented on 3/2/23, 3/11/23, 3/12/23, and 3/14/23. On 3/16/23 at 10:33 a.m., RN (registered nurse) #1 was interviewed. She stated prior to administering an as needed pain medication, she attempts to reposition the resident or offer ice packs as non-pharmacological interventions and if those do not help, or if the resident refuses the non-pharmacological interventions, she asks the resident to rate and describe the location of the pain. She stated the facility's EMR (electronic medical record) software prompts the nurse to write a progress note for each as needed medication and she would document the non-pharmacological interventions and the location of the pain in the progress note. She stated non-pharmacological interventions are important because they give the residents an option other than medication. After reviewing R32's March 2023 progress notes and MAR, RN#1 agreed that there was no documentation of non-pharmacological interventions at each administration, and a lack of documentation of the location of the resident's pain on four occasions. On 3/16/23 at 11:47 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Pain Management Protocol, revealed, in part: Non-pharmacological intervention[s] will be attempted prior to the administration of PRN pain medications. When it is determined the resident's pain will need pharmacological interventions: Documentation of administration of medications will be located in the electronic medication record (eMAR) .The effectiveness of the medication(s) will be identified on the eMAR. No further information was provided prior to exit. 31753 2. For Resident #6 (R6), the facility staff failed to initiate a complete pain assessment on 3/6/23 when the as needed pain medication tramadol was administered, and failed to attempt non-pharmacological interventions on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23 when as needed tramadol was administered. R6's comprehensive care plan dated 3/7/17 documented, At risk for pain r/t (related to) multiple health risk factors. Non-pharmacological interventions as appropriate . Further review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's March 2023 MAR (medication administration record) revealed the resident was administered as needed tramadol on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. Further review of R6's clinical record (including the March 2023 MAR and March 2023 progress notes) failed to reveal a complete pain assessment, including the location of pain, was completed on 3/6/23 and failed to reveal non-pharmacological interventions were attempted on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that if a resident complains of pain, then she asks where the pain is located and if the pain is in their back or legs, she will try repositioning and ice packs before medication administration, if the resident allows this. RN #1 stated nurses should not immediately give medications because nurses should give more options. RN #1 stated she documents the location of pain and non-pharmacological interventions in the progress notes. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff administered the as needed pain medication, tramadol, outside of the physician's order for pain rated between six to ten on a scale of one to ten (one being least and ten being most) on multiple dates in January 2023 and February 2023. The staff administered tramadol for a pain rating less than six. A review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's January 2023 and February 2023 MARs (medication administration records) revealed the resident was administered as needed tramadol for pain rated less than six on the following dates: 1/3/23 (pain rated as two) 2/4/23 (pain rated as four) 2/20/23 (pain rated as zero) 2/23/23 (pain rated as zero) 2/28/23 (pain rated as three) 2/28/23 (pain rated as five) On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the pain rating documented on R6's MAR beside as needed tramadol administration is the resident's initial pain rating. RN #1 stated if a resident complains of pain, then nurses should check the physician's orders to see what medication should be given based on the resident's pain rating. RN #1 stated that for R6, tramadol should only be given for a pain rated between six to ten. RN #1 stated R6 should have been administered Tylenol (per physician's order) instead of tramadol on the above dates. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled; Pain Management Protocol failed to document information regarding the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 37 residents in the survey sample, Residents #32, #31, and #6. The findings include: 1. For Resident #32 (R32), the facility staff failed to implement the care plan to attempt non-pharmacological interventions as part of the resident's pain management program. A review of R32's physician orders revealed the following order dated 1//17/23: Oxycodone-Acetaminophen (opioid pain medication) 5-325 mg (milligrams) .Give 1 tablet by mouth every 8 hours as needed for moderate or severe pain. A review of R32's March 2023 MAR (medication administration record) revealed the resident received the Oxycodone-Acetaminophen as ordered on 3/2/23, 3/4/23, 3/6/23, 3/11/23, 3/12/23, and 3/14/23. Further review of the clinical record revealed no evidence that non-pharmacological interventions were offered to R32 prior to the administration of Oxycodone-Acetaminophen on all six of the dates in March 2023. A review of R32's care plan dated 9/6/17 and most recently updated 10/2/17 revealed, in part: [R32] has diagnosis of chronic pain .Staff to attempt non-pharmacological interventions. On 3/16/23 at 10:33 a.m., RN (registered nurse) #1 was interviewed. She stated prior to administering an as needed pain medication, she attempts to reposition the resident or offer ice packs as non-pharmacological interventions and if those do not help, or if the resident refuses the non-pharmacological interventions, she asks the resident to rate and describe the location of the pain. She stated the facility's EMR (electronic medical record) software prompts the nurse to write a progress note for each as needed medication and she would document the non-pharmacological interventions and the location of the pain in the progress note. She stated non-pharmacological interventions are important because they give the residents an option other than medication and the purpose of the care plan is to show different aspects of how to care for a resident. She stated the care plan lets the facility staff know what the resident needs, and the resident's goals, and typically nurses are mostly responsible for implementing a resident's care plan, although other departments have some specific aspects of the care plan for which they are responsible. She stated all nurses have access to the care plan through the EMR. On 3/16/23 at 11:47 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Comprehensive Care Planning, revealed, in part: All staff must be familiar with each resident's Care Plan and all approaches must be implemented. No further information was provided prior to exit. 31753 2. For Resident #31 (R31), the facility staff failed to implement the resident's comprehensive care plan for oxygen administration. R31's comprehensive care plan revised on 5/10/22 documented, Oxygen as ordered by the physician . Further review of R31's clinical record revealed a physician's order dated 12/5/22 for oxygen at three liters per minute via nasal cannula every shift. On 3/14/23 at 12:39 p.m. and 3/15/23 at 8:28 a.m., R31 was observed lying in bed receiving oxygen via nasal cannula at three and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the three-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is, Different aspects of how to care for them, being able to review what they need, what their goals are, things that happened in the past to prevent in the future. RN #1 stated care plan implementation depends on the intervention but typically the nurses are responsible. RN #1 stated nurses can easily access residents' care plans through the computer system. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's physician's order. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan for pain management. R6's comprehensive care plan dated 3/7/17 documented, At risk for pain r/t (related to) multiple health risk factors. Non-pharmacological interventions as appropriate . Further review of R6's clinical record revealed a physician's order dated 11/23/20 for tramadol 50 mg (milligrams)- one tablet by mouth every eight hours as needed for pain rated six to ten. A review of R6's March 2023 MAR (medication administration record) revealed the resident was administered as needed tramadol on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. Further review of R6's clinical record (including the March 2023 MAR and March 2023 progress notes) failed to reveal non-pharmacological interventions were attempted on 3/2/23, 3/4/23, 3/6/23, 3/7/23, 3/9/23 and 3/11/23. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is, Different aspects of how to care for them, being able to review what they need, what their goals are, things that happened in the past to prevent in the future. RN #1 stated care plan implementation depends on the intervention but typically the nurses are responsible. RN #1 stated nurses can easily access residents' care plans through the computer system. RN #1 stated nurses should attempt non-pharmacological interventions and should not immediately give medications because nurses should give more options. RN #1 stated she documents non-pharmacological interventions in the progress notes. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per physician orders, for two of 37 residents in the survey sample, Residents #18 and #31. The findings include: 1. For Resident #18 (R18), the facility staff failed to administer oxygen at the physician prescribed rate of four liters per minute. A review of R18's clinical record revealed a physician's order dated 1/22/23 for oxygen at four liters per minute via nasal cannula every shift. R18's comprehensive care plan revised on 1/24/23 documented, Oxygen as needed . On 3/14/23 at 12:40 p.m. and 3/15/23 at 2:31 p.m., R18 was observed lying in bed receiving oxygen via nasal cannula at one and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the one-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's physician's order. RN #1 stated the middle of the ball in the oxygen concentrator flowmeter should be on the four-liter line if the physician's order is for four liters. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The oxygen concentrator manufacturer's instructions documented, 2. Check the flow meter to make sure that the flow meter ball is centered on the line next to the prescribed number of your flow rate. The facility policy titled, Oxygen Administration (all routes) Policy documented, Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider. No further information was presented prior to exit. 2. For Resident #31 (R31), the facility staff failed to administer oxygen at the physician prescribed rate of three liters per minute. R 31's comprehensive care plan revised on 5/10/22 documented, Oxygen as ordered by the physician . Further review of R31's clinical record revealed a physician's order dated 12/5/22 for oxygen at three liters per minute via nasal cannula every shift. On 3/14/23 at 12:39 p.m. and 3/15/23 at 8:28 a.m., R31 was observed lying in bed receiving oxygen via nasal cannula at three and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the three-and-a-half-liter line. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated nurses should know how much oxygen to administer to a resident based on the resident's physician's order. RN #1 stated the middle of the ball in the oxygen concentrator flowmeter should be on the three-liter line if the physician's order is for three liters. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to initiate a written grievance for one of 37 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to initiate a written grievance when the resident reported a missing coat. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/2/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. On 3/14/23 at 3:31 p.m., an interview was conducted with R6. The resident stated someone stole their winter coat in November 2022. R6 stated this was reported to multiple staff and the coat was supposed to be replaced but it had not yet been replaced. A review of R6's clinical record failed to reveal documentation regarding R6's missing coat. A review of the November 2022 and December 2022 grievances failed to reveal documentation regarding R6's missing coat. On 3/16/23 at 9:17 a.m., an interview was conducted with OSM (other staff member) #1 (the director of social services). OSM #1 stated missing clothing is a concern/grievance. OSM #1 stated if a resident reports missing clothing, then she writes up a grievance and staff looks through the laundry. OSM #1 stated that if the missing clothing is not found then she talks to the resident to see if they want to be reimbursed for the missing clothing or if they want the clothing replaced. OSM #1 stated R6 did report a missing green coat and the coat was replaced. OSM #1 stated there was no grievance form regarding the missing coat because the replacement coat was purchased for R6 as a Christmas gift. On 3/16/23 at 9:34 a.m., ASM (administrative staff member) #2 (the director of nursing) provided evidence that a coat was purchased on 12/16/22. ASM #2 stated there probably was not a grievance form regarding R6's missing coat because the reporting of missing clothing is a behavior that R6 presents with, and the staff typically accommodates the resident. ASM #2 stated R6 has lost multiple pairs of white pants and the staff has reimbursed the resident. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Resident Grievances and Concerns Policy documented, 3. Investigation. The Grievance Committee/Grievance Official shall complete an investigation of the resident's grievance. This may include a review of facility processes, programs and policies, as well as interviews with staff, residents and visitors, as indicated, and any other review deemed necessary by the Grievance Committee .5. Grievance Decision. Upon completion of the review, the Grievance Official will complete a written grievance decision that includes the following: a. The date the grievance was received. b. A summary of the statement of the resident's grievance. c. The steps taken to investigate the grievance. d. A summary of the pertinent findings or conclusions regarding the resident's concern(s). e. A statement as to whether the grievance was confirmed or not confirmed. f. Whether any corrective action was or will be taken. g. If corrective action was or will be taken, a summary of the corrective action. If corrective action will not be taken, then an explanation of why such action is not necessary .

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide adequate supervision for one of 37 residents in the survey sample, Residents #272. This deficiency is cited as past non-compliance. The findings include: The facility staff failed to have effective interventions implemented to prevent Resident #272 from wandering into other resident rooms. Resident #272 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus, hypertension and adult failure to thrive. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/21/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, which indicated the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, hygiene and bathing; supervision for walking, locomotion, dressing and eating. A review of the annual MDS dated Section E: 0200 A. Physical behavior symptoms exhibited towards others e.g., abusing other sexually. Coded=0 behavior not exhibited. A review of the comprehensive care plan dated 9/11/21, revealed, FOCUS: Resident is at risk for alteration in psychosocial wellbeing related to visitation restrictions, social distancing, and other protective restrictions in facility. Resident enjoys watching Western movies, listening to movies playing doorway bingo and other doorway activities. Impaired cognitive-communication function/impaired thought processes related to mild dementia. INTERVENTIONS: Encourage social activities for additional socialization opportunity. Provide activity items resident requires to complete self-initiated activities. Keep resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Encourage resident to make routine, daily decisions. A review of the social worker (SW) progress noted dated 1/5/22 at 10:19 AM, revealed, Nurse updated SW that resident is taking advantage and rubbing on a female resident. The SW will speak with resident. OSM (other staff member) #1, the director of social work, wrote this note. A review of the social worker progress (OSM #1) note dated 1/5/22 at 10:38 AM, revealed, Talked to resident about acting inappropriate to another resident. The resident was not very happy with SW, but said he understood to stay away. A review of the nursing progress note dated 2/13/22 at 6:31PM, revealed, Resident has been wandering into other resident's rooms. Resident has been redirected multiple times and becomes angry and curses at this writer. Resident said, There's no damn problem with me going in there. They don't mind. Why are you still here? Why don't [you] go home! A review of the nursing progress note dated 3/17/22 at 8:26 PM, revealed, Resident had an incident with a female resident. Police were notified and resident was placed on one-to-one observation. Resident was interviewed by detectives and removed from facility by police. A review of the facility's five-point plan dated 3/17/22, revealed, Root Cause Analysis Results: Unable to determine at this time as no previous sexual behavior documented. Action Items: Head to toe assessment was completed on female resident. RP (responsible party) and physician notified. Resident transferred to ER for evaluation. She will be monitored for any changes in behavior. Male resident was placed on 1:1. RP and police notified. Male was arrested and removed from facility by police officers. Residents with a BIMs of 12 and above were interviewed to determine if they had concerns and felt safe in the facility. Actions completed on 3/17/22. An interview was conducted on 3/14/23 at 4:23 PM with ASM #1, the administrator and ASM #2, the director of nursing. When asked about Resident #272's behaviors, ASM #1 stated, we were aware that he would go through the halls, that he had been redirected. ASM #2 stated, we do that with multiple residents. We were aware he was sometimes going into other people's rooms. For those he was showing interest in, there was a stop sign put up on those resident rooms. When asked if he would respond to the stop sign, ASM #2 stated, he was redirectable. ASM #1 stated, some stop signs were put up. I think I had talked to him a month before the incident (January), and things seemed to have calmed down. When asked to describe actions on 3/17/22, ASM #1 stated, once we realized what had happened, we called the police. We separated them. We put him on 1:1. He acknowledged that he had touched her, and he was arrested. He was sent to the hospital. Survey team conducted multiple interviews of staff on the evening shift. An interview was conducted on 3/14/23 at 5:35 PM with CNA (certified nursing assistant) #2, when asked if she remembered Resident #272, CNA #2 stated, No I do not remember him. An interview was conducted on 3/14/23 at 5:35 PM with RN (registered nurse) #2, when asked to describe Resident #272's behavior, RN #2 stated, Mainly I worked downstairs, when I up there working, he liked to wander, he liked to watch TV in the sitting area by the elevator. He would come back to get snacks then go to his room. When asked if he wandered, what actions were put into place? RN #2 stated, Never remember him going in any other resident's rooms, do not remember any interventions. He was alert and oriented, do not remember any behaviors. An interview was conducted on 3/14/23 at 5:41 PM with CNA #6, when asked if she remembered Resident #272, CNA #6 stated, yes, I used to work with him. He was okay. He was nice. He was chill. Never had a problem with him. Did not have good memory, he could be forgetful. I never witnessed any trouble with being angry toward staff. If he had a problem with someone, he would tell you and that was with staff only. He did not have any problems with other residents. He would wander into other residents' rooms. He was just peeking. We used stop signs to try to keep him out of resident rooms. We would watch where he focused and put up a stop sign. He used to really peek in Resident #74's room a lot. He would sit and stare into her room. We had a stop sign there. We had no idea, that he had any inclination of sexual behaviors. It is the last thing we would ever have expected. An interview was conducted on 3/15/23 at 8:57 AM with CNA #1, when asked what she remembered about Resident #272's behaviors, CNA #1 stated, took care of him on the 3-11 PM shift, he really needed redirected. Trying to go into other resident rooms. When asked to describe events of 3/17/22, CNA #1 stated, we had just laid Resident #74 down. I was at nurses' station talking with the nurse and saw him (Resident #272) speeding out of Resident #74's room. I went down the hall and heard water running in his bathroom and he was washing his hands in his room. He was in the room right across from Resident #74. He acted like nothing happened. He would be very aggressive verbally; he would curse at me and some other staff but not with residents. I got the nurse and unit manager and explained that something had happened. Resident #74's brief was torn open and feces was smeared all over. I stayed late, and they called the police. This was first time of physical contact by Resident #272 and Resident #74 or any female resident to my knowledge. Resident #272 was alert and aware of his surroundings and what was going on, he may have had a little dementia. An interview was conducted on 3/15/23 at 9:25 AM with OSM (other staff member) #3, the physical therapist assistant. When asked if he remembered Resident #272, OSM #3 stated, yes, I know him very well. I never thought anything like would happen. He was always very cordial to me. He was never verbally aggressive to me. I almost thought I was dreaming when I heard about this situation. I remember them blocking the door to Resident #74's room, he had been in the room or looking in the room and they put the stop sign up. If I see anything happening, I address it immediately. An interview was conducted on 3/15/23 at 1:56 PM with RN #3. When asked if she remembered Resident #272, RN #3 stated, yes, he liked to be in his room and in his bed, get up for breakfast, come watch TV and lay down till lunch and go to activities. I never saw him going into any resident rooms. If you tried to redirect him, he would get abrupt with you. I mainly had to redirect him from taking cereal or snacks off of the cart. When asked to describe the events of 3/17/22, RN #3 stated, I was sitting at the nurses' station and CNA #1 was talking with me and I was on the computer and I saw a flash of him going from one side of the hall to the other side. We went down there and you could see, in Resident #74's room, that the sheet was brown and we looked at her, the resident stated I am okay, I am okay, I am alright. She was fidgety. Resident #272 was in the [his] bathroom washing his hands. We told the unit manager and the police were called and we moved the female resident. An interview was conducted on 3/15/23 at 2:15 PM with RN #1, the unit manager. When asked to describe Resident #272's behavior, RN #1 stated, 'he was fine with residents, he would get agitated with redirection, he was a wanderer, he was nosey, would look in rooms, cereal and snack cart. He would raise his voice at times with staff when redirected. He was flirtatious, most of females enjoy that. When asked to describe the event on 3/17/22, RN #1 stated, RN #4 called me and she felt that Resident #272 had done something to Resident #74. I told the administrator. I went to Resident #74's room and saw bowel movement on bedsheet, I asked RN #4 what had happened and she stated that she had seen Resident #272 roll quickly from Resident #74's room to his room across the hall. RN #4 went into Resident #272's room and there was bowel movement smeared in the sink. We sent them both to the hospital as soon as the incident happened. When Resident #74 returned from the hospital we had move her room to the first floor. On 3/15/23 at 6:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing (DON), were made aware of the findings. An interview was conducted on 3/16/23 at 9:58 AM with RN #4. When asked to describe the events of 3/17/22, RN #4 stated, one of the aides had told me that Resident #272 was leaving Resident #74's room. In Resident #74's room there was stool smeared across her bed and her [brief] was torn open and stool was on it. I went to Resident #272's room and saw stool on his hands and in the sink where he was washing his hands. We called the police. A review of the facility's Resident Observation policy dated 5/28/21 revealed, To provide enhanced observation as a temporary safety mechanism during an acute episode where a resident is endangered. Procedure: A) Charge nurse will contact DON who, if necessary, will consult with administrative staff and/or Director of Mental Health, if applicable, to determine the appropriate observation/interventions if resident meets one of the following criteria: 1. Resident is a danger to themselves, to include but not limited to: self-harm; suicidal ideation/threat; 2. Resident is acting out behaviorally, to include but not limited to: throwing items; continuous screaming/disruptive behavior; 3. Resident is a danger to others, to include but not limited to: homicidal comments/threats/actions; 4. Immediate risk of elopement. B) DON will assign a staff member to complete appropriate observation/interventions which may include but are not limited to every 15 or 30 minutes checks or 1:1 monitoring. A review of the facility's five-point plan dated 3/17/22, revealed, Root Cause Analysis Results: Unable to determine at this time as no previous sexual behavior documented. Action Items: Head to toe assessment was completed on female resident. RP (responsible party) and physician notified. Resident transferred to ER for evaluation. She will be monitored for any changes in behavior. Male resident was placed on 1:1. RP and police notified. Male was arrested and removed from facility by police officers. Residents with a BIMs of 12 and above were interviewed to determine if they had concerns and felt safe in the facility. Weekly resident interviews will be conducted with residents with BIMS of 12 and above by the Social worker/designee for 12 weeks. Skin checks of 10 residents with a BIMS of 11 and below will be conducted by director of nursing/designee for 12 weeks. Weekly staff interviews with 10 staff members to ask if any unusual or concerning behaviors occurred. Staff education regarding abuse 3/17/22-3/21/22. Resident Council meeting on 3/18/22 to discuss abuse and reporting of abuse. Discussion at QAPI (quality assurance process improvement) committee on 3/18/22. Actions completed on 3/21/22. This deficiency is cited as past non-compliance. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a urinary catheter for one of 37 residents in the survey sample, Resident #53. The findings include: For Resident #53 (R53), the facility staff failed to secure the resident's urinary catheter bag in a sanitary manner. A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. (1) A review of R53's clinical record revealed a physician's order dated 2/12/23 for a urinary catheter. On 3/15/23 at 8:19 a.m., R53 was observed lying in bed. The resident's urinary catheter bag was secured to the bed frame under the bed and touching the floor. On 3/16/23 at 10:33 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that if a resident is lying in bed, then their urinary catheter bag should hang on a bar under the bed and should not touch the floor because someone could step on it and because of infection. On 3/16/23 at approximately 12:00 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Indwelling Urinary Catheter Care Procedure documented, 10. Check drainage tubing and bag to ensure that the catheter is draining properly, and no kinks are present. The urinary drainage bag must be placed below the bladder level but not on the floor. No further information was presented prior to exit. Reference: (1) https://medlineplus.gov/ency/article/003981.htm

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 37 residents in the survey sample, Resident #26. The findings include: For Resident #26 (R26), the facility staff failed to maintain an accurate ADL (activities of daily living) documentation record for February 2023. On the most recent MDS (minimum data set), a five day admission assessment with an ARD (assessment reference date) of 2/8/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) indicating they were cognitively intact for making daily decisions. Section G documented R26 required extensive assistance of one person for bed mobility and limited assistance of one person for transfers, toileting and personal hygiene. The comprehensive care plan for R26 documented in part, At risk for self care deficit severe sepsis and amputation. Date Initiated: 02/05/2023. A review of the ADL documentation for R26 failed to evidence documentation of personal hygiene, mouth care, bladder and bowel continence, barrier cream application, behavior monitoring, skin observations or toilet use on the evening shift (3:00 p.m. to 11:00 p.m.) on 2/13/2023. On 3/15/2023 at 2:12 p.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that ADL care was documented in the medical record. CNA #3 stated that some of the staff work 12 hour shifts but they still documented the ADL care in eight hour shifts in the medical record. CNA #3 stated that if the ADL documentation was left blank they could not say that the care was not provided, but that it was not documented. On 3/16/2023 at 11:30 a.m., an interview was conducted with CNA #5. CNA #5 stated that they documented ADL care in the computer and had to complete the documentation before they could leave. CNA #5 stated that if the ADL documentation was blank it meant that no one documented anything. CNA #5 stated that if the care was not documented, the record was not complete because it did not show what they did for the resident. The facility policy, Medical Records Storage and Retention Policy dated April 2008 failed to evidence guidance regarding maintaining a complete and accurate medical record. On 3/16/2023 at 11:47 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to properly store medications for one of 37 residents in the survey sample, Resident #59. The findings include: For Resident #59 (R59), the facility staff failed to secure a bottle of Vitamin D 10000 IU (international units) and one bottle of multivitamins in the resident room. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/21/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. On 3/14/2023 at 1:46 p.m., an observation was made of Resident #59's (R59) room. R59 was not in the room at the time however their family member was in the room. R59's family member stated that the resident was in therapy. Observation of R59's room revealed two bottles of medication on top of the nightstand beside the bed. One bottle was labeled Vitamin D 10000 IU and one bottle of multivitamins were observed. On 3/14/2023 at 3:30 p.m., R59 was observed in bed asleep. The bottle of Vitamin D 10000 IU and the bottle of multivitamins remained on top of the nightstand beside the bed. On 3/15/2023 at 8:15 a.m., R59 was observed sitting in the wheelchair in their room. The bottle of Vitamin D 10000 IU and bottle of multivitamins remained on top of the nightstand beside the bed. When asked about the medications, R59 stated that they did not know why they were there. R59 stated that the nurse had brought them down the day before and left them and they were not sure why. R59 stated that they normally took Vitamin D and a multivitamin every day but had not taken any from the bottles and was going to ask the nurse about them when they came in. The physician orders for R59 documented in part, Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for supplement. Order Date: 02/16/2023. Start Date: 02/17/2023. The physician orders further documented, Cholecalciferol Oral Tablet 50 MCG (2000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for supplement. Order Date: 02/16/2023. Start Date: 02/17/2023. A resident self-administration of medication assessment for R59 dated 2/22/2023 documented R59 being a candidate for self-administration of medications. On 3/15/2023 at 1:57 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that medications needed to be secured by keeping them locked up. LPN #4 stated that the medications in R59's room were brought in by the family and they could not keep them on the medication cart because they were not prescribed. LPN #4 stated that when family members brought medications in they were given to the unit manager to be locked up and not left in the room. LPN #4 stated that they had given the Vitamin D and Multivitamin back to the family member to take home on 3/14/2023 and they had left them in the room. LPN #4 stated that they had observed the bottles on the nightstand when they went into the room this morning and they should not have been left there because it was a safety issue. LPN #4 stated that they would remove the medication and follow up with the family to ensure that they would take the medication home. The facility policy, Storage and Expiration Dating of Medications, Biologicals dated 12/01/07 documented in part, .Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should store bedside medications or biologicals in a locked compartment within the resident's room . On 3/15/2023 at 5:06 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to ensure food storage in a safe manner, and failed to clean the kitchen stove. The walk-in refrigerator contained expired milk cartons and pudding. The stove top contained areas of built-up grease that was burned on to the grates, elements, and stove top surface. The stove top also contained ashy material that scraped up easily with a gloved finger. The findings include: On [DATE] at 10:50 a.m., observation was made of the facility kitchen. The walk-in refrigerator contained approximately 1 ,d+[DATE] quarts of a dark brown, thick substance labeled nutritional pudding. The label had an expiration date of [DATE]. The walk in refrigerator also contained 19 individual cartons of milk, all with expiration dates of [DATE]. The stove top contained areas of crusty, black debris, which flaked off easily. Some of the debris had the appearance of ash. The loose debris was easily wiped away with a gloved finger. The stove top and grates contained areas of built-up grease. OSM (other staff member) #1, dietary manager was interviewed during this observation. She stated the milk and pudding were available for resident use, and should have been thrown out on their expiration dates. She stated the debris and grease build-up on the stove were from the current day's use, and would be cleaned at night. She stated the stove top is cleaned every evening after supper, and the grates are soaked in the large sinks and cleaned every night. On [DATE] at 7:47 a.m., observation was again made of the stove top. There were no changes from the previous day's observation. OSM #1 was interviewed at this time, and stated the stove top was dirty. She stated: Like I told you yesterday, we usually clean it every night. She stated she did not clean it last night because I don't have any staff. She stated she needs five people to work in the evenings, and it was just me last night. She stated she just did not get to the stove to clean it. When asked if the stove should have been cleaned of the loose debris and grease build-up, even if it was between a weekly scheduled cleaning, she said it should be. She stated the refrigerator should be checked each evening, and all expired foods should be thrown away. On /,d+[DATE] at 1:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Freezers and Refrigerators, revealed, in part: Food and Nutrition Services Director and staff will be responsible for ensuring food items in refrigerators and freezers are not expired or past perish dates. A review of the facility policy, Kitchen Sanitation and Cleaning Schedule, revealed, in part: Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule A review of the accompanying Closing Checklist for the Evening Cook revealed no daily tasks related to cleaning of the stove. The checklist documented: Wednesday: Take apart stove top & run through dish machine. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff to provide evidence of written notification to the resident and or RP (responsible party) for hospital discharges for four of 28 residents in the survey sample, Residents #67, #14, #35, and #44. The findings include: 1. The facility staff failed to evidence written notification to the RP [responsible party] of Resident #67's discharge to the hospital on 8/19/21. Resident #67 was admitted to the facility on [DATE], and most recently readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/2/21, Resident #67 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). A review of Resident #67's clinical record revealed the following note: 8/19/2021 11:06 a.m. Nursing Note Text: Order received from [name of Nurse Practitioner] to send resident to ER (emergency room ) for [CONDITION(S)] (hypertension) post fall, and the resident's needs can no longer be met in the facility. Res (resident) has been notified that she is going to ER and the reason she is going. Res is unable to voice understanding. Bed hold and care plan goals sent with resident. Resident's RP (responsible party) [name of RP] also notified of the above and of all the documents that accompanied the resident. A copy of the written notice to the resident/RP regarding this discharge was requested. On 8/25/21 at 7:30 a.m., the facility staff provided a packet of materials regarding the discharge. The packet did not contain any evidence that the resident/RP were notified in writing about the discharge. On 8/25/21 at 12:22 p.m., OSM (other staff member) #2, social services director, was interviewed. She stated she does send written notification to the resident/RP. However, OSM #2 stated she could not provide evidence of the notification because she does not keep copies of the letter. She stated she gets receipts for certified mail. On 8/25/21 at 12:28 p.m., OSM #3, social worker, was interviewed. She stated she does not have evidence of written notification of Resident #67's hospital discharge to the RP. When asked if she was aware of the need to have evidence of the notification, OSM #3 stated she did not. On 8/25/21 at 1:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Discharge/Transfer Letter Policy, revealed, in part: The Administrator or designee will complete the appropriate discharge letter utilizing State Specific forms .Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to Department of Health .and filed in the business file and/or scanned into [electronic health record] with certified receipt, if applicable. No further information was provided prior to exit. 2. The facility staff failed to provide Resident # 14 and the resident's representative written notification of a facility-initiated transfer on 05/19/2021 and 06/22/2021 for Resident # 14. Resident # 14 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 14's most recent MDS [minimum data set], a quarterly assessment with an ARD (assessment reference date) of 05/30/2021, coded Resident # 14 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The facility's Progress Note for Resident # 14 dated 05/19/2021 at 3:05 p.m., documented in part, Resident currently transferred to [Name of Hospital] for evaluation of possible GI [gastrointestinal (stomach and intestines)] bleed. The facility's Progress Note for Resident # 14 dated 06/22/2021 at 12:31 p.m., documented in part, Resident noted to have blood in her stool x 2 [times two] and has been loosing [Sic.] weight, GI [gastrointestinal] appointment in July, labs [laboratory tests] obtained 6/21/21 MD [medical doctor] suggest resident go to hospital but resident refused. Education provided to resident and resident agreed to go to ER [emergency room ] for eval [evaluation]. Review of the clinical record and the EHR (electronic health record) for Resident # 14 failed to evidence that a written notification of discharge was provided to the resident and resident's representative for the facility-initiated transfer on 05/19/2021 and 06/22/2021 for Resident # 14. On 08/25/21 at 12:22 p.m., an interview was conducted with OSM [other staff member] # 2, social services director and OSM # 3, social worker. When asked about providing evidence that a written notification to a resident and a resident's representative of a facility initiated transfer OSM # 3 stated, I don't keep copies of the letter, I get receipts for certified mail. I need to work on streamlining that. There is no written information to the resident unless they are their own RP [responsible party]. When asked if they had a certified mail receipt for Resident # 14's facility initiated transfers on 05/18/221 and 06/22/2021, OSM # 3 stated no. On 08/25/2021 at approximately 1:00 p.m., ASM [administrative staff member] #1, the administrator and ASM # 2, director of nursing, were made aware of the above concern. No further information was presented prior to exit. 3. The facility staff failed to provide Resident # 35 and Resident # 35's representative written notification of a facility-initiated transfer on 05/26/2021 for Resident # 35. Resident # 35 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 35's most recent MDS [minimum data set] assessment, a significant change assessment with an ARD (assessment reference date) of 06/25/2021, coded Resident # 35 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. The facility's progress note for Resident # 35 dated 05/26/2021 at 12:40 p.m. documented in part, Order received from [Name of Doctor] to send [Resident # 35] to E.R. [emergency room ] for CT [computerized tomography (x-ray images)] of abdomen .[Name of Transportation Company] picked up resident at 12:12 p.m. to transfer him to [Name of Hospital]. Review of the clinical record and the EHR (electronic health record) for Resident # 35 failed to evidence that a written notification of discharge was provided to the resident and resident's representative for the facility-initiated transfer on 05/26/2021 for Resident # 35. On 08/25/21 at 12:22 p.m., an interview was conducted with OSM [other staff member] # 2, social services director and OSM # 3, social worker. When asked about providing evidence that a written notification to a resident and a resident's representative of a facility initiated transfer OSM # 3 stated, I don't keep copies of the letter, I get receipts for certified mail. I need to work on streamlining that. There is no written information to the resident unless they are their own RP [responsible party]. When asked if they had a certified mail receipt for Resident # 14's facility initiated transfers on 05/18/221 and 06/22/2021, OSM # 3 stated no. On 08/25/2021 at approximately 1:00 p.m., ASM [administrative staff member] #1, the administrator and ASM # 2, director of nursing, were made aware of the above concern. No further information was presented prior to exit. 4. The facility staff failed to provide Resident # 44 and Resident # 44's representative written notification of a facility-initiated transfer on 05/26/2021 for Resident # 44. Resident #44 was admitted to the facility on [DATE]. Resident #44's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44's most recent MDS (minimum data set) assessment, a discharge return not anticipated assessment, with an assessment reference date of 8/10/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. Section O-Special Treatments and Procedures: coded the resident as [CONDITION(S)] 'yes'. A review of the eINTERACT (interventions to reduce acute care transfers) Transfer Form V5 dated 8/10/21, documented in part, Transfer to hospital. Resident sent to the emergency room related to shortness of breath and oxygen saturation dropping from 91% to 71% on room air. Alert but lethargic. Respirations 26. Color pale. A review of the nursing progress note dated 8/10/21 at 5:30 PM, documented in part, Order received from Dr. Clay to send resident to ER [emergency room ] for SOB, low oxygenation, and AMS. Resident and a POA notified of the reason that she was going. Resident agreed, and verbalized understanding. Care plan goals sent with resident. On 8/24/21 at 4:45 PM, evidence of the provision of written notice to the resident/RP (responsible party) and ombudsman for the transfer of Resident #44 to the hospital on 8/10/21, was requested via written request for documents to the facility. Documents provided included: ombudsman notification and the above nursing progress note dated 8/10/21 at 5:30 PM. The facility staff failed to provide any evidence or documentation that Resident # 44 and Resident # 44's representative were provided written notification of Resident #44's facility-initiated transfer on 05/26/2021. An interview was conducted on 8/25/21 at 12:22 PM with OSM (other staff member) #2, social services director. When asked the process to provide written notification of transfer, OSM #2 stated, I do not keep copies of the letter, I get receipts for certified mail. I need to work on streamlining that process. There is no written information to resident unless they are their own RP (responsible party). An interview was conducted on 8/25/21 at 12:28 PM with OSM #3, the social worker. When asked if she had written evidence of documentation provided to Resident #44, who is her own RP, OSM #3 stated, No, I do not have any evidence for her. OSM #3 stated, I am aware that we need to send the letters out, but I did not realize we needed to have evidence of that. On 8/25/21 at 1:00 PM, ASM (administrative staff member) #1, the executive administrator and ASM #2, the director of nursing were made aware of the above findings. A review of the facility's policy Discharge and Transfer policy revised 10/5/17, which documents in part, Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to the Department of Health Ombudsman Office and filed in the business file and/or scanned into PCC (point click care) documents tab with administrator/designee signature, with the certified receipt if applicable. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 133. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 54. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 119.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement infection control practices for one of eight residents in the medication administration observation, Resident #281. The facility staff failed to administer medication in a sanitary manner to Resident #281 on 8/25/21. LPN (Licensed practical nurse) #1 touched and administered a dropped pill to Resident #281 with gloved hands that were worn while touching the medication cart and vital sign machine. The findings include: Resident #281 was admitted to the facility on [DATE]. Resident #281's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #281's admission minimum data set assessment with an assessment reference date of 8/18/21, coded the resident as being cognitively intact. On 8/25/21 at 8:34 a.m. LPN #1 was observed preparing Resident #281's medications with gloved hands. LPN #1 touched the medication cart with gloved hands then touched the vital sign machine with gloved hands while obtaining Resident #281's vital signs. After obtaining Resident #281's vital signs, LPN #1 administered medications to the resident. The resident dropped one pill on a blanket covering her. LPN #1 picked up the pill with the same gloves, placed the pill into the medicine cup and administered the pill to Resident #281. On 8/25/21 at 9:52 a.m., LPN #1 was asked what should be done if a resident drops a pill on his or her bed. LPN #1 stated the pill should be thrown away if it's on the bed for infection control reasons but she did not discard Resident #281's pill because it landed on the resident. LPN #1 was made aware that she was observed touching the medication cart and vital sign machine with the same gloves used to pick up the dropped pill then the pill was administered to Resident #281. LPN #1 stated she wasn't thinking and she was solely using the gloves for Resident #281. LPN #1 stated she did not know if this practice was sanitary. On 8/25/21 at 1:04 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, 6.0 General Dose Preparation and Medication Administration documented, 3.4 Facility staff should not touch the medication when opening a bottle or unit dose package. 3.5 If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one the drug regime for one of 28 residents in the survey sample, Resident #72, was free of unnecessary pain medications. The facility staff administered Tylenol prescribed for Resident #72, for pain scale ratings above below the physician ordered parameters of 1-4 and administered [MEDICATION(S)] for a pain rating 4, for which the physician prescribed Tylenol. The findings include: Resident #72 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The narrowing puts pressure on your nerves and spinal cord and can cause pain.)(4) The Medicare, admission/5-day MDS (minimum data set) with an ARD (assessment reference date) of 8/8/21 coded the resident as being moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, transfers, and bed mobility; supervision for ambulation and eating; was incontinent of bowel. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 MAR (medication administration record) documented the above orders for Acetaminophen and [MEDICATION(S)]. The Acetaminophen was documented as administered on 8/15/2021 at 3:08 p.m. for a pain level of 5. The [MEDICATION(S)] was documented as administered on 8/6/2021 at 4:28 a.m. for a pain level of 4. The comprehensive care plan dated, 8/12/2021, documented in part, Focus: Altercation in musculoskeletal status r/t (related to) dx (diagnosis) Spondylosis with lumbar radiculopathy, spinal stenosis. The Interventions documented in part, Give med (medication) as ordered by the physician. Monitor and document for side effects and effectiveness. An interview was conducted with LPN (licensed practical nurse) #1, on 8/25/2021 at 10:09 a.m. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if the Tylenol should have been given for a pain level of 5, LPN #1 stated, no, it shouldn't have been given. When asked if the [MEDICATION(S)] should have been given for a pain scale of 4, LPN #1 stated, no the Tylenol should have been given An interview was conducted on 8/25/2021 at 10:15 a.m. with RN (registered nurse) #2, the unit manager. The above orders for Tylenol and [MEDICATION(S)] were reviewed with RN #2. When asked if the Tylenol should have been given for a pain level of 5, RN #2 stated, no the order says for pain level of 1-4. When asked if the resident should have received the [MEDICATION(S)] for a pain level of 4, RN #2 stated, no, the Tylenol should have been given for that level of pain. ASM (administrative staff member) #1, administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/25/2021 at 1:02 p.m. The facility policy, General Dose Preparation and Medication Administration documented in part, verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. Confirm that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] References: (1) This information was obtained from the following website: https://medlineplus.gov/enlargedprostatebph.html (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[CONDITION(S)]&_ga=2XXX 3059XXX 2701XXX - XXX (4) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Spinal+stenosis+ (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 4.html (6) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[MEDICATION(S)]

Based on employee record review and staff interview, it was determined that the facility staff failed to perform an annual performance review for one of five CNA (certified nursing assistant) records reviewed. The findings include: On 8/24/2021 at 4:15 p.m., a review of the facility's CNA annual training and performance review was conducted. Review of five CNA transcripts revealed one of five CNAs selected for review did not have an annual performance review. Review of CNA #2's transcript documented a hire date of 6/1/2018. Further review of the transcript documents provided dated 6/1/2020 through 6/1/2021 failed to evidence documentation of an annual performance review. On 8/24/2021 at approximately 4:45 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the annual performance review for CNA #2. ASM #1 stated that CNA #2's annual performance review had not been completed. ASM #1 stated that CNA #2 only worked prn (as needed) and they were not sure when they had last worked. A request was made to ASM #1 for documentation verifying CNA #2's schedule since their anniversary date of 6/1/2021. On 8/25/2021 at approximately 7:30 a.m., ASM #1, the administrator provided the document Time Card Report 06/01/2021-08/24/2021 for CNA #2. It documented CNA #2 working the night shift (10:59 p.m.- 6:03 a.m.) on 7/15/2021. On 8/25/2021 at approximately 11:35 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that a member of the nursing team conducted the CNA performance reviews. ASM #2 stated that human resources notified them during a staff member's anniversary month that the evaluation was due by the end of the month. ASM #2 stated that they conducted the review or delegated to the unit manager if they were more familiar with the staff member. ASM #2 stated that staff who worked as needed were harder to catch up with than full time staff and they had not been able to do CNA #2's performance review because they had only worked one time since their anniversary date. ASM #2 stated that they performed the reviews face to face and they come in early to catch the night shift staff before they left to do the evaluations. ASM #2 stated that the performance evaluations were used to determine education needs if there were issues with the staff member. On 8/25/2021 at approximately 9:15 a.m., a request was made to ASM #1 for the facility policy for employee performance reviews. On 8/25/2021 at approximately 10:00 a.m., ASM #1 stated that the facility did not have a written policy for the employee performance reviews. ASM #1 provided a document titled, Performance Management which documented in part, Performance appraisals will generally be conducted after 90 days of employment and annually thereafter based on your date of hire .The performance appraisal provides a systematic and regular opportunity for you to discuss your work with your department head and to find out how you are developing and where you stand in relation to what is expected of you . On 8/25/2021 at approximately 1:00 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services in a sanitary manner for two of 28 residents in the survey sample, Resident #130 and Resident #72. 1. Resident #130's nebulizer mask and medication delivery tank was observed on separate occasions uncovered when not in use and the residents oxygen tubing was observed uncovered and wrapped around the top of an oxygen tank on the back of the resident's wheelchair. 2. The facility staff failed to store oxygen equipment in a sanitary manner for Resident #72. Nasal cannula tubing was observed uncovered and wrapped around the top of the tank that was not in use, located on the back of Resident #72's wheelchair. The findings include: 1. Resident #130 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) (2), and [CONDITION(S)] (a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria)(3). The [Name of corporation] Admission/Readmission Evaluation dated 8/22/2021 documented in part, 7. LOC (level of consciousness): alert and oriented X4 (person, place, time and situation). 16. One person assist for all ADLs (activities of daily living) except eating. The form documented the use of oxygen via a nasal cannula. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 3 LPM (liters per minute) via nasal cannula every shift for sob (shortness of breath). [MEDICATION(S)] - [MEDICATION(S)] Solution (used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with [CONDITION(S)]) (4) 0.5 - 2.5 MG/3 ML (milligrams per milliliter) 3 ML inhale orally every 6 hours as needed for wheezing. On 8/24/2021 at 11:00 a.m., observation of Resident #130's room, revealed a nebulizer machine sitting on Resident #130's nightstand. The nebulizer mask and the medication delivery container was not covered. Two other observations were made on 08/24/2021 2:21 p.m. and 8/25/2021 at 8:12 a.m., and revealed the nebulizer delivery container and mask were uncovered. On 08/25/2021 at 10:20 a.m. an interview and observation of Resident #130's nebulizer was conducted with LPN (licensed practical nurse) #2. LPN #2 was shown the nebulizer equipment that was uncovered. LPN #2 stated, It [nebulizer mask and medication delivery container] should be covered. Observation was made at this time of Resident #130 in wheelchair with an O2 (oxygen) tank on the back of the wheelchair. There was oxygen tubing wrapped around the tank top. When asked why the tubing was wrapped around the top of the tank, LPN #2 stated that it should be in a bag also and there should be another bag on the concentrator to store the tubing when it's not in use while the resident is hooked up to the tank. LPN #2 stated she needed three bags, one for nebulizer, one for tubing on the tank and one for the tubing on the oxygen concentrator. An interview was conducted with RN (registered nurse) #2, on 08/25/2021 10:29 a.m. When asked about nebulizer equipment storage when not in use, RN #2 stated it should be in a bag. When asked about oxygen tubing storage when not in use, RN #2 stated, it should be in a bag. When asked if oxygen tubing should be wrapped around the top of an oxygen tank on the back of a wheelchair, RN #2 stated, no. The baseline care plan dated, 8/23/2021, documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) dx (diagnosis) pneumonia, pleural effusion and acute hypoxic respiratory failure. The Interventions documented in part, Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Change O2 tubing per facility protocol. Provide oxygen as ordered. The facility policy, Oxygen Administration (all routes) Policy, documented in part, 3. When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag. According to Fundamentals of Nursing, 6th edition, Potter and Perry, 2005, page 780, Box 33-2 Sites for and causes of nosocomial infections Respiratory Tract - Contaminated respiratory therapy equipment. ASM (administrative staff member) #1, administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/25/2021 at 1:02 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) This information was obtained from the following website: https://medlineplus.gov/pneumonia.html (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 3.html 2. The facility staff failed to store oxygen equipment in a sanitary manner for Resident #72. Nasal cannula tubing was observed uncovered and wrapped around the top of the tank that was not in use, located on the back of Resident #72's wheelchair. Resident #72 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The narrowing puts pressure on your nerves and spinal cord and can cause pain.)(4) The Medicare, admission/5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 8/8/21 coded the resident as moderately impaired to make daily cognitive decisions. Resident #72 was coded as requiring extensive assistance for bathing, hygiene, toileting, dressing, transfers, and bed mobility; supervision for ambulation and eating; and as incontinent of bowel. Observation was made of Resident #72 on 8/25/2021 at 08:06 a.m. The resident was up in the wheelchair with oxygen on via a nasal cannula connected an oxygen concentrator that was running. Observation of the oxygen concentrator flow meter revealed the oxygen flow rate was set at 2 LPM (liters per minute). An oxygen tank was observed on the back of the wheelchair, not in use with nasal cannula tubing wrapped around the top of the tank, uncovered. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 2 LPM (liters per minute) via nasal cannula as needed. The comprehensive care plan for Resident #72, dated, 8/11/2021, documented in part, Focus: The resident has impaired cardiovascular status r/t (related to) high blood pressure, blood loss, and heart disease. The Interventions documented in part, Oxygen as ordered by the physician. An interview was conducted with LPN (licensed practical nurse) #1 on 8/25/2021 at 10:12 a.m. When the tubing wrapped around the oxygen tank located on the back of Resident #72's wheelchair was described to LPN #1, she stated the tubing should be stored in a bag when not in use. An interview was conducted with RN (registered nurse) #2, on 08/25/2021 10:29 a.m. When asked if oxygen tubing should be wrapped around the top of an oxygen tank on the back of a wheelchair, RN #2 stated, no. ASM (administrative staff member) #1, administrator, and ASM #2, the director of nursing, were made aware of the above concern on 8/25/2021 at 1:02 p.m. No further information was provided prior to exit. References: (1) This information was obtained from the following website: https://medlineplus.gov/enlargedprostatebph.html (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55. (3) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=[CONDITION(S)]&_ga=2XXX 3059XXX 2701XXX - XXX (4) This information was obtained from the following website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=Spinal+stenosis+

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #8. The facility staff failed to implemented Resident #8's comprehensive care plan for maintaining the resident's call bell within reach. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's quarterly minimum data set with an assessment reference date of 5/17/21, coded the resident's cognition as moderately impaired. Section G coded Resident #8 as requiring limited assistance of two or more staff with bed mobility and as requiring extensive assistance of one staff with transfers. Resident #8's comprehensive care plan dated 2/16/17 documented, Self-care deficit. Resident has dx (diagnosis) Muscle Weakness, [CONDITION(S)], CAD ([CONDITION(S)]), Psychotic Disorder and Dementia. Keep call bell in reach . On 8/24/21 at 12:04 p.m. and 12:47 p.m., Resident #8 was observed lying in bed watching television. The resident's call bell was under the bed and out of the resident's reach. On 8/24/21 at 12:47 p.m., CNA (certified nursing assistant) walked into Resident #8's room, served a lunch tray, exited the room, obtained tea, walked back into the room, placed the tea on the table then exited the room. CNA #1 did not pick up the call bell from under the bed. On 8/25/21 at 10:08 a.m., an interview was conducted with CNA #1. CNA #1 stated call bells should be kept within residents' reach and CNAs round at least every two hours to make sure call bells are in place. CNA #1 stated she checks call bells each time she is in a resident's room. CNA #1 stated Resident #8 does sometimes use the call bell but it may become unclipped from the sheet and fall off the bed if the resident gets up. CNA #1 stated she could not remember if she observed Resident #8's call bell while serving lunch on 8/24/21. On 8/25/21 at 10:25 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is to plan the resident's care. RN #1 stated that in order to implement a resident's care, nurses and CNAs would have to read and follow the care plan but many care planned items are present in physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/25/21 at 1:04 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Comprehensive Care Planning documented, D) All staff must be familiar with each resident's Care Plan and all approaches must be implemented. No further information was presented prior to exit. A review of the facility's policy Discharge and Transfer policy revised 10/5/17, which documents in part, Social Services or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to the Department of Health Ombudsman Office and filed in the business file and/or scanned into PCC (point click care) documents tab with administrator/designee signature, with the certified receipt if applicable. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 133. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 54. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 119.

Based on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 28 current residents in the survey sample, Resident #430. The facility failed to develop a baseline care plan to address the physician prescribed anticoagulant medication [MEDICATION(S)] and monitoring for the medication for Resident #430 upon admission. The findings include: Resident #430 was admitted to the facility on [DATE]. Resident #430's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #430's most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an assessment reference date of 8/19/21, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as supervision with eating; extensive assistance with transfer, bed mobility, dressing, hygiene, bathing and locomotion. Walking did not occur. MDS Section H- Bowel and Bladder: coded the resident as occasionally incontinent for bowel and always incontinent for bladder. A review of Resident #430's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 5 milligram tablet, give 1 tablet by mouth one time a day every Tuesday, Thursday, Saturday Sunday for blood thinner. A review of the MAR (medication administration record) documented administration of [MEDICATION(S)] 5 milligram and [MEDICATION(S)] 2.5 milligram as ordered from 8/14/21-8/25/21. [MEDICATION(S)] was held per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #430's baseline care plan dated 8/13/21, failed to document or address the administration of and monitoring for the prescribed anticoagulant medication. The baseline care plan, documented in part, FOCUS-The resident has a pacemaker related to [CONDITION(S)]. The resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . INTERVENTIONS-Assess/document/report to physician as needed any signs or symptoms of infection at incision site: redness, drainage and warmth. Monitor/document/report to physician as needed any signs or symptoms of [CONDITION(S)]. Oxygen therapy and give medications as ordered. A review of the baseline care plan checklist dated 8/20/21, documented in part, Once the baseline care plan is completed, the resident and their representative will receive at least a summary of the baseline care plan that includes the following: (check off below items that were shared with resident/resident representative): a list of the resident's medications, therapy orders and dietary instructions given with explanation to resident/resident representative (print out orders and/or MARs 'medication administration record'). There was a check mark by a list of the resident's medications. A review of the nursing progress noted dated 8/16/20 at 12:44 PM, documented in part, Most Recent Admission: 08/13/2021 12:44 PM. Check List: Summary of resident's medication, therapy orders, and dietary instructions shared. Social service needs and recommendations shared with resident/resident representative. PASARR recommendations shared with resident/resident representative. Baseline care plan given to resident/resident representative. Name of Resident and/or Representative Receiving 48 hour baseline care plan: Self and daughter Received on: 08/20/2021. An interview was conducted on 8/25/21 at 9:40 AM with RN (registered nurse) #2, the unit manager. When asked if anticoagulants should be on the care plan, RN #2 stated, Yes, anticoagulants should be on the care plan. RN #2 was shown the provided printed baseline care plan for Resident #430. RN #2 stated, Yes, this is the baseline care plan. I do not see it here [on Resident #430's baseline care plan]. Let me look up the comprehensive care plan, which will be done once he is here for 21 days. RN #2 stated, Oh here it is anticoagulant. When asked if [MEDICATION(S)] a high risk medication should it be addressed/included in the baseline care plan, RN #2 stated, Well, the care plan is to provide what care is needed for the resident. An interview was conducted on 8/25/21 at 9:53 AM with ASM (administrative staff member) #2, the director of nursing. When asked if anticoagulants should be included in the baseline care plan, ASM #2 stated, No, anticoagulants are not included in the baseline care plan. We just focus on falls, pressure/skin, nutrition, and ADL's (activities of daily living) and there is one other focus for the baseline care plan. Anticoagulants would be addressed in the comprehensive care plan. Purpose of the baseline care plan is to give a basis of care for the resident. An interview was conducted on 8/25/21 at 10:27 AM with RN #1, the MDS coordinator. When asked the purpose of the baseline care plan, RN #1 stated, Baseline care plan includes the basic items and a resident's orders. We do try to make sure everything is on the baseline care plan and we definitely make sure it is on the comprehensive care plan. On 8/25/21 at 1:00 PM AM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the above findings. The facility's Interim/Baseline Care Planning policy dated 8/11/20, documents in part, Within 48 hours of admission, the facility will develop and implement and interim/baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident until a comprehensive assessment can be completed, leading to a comprehensive care plan. The baseline care plan will include the minimum healthcare information necessary to care for a resident including but not limited to: initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 133. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 259. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 427. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 119.(5) 2019 Lippincott Pocket Drug Guide for Nurses, Wolters Kluwer, page 406.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a call bell within reach for one of 28 residents in the survey sample, Resident #8. The facility staff failed to maintain Resident #8's call bell within reach on 8/24/21. Resident #8 was lying in bed and the resident's call bell was on the floor under the bed. The findings include: Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's quarterly minimum data set assessment with an assessment reference date of 5/17/21, coded the resident's cognition as moderately impaired. Section G coded Resident #8 as requiring limited assistance of two or more staff with bed mobility and as requiring extensive assistance of one staff with transfers. On 8/24/21 at 12:04 p.m. and 12:47 p.m., Resident #8 was observed lying in bed watching television. The resident's call bell was under the bed and out of the resident's reach. On 8/24/21 at 12:47 p.m., CNA (certified nursing assistant) #1 walked into Resident #8's room, served a lunch tray, exited the room, obtained tea, walked back into the room, placed the tea on the table then exited the room. CNA #1 did not pick the call bell up from under the bed. On 8/25/21 at 10:08 a.m., an interview was conducted with CNA #1. CNA #1 stated call bells should be kept within residents' reach and CNAs round at least every two hours to make sure call bells are in place. CNA #1 stated she checks call bells each time she is in a resident's room. CNA #1 stated Resident #8 does sometimes use the call bell but it may become unclipped from the sheet and fall off the bed if the resident gets up. CNA #1 stated she could not remember if she observed Resident #8's call bell while serving lunch on 8/24/21. On 8/25/21 at 1:04 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Communication System and Call light policy documented, It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas. The facility responds to resident needs and requests. No further information was presented prior to exit.

Based on clinical record review, staff interview, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for one of eight residents in the survey sample, Resident #8. The findings include: Resident #8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/16/2020, coded Resident #8 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section G coded Resident #8 as requiring extensive assistance of two or more persons with bed mobility and transfers and one person for toileting. Section H documented Resident #8 as always being incontinent of the bladder and frequently incontinent of bowel. Resident #8 no longer resided at the facility and could not be observed during the survey dates. Review of the Admission/Readmission Evaluation dated 10/14/2020 20:00 (8:00 p.m.) for Resident #8 documented the resident having a pacemaker and having generalized [CONDITION(S)] (swelling) on admission. On 4/28/2021 at approximately 9:45 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the baseline and comprehensive care plan for Resident #8. On 4/28/2021 at approximately 10:30 a.m., ASM #2 provided a copy of Resident #8's care plan. ASM #2 stated that the baseline care plan was developed on admission and the comprehensive care plan was built on the baseline care plan so it was all contained in one document. The comprehensive care plan for Resident #8 dates initiated of 10/15/2020 and 10/20/2020 failed to evidence documentation for a focus on Resident #8's kidney disease, pacemaker or heart failure. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - ACE Wraps (compression bandage) to BLE (bilateral lower extremities) QAM (every morning) one time a day for [CONDITION(S)] and remove per schedule. Order Date: 10/18/2020 . - Weight on admission and then weekly x 4 (for four weeks). one time a day for monitoring for 3 days and one time a day every Mon (Monday) for monitoring. Order Date: 10/15/2020. - [MEDICATION(S)] Tablet (diuretic) (4) 80 MG (milligram) Give 80 mg by mouth one time a day for HF (heart failure); fluid retention. Order Date: 10/14/2020. The Progress Notes documented in part the following: - 10/14/2020 20:00 (8:00 p.m.) Admission.[CONDITION(S)] is present Generalized [CONDITION(S)], pacemaker . - 10/16/2020 23:40 (11:40 p.m.) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .Past medical history: .Cardiac pacemaker placement . CHF (congestive heart failure) Monitor input and output .CKD ([CONDITION(S)]) Avoid nephrotoxic (damaging to the kidney) medication, Follow BMP (basic metabolic panel) (laboratory test), Afib ([CONDITION(S)] fibrillation) (5), Denies any palpitation, Continue home medication, Patient denies any chest pain, shortness of breath, Follow patient vitals . - 10/17/2020 15:00 (3:00 p.m.) Baseline Care Plan Checklist .Summary of residents medication, therapy orders, and dietary instructions shared. Social service needs and recommendations shared with resident/resident representative. Baseline care plan given to resident/resident representative. Name of Resident and/or Representative Receiving 48 hour baseline care plan: wife Recieved on: 10/21/2020. - 10/18/2020 11:24 (11:24 a.m.) physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . +1 pitting [CONDITION(S)] (6) to BLE (bilateral lower extremities) .[CONDITION(S)]: States he typically has some [CONDITION(S)] to legs. Start ACE wraps to BLE QAM (every morning) for 12H (twelve hours) . On 4/28/21 at approximately 8:10 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that residents with a history of heart failure were monitored for weight gain and had interventions in place for [CONDITION(S)] ordered by the physician. RN #1 stated that residents with a history of heart failure were weighed daily at 7:00 a.m. On 4/28/21 at approximately 9:13 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that residents with a history of heart failure were monitored for shortness of breath, weight gain and swelling. LPN #1 stated that weights were completed daily to monitor for weight gain. LPN #1 stated that any significant weight gain was called to the physician or nurse practitioner immediately. LPN #1 stated that they reported a weight gain of three to five pounds in one day as a significant weight gain. On 4/28/21 at approximately 10:30 a.m., an interview was conducted with RN #3. RN #3 stated that weights were completed daily for residents with a history of heart failure and the physician was notified of a weight gain of three to five pounds within a week. RN #3 stated that residents who were prescribed diuretics were monitored for urination, weights and with lab testing. On 4/28/21 at approximately 3:00 p.m., a request was made to ASM #2, the director of nursing for the facility policy/procedure that staff follows for monitoring residents with a history of heart failure and to speak with the staff member responsible for developing and revising care plans. On 4/28/21 at approximately 3:30 p.m., an interview was conducted with RN #6, MDS coordinator. RN #6 stated that they completed the MDS for a resident and then follow up with the care plan to ensure that it is complete. RN #6 stated that when a resident was admitted to the facility the admitting nurse developed a preliminary care plan which they followed up with and completed. RN #6 stated that they reviewed the resident's diagnosis, medications that were prescribed, complications, behavioral concerns and any MDS triggers identified when completing the comprehensive care plan. RN #6 stated that the care plan should address heart failure, pacemaker and kidney disease. RN #6 stated that the staff use the care plan to manage the residents care. RN #6 stated that they had reviewed Resident #8's care plan and the heart failure, pacemaker and kidney disease were not addressed. RN #6 stated that they should have been on the care plan. On 4/28/21 at approximately 4:00 p.m., ASM #2 provided the facility policy, COVID-19 (7) Transitional Weight Protocol dated 6/2/2020. ASM #2 stated that they were following the policy during the timeframe that Resident #8 was in the facility. The policy documented in part, .Newly admitted residents on the observation unit will have an admission weight taken, weekly weights will resume per policy once isolation is completed. Take extra care with newly admitted residents who are on isolation pending COVID-19 status confirmation. Residents diagnosed with CHF or other conditions that warrant closer weight monitoring should be reviewed by DON (director of nursing) and physician with the goal of taking fewest weights possible to observe status while minimizing resident exposure to common areas. This weight monitoring will be individualized based on resident condition and will include parameters of weight change that will trigger an intervention or MD (medical doctor) notification . ASM #2 also provided a copy of the document, Heart Failure dated 11/19/2019 and stated that the nurses use as an educational document. The documented provided educational information directed towards the patient, however it failed to document guidance for staff on monitoring residents with a history of heart failure. On 4/29/21 at approximately 10:45 a.m., ASM (administrative staff member) #1, the administrator, ASM #4, the regional quality director and LPN #2, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. [CONDITION(S)]: Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. 2. Heart failure: A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. 3. Pacemaker: A pacemaker is a small, battery-operated device. This device senses when your heart is beating irregularly or too slowly. It sends a signal to your heart that makes your heart beat at the correct pace. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm 4. Diuretic: Diuretics help your body get rid of extra fluid. They are often called water pills. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 2.htm 5. [CONDITION(S)] fibrillation: A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html> 6. Pitting [CONDITION(S)]: Pitting [CONDITION(S)] occurs when fluid collects in the tissue. By pressing a thumb or finger firmly against the tissue for a few seconds, a dent can be produced. When the finger is withdrawn the dent may persist for several minutes. This information was obtained from the website: https://medlineplus.gov/ency/imagepages/2916.htm 7. COVID-19 is caused by a coronavirus called [CONDITION(S)]-CoV-2. Coronaviruses are a large family of viruses that are common in people and may different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people. This occurred with [NAME]-CoV and [CONDITION(S)]-CoV, and now with the virus that causes COVID-19. The [CONDITION(S)]-CoV-2 virus is a betacoronavirus, like [NAME]-CoV and [CONDITION(S)]-CoV. All three of these viruses have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir. However, the exact source of this virus is unknown. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#How-COVID-19-Spreads

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the Advanced Directives policy to ensure periodic reviews with resident and/or responsible party, were provided to formulate Advance Directives, or, if applicable, make changes to their existing Advance Directives or maintain them as written, for seven of 40 residents in the survey sample, Residents #22, #15, #30, #20, #57, #36, and #14. The findings include: 1. Resident #22 did not have any Advance Directives, the facility staff failed to conduct a periodic review to determine if the resident or responsible party wished to develop Advance Directives later. Resident #22 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/15/19 coded the resident as severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record failed to reveal the presence of any Advance Directives. Further review revealed that the resident/responsible party were provided with information for developing Advance Directives around the time of admission, dated 3/14/18. Review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to provide an opportunity and determine if the resident and or RP (responsible party) wished to develop an Advance Directives later. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them (Advanced Directives), only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon Admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 2. The facility staff failed to conduct a periodic review to determine if the Resident #15 or the responsible party wished to make any changes and or maintain the Advance Directives as written. Resident #15 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19, coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive care for mobility, transfers, dressing, hygiene, and toileting; limited assistance for bathing; and supervision for eating. A review of the clinical record revealed the presence of Advance Directives in the resident's chart, dated 10/20/12. Further review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to determine if, and provide opportunity for, making any changes to the resident's existing Advance Directives. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them (Advanced Directives), only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon Admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 3. Resident #30 did not have any Advance Directives, the facility staff failed to conduct a periodic review to determine if the resident or responsible party wished to develop Advance Directives later. Resident #30 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) coded the resident as being moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive assistance for transfers, mobility, dressing, toileting and hygiene; and supervision for eating. A review of the clinical record failed to reveal the presence of any Advance Directives. Further review revealed that the resident and/or responsible party were provided with information for developing Advance Directives at the time of admission, dated 8/2/17. Review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to determine if, and provide opportunity for, the development of Advance Directives later. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them (Advanced Directives), only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon Admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 4. The facility staff failed to conduct a periodic review to determine if the Resident #20 or the responsible party wished to change anything or maintain the Advance Directives as written. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/13/19, coded the resident as cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing, extensive assistance for transfers, mobility, dressing, toileting and hygiene; and supervision for eating. A review of the clinical record revealed the presence of Advance Directives in the resident's chart, dated 3/27/14. Further review of the clinical record failed to reveal any evidence that the resident's Advance Directives status was periodically reviewed with the resident/responsible party, to determine if, and provide opportunity for, making any changes to the resident's existing Advance Directives. On 9/5/18 at 4:32 PM, an interview was conducted with OSM #1 (Other Staff Member) Social Services. When asked about periodic review of residents Advance Directives, OSM #1 stated that it (advanced directives) is reviewed and documented in the care plan meetings. OSM #1 was informed that only code status was noted on the care plan meeting documentation and was asked about reviews of Advanced Directives. OSM #1 stated that only the code status is reviewed, the Advance Directives are not. OSM #1 was asked if she periodically reviews Advance Directives with residents who do not have one in place to determine if they wish to develop one, or to determine if a resident with an Advance Directives, wishes to change anything. OSM #1 stated, No, we only review code statuses. When asked , if she reviews their Advance Directives with residents that are newly admitted , OSM #1 stated she does not review them (Advanced Directives), only the code status. When asked if, Advance Directives are discussed during the first care plan meeting, OSM #1 stated only code status is discussed. On 9/6/19 at 8:02 AM, an interview was conducted with OSM #4, the Admissions Coordinator. OSM #4 was asked if newly admitted residents are provided any information on Advance Directives. OSM #4 stated, Yes, and I will ask them if they have one, and if so get a copy into the medical record. OSM #4 stated, I ask them if they know what an Advance Directive is and provide them information on it, and if they want to execute one, I direct them to the Social Worker or Administrator. When asked how the facility evidence the resident was provided with information on Advance Directives, OSM #4 stated, they are given a facility handbook which contains information on Advance Directives and they sign a receipt that they are given the handbook. She also provided pages from the resident's admission agreement that reflected that the resident was offered information and opportunity about developing Advance Directives. When asked about periodically reviewing the Advance Directives with residents to see if they wish to formulate one and or make any changes, OSM #4 stated, That is done in the meetings with the social worker (care plan meetings). I don't have anything to do with that. A review of the facility policy, Advance Directives Protocol documented, Written instructions about future medical care should you become unable to make decisions .These are also called healthcare directives. Upon Admission and during Your Path Meetings, advance directives will be discussed with resident and/or resident representative to determine if any advance directives have be {sic} chosen Advance directives will be reviewed at minimum annually according to MDS schedule On 9/6/19 at 10:15 AM, ASM #1 (Administrative Staff Member), the Administrator, was notified of the concern. No further information was provided. 5. The facility staff failed to periodically review Resident #36's (or the resident's representative) decisions regarding advance directives. Resident #36 was admitted to the facility 12/03/2010 with a readmission on 04/20/2016 with diagnoses, that included but were not limited to heart failure (1) and [MEDICAL CONDITION] (2). Resident #36's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/17/19, coded Resident #36 as scoring a 6 (six) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 6- being severely impaired for making daily decisions. Review of Resident #36's clinical record failed to reveal documentation of periodic review regarding advance directives. The comprehensive care plan for Resident #36 dated 07/26/2019 documented, Resident has chosen full code status. Date Initiated: 01/19/2018 Revision on: 01/19/2018. Under Interventions, it documented, Review per routine with resident and/or responsible party. Date Initiated 01/19/2018. Revision on: 01/19/2018. On 9/5/19 at approximately 4:40 p.m., a request was made to OSM #1 for any evidence of documentation of review of Advance Directives for Resident #36. On 9/6/19 at approximately 8:15 a.m., a request was made to OSM #4 for any evidence of documentation of review of Advance Directives for Resident #36. On 9/6/19 at approximately 9:00 a.m., a document titled, Acknowledgment of Receipt for Resident #36 was provided by OSM #4. Review of the document revealed a date of 12/3/2010 with the representative for Resident #36's signature acknowledging receipt of the facility's resident handbook. It documented, vi. Facility's Advance Directive Policy and explanation of Resident rights concerning Advance Directives . On 9/6/19 at approximately 10:00 a.m., ASM (administrative staff member) #1, the administrator provided the document Care Plan Conference Notes dated 8/11/19 for Resident #36. The document revealed DNR Status: Full Code but failed to evidence periodic review of Advance Directives for Resident #36. On 9/06/19 at approximately 10:20 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services, were made aware of the findings. No further information was provided prior to exit. References: 1. Heart failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. 2. [MEDICAL CONDITION] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 6. The facility staff failed to periodically review Resident #14's (or the resident's representative) decisions regarding advance directives. Resident #14 was admitted to the facility 08/22/2017 with diagnoses, that included but were not limited to repeated falls and muscle weakness generalized. Resident #14's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 06/08/19, coded Resident #14 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being cognitively intact for making daily decisions. On 9/04/19 at approximately 12:30 p.m., an interview was conducted with Resident #14. When asked if he is participates in his plan of care, Resident #14 stated that he has gone to meetings but not always. When asked if advanced directives are discussed with him at the meetings or at any other time, Resident #14 stated that he did not think so or did not remember it being discussed. Review of Resident #14's clinical record failed to reveal documentation of periodic review regarding advance directives. The comprehensive care plan for Resident #14 dated 07/26/2019 documented, Resident has full code. Date Initiated: 05/15/2018. Under Interventions, it documented, Review annually, PRN (as needed) with resident and/or responsible party. Date Initiated: 05/15/2018. On 9/5/19 at approximately 4:40 p.m., a request was made to OSM #1 for any evidence of documentation of review of Advance Directives for Resident #14. On 9/6/19 at approximately 8:15 a.m., a request was made to OSM #4 for any evidence of documentation of review of Advance Directives for Resident #14. On 9/6/19 at approximately 9:00 a.m., a document titled, Admission Agreement Signature Page for Resident #14 was provided by OSM #4. Review of the document revealed a date of 08/24/17 with Resident #14's signature. It documented, 13. A written summary of the FACILITY Advance Directive policy. (App. C). I have not executed an Advanced Directive. The documented failed to evidence periodic review of Advance Directives. On 9/6/19 at approximately 10:00 a.m., ASM (administrative staff member) #1, the administrator provided the document Care Plan Conference Notes dated 618 for Resident #14. The document revealed DNR Status: Full Code but failed to evidence periodic review of Advance Directives for Resident #14. On 9/06/19 at approximately 10:20 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #5, the regional director of clinical services, were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement interventions to prevent falls for three of 16 residents in the survey sample, Residents #103, 102 and 109. 1. For Resident #103, the facility staff failed to ensure a physician ordered chair alarm was in place. 2. The facility staff failed to provide a physician-ordered wheelchair alarm for Resident #102. 3. The facility staff failed to provide a physician-ordered wheelchair alarm for Resident #109 The findings include: 1. Resident #103 was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #103's most recent MDS (minimum data set), a 14 day Medicare assessment, with an ARD (assessment reference date) of 8/12/13 coded the resident as being cognitively intact. Resident #103 was coded as requiring extensive assistance of one staff member with bed mobility, transfers and toileting. Section J1800 documented, "Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent? 0. No." Review of Resident #103's clinical record revealed a nurse's note dated 7/24/13 that documented, "Resident heard yelling 'Help, help.' Writer arrived to room to find Resident laying on (R) (right) hip, on roomates (sic) side of room. When investigating cause of incident, Resident stated she was trying to get roomate (sic) out of Room, and to breakfast. Resident rose from her wheelchair to propel Roomate (sic), but stated she slipped, causing her to lose balance and fall..." Further review of nurse's notes revealed that on that date, Resident #103 was sent to the local emergency department. Review of Resident #103's hospital history and physical dated 7/25/13 documented a [DIAGNOSES REDACTED]. Review of facility nurse's notes revealed the resident was readmitted to the facility on [DATE]. Review of a fall risk assessment dated [DATE] documented, "TOTAL SCORE: 10. A SCORE OF TEN OR MORE MAY REPRESENT HIGH RISK FOR FALLS. Fall interventions should be initiated immediately and documented on the care plan..." Review of a physical therapy progress report dated 9/2/13 documented, "Background. Precautions: R (right) hip is PWB (partial weight bearing), fall risk..." Review of Resident #103's initial-admission care plan documented, "Date of Admission: 7/29/13. Falls/Safety/Elopement: Will remain free of injury and falls; chair alarm..." Review of Resident #103's comprehensive care plan initiated on 8/7/13 documented, "Focus: Risk for falls characterized by history of falls, injury, and/or multiple risk factors related to: poor coordination, unstable health condition, hx (history) of fall with fx (fracture). Goals: Minimize fall related injuries through next review. Interventions: Provide assistance with toileting as needed..." The "Interventions" column failed to document information regarding a chair alarm. Review of Resident #103's September 2013 physician's orders [REDACTED]. Review of the clinical record from Resident #103's readmission on 7/29/13 to 9/5/13 failed to reveal any documentation that the resident was non-compliant or refused the chair alarm. Review of Resident #103's September 2013 TAR (treatment administration record) documented, "8/23/13- CHAIR ALARM- CHECK FOR PLACEMENT AND FUNCTION EVERY SHIFT..." Initials were documented for each shift September 1, 2013 through the 7:00 a.m. to 3:00 p.m. shift on September 5, 2013 indicating the resident's chair alarm had been checked for placement and function every shift on those dates. On 9/5/13 at 10:15 a.m., Resident #103 was being propelled in her wheelchair from her room to the second floor day room by OSM (other staff member) #10, the activities assistant. No chair alarm was observed on her wheelchair. On 9/5/13 at 10:55 a.m., Resident #103 was observed sitting in her wheelchair in the second floor day room. No chair alarm was observed on her wheelchair. On 9/5/13 at 1:55 p.m., Resident #103 was observed in her wheelchair, propelling herself out of her bathroom. No chair alarm was observed on her wheelchair. The resident stated she had just used the restroom. When asked if staff ever apply an alarm to her wheelchair, Resident #103 stated, "No." On 9/5/13 at 2:25 p.m., Resident #103 was observed sitting in her wheelchair in her room. No chair alarm was observed on her wheelchair. On 9/5/13 at 2:40 p.m., an interview was conducted with CNA (certified nurse's aide) #5, the CNA caring for Resident #103 that shift. CNA #5 stated CNAs and nurses are responsible for ensuring the proper safety devices are in place for each resident. CNA #5 stated she was not aware of any safety devices that Resident #103 was supposed to have in place. This surveyor and CNA #5 reviewed the resident's kardex report. The kardex report failed to document a chair alarm was supposed to be in place for Resident #103. On 9/5/13 at 3:00 p.m., an interview was conducted with LPN #10, the nurse caring for Resident #103 since approximately 1:50 p.m. that day. LPN #10 stated CNAs and nurses are responsible for ensuring the proper safety devices are in place for each resident. LPN #10 reviewed Resident #103's TAR and stated the resident was supposed to have a chair alarm in place. On 9/5/13 at 3:05 p.m., observation of Resident #103 was conducted. The resident was sitting in her wheelchair in the dining room listening to music. LPN #10 confirmed no chair alarm was in place. LPN #10 stated, "I am going to go get her one now." On 9/5/13 at 6:00 p.m., ASM (administrative staff member) #1, the Administrator and ASM #4, the Director of Nursing were made aware of the above findings. ASM #1 stated the nurses and unit managers are responsible for updating the kardex reports. On 9/6/13 at approximately 8:00 a.m., further review of Resident #103's clinical record was conducted. A nurse's note dated 9/5/13 at 10:00 p.m. documented the resident was tearful and stated she didn't want or need an alarm on her wheelchair. A physician's orders [REDACTED]. On 9/6/13 at 8:55 a.m., an interview was conducted with LPN #5, the unit manager. LPN #5 stated every morning she tries to update the kardex reports when she is updating care plans. LPN #5 stated, "I am not 100 percent perfect." On 9/6/13 at 9:45 a.m., an interview was conducted with LPN #4, the nurse caring for Resident #103 on 9/5/13 from approximately 7:00 a.m. until approximately 1:50 p.m. and the nurse who signed off the resident's chair alarm on the TAR for the 7:00 a.m. to 3:00 p.m. shift on 9/5/13. LPN #4 stated that on 9/5/13 at 7:30 a.m., she observed a chair alarm on Resident #103's wheelchair but that was the last time she saw the alarm because the resident goes to a lot of activities. On 9/6/13 at 10:30 a.m., an interview was conducted with ASM #1 regarding who is responsible for monitoring alarms. ASM #1 stated charge nurses are responsible for monitoring alarms but department heads also conduct rounds two to three times a day to monitor rooms and ensure alarms are in place. When asked if activity employees are aware of residents who should have alarms in place, ASM #1 stated the activities director is aware and the activities assistants should be in-serviced. The facility policy titled "Fall Evaluation and Management" documented in part, "Policy: All residents will be assessed for fall risk and interventions will be initiated to decrease fall risk and potential injury. Resident falls will be analyzed and interventions will be established/modified to reduce future risk. All resident falls will be reviewed by members of the interdisciplinary team to determine if interventions are appropriate and monitor facility trends..." In "Fundamentals of Nursing" 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates." No further information was presented prior to exit. 2. The facility staff failed to apply a physician-ordered wheelchair alarm for Resident #102. Resident #102 was admitted to the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED].*C. Diff, pulmonary hypertension, diabetes, atrial fibrillation, rheumatoid arthritis, depression and congestive heart failure. Because the resident was recently admitted to the facility, there was no MDS (minimum data set) available for review. A review of the ADL (activities of daily living)tracking form for Resident #102 for the month of September 2013 revealed that Resident #102 was totally dependent on the assistance of two staff members for bed mobility, transferring from bed to chair, dressing, toileting, personal hygiene and bathing. The admitting nurse's note on 9/3/13 states: "Res (resident) alert & (and) oriented & able to make needs known." On 9/4/13 at 2:35 p.m., Resident #102 was observed in a wheelchair in the hallway outside his room. A CNA (certified nursing assistant) was pushing the resident back into his room. No wheelchair alarm was visible. On 9/5/13, Resident #102 was observed at multiple times throughout the morning and afternoon: 8:45 a.m., 10:25 a.m., 11:45 a.m., 2:25 p.m., and 3:15 p.m. At each observation, Resident #102 was seated in a wheelchair in his room. No chair alarm was visible on Resident #102's wheelchair during any of these observations. A review of Resident #102's clinical record revealed the following order, dated 9/3/13, signed by the physician on 9/4/13: "Falling Leaf program. Chair alarm when in chair; check placement q (each) & functioning q shift." A review of the Resident Care Card for Resident #102 revealed the following documentation under the box labeled "Other Instructions:" "Falling Leaf. Bed, chair alarm." A review of the Initial Care Plan for Resident #102 revealed the following, dated 9/4/13: "Bed/chair alarm." On 9/5/13 at 3:15 p.m., RN #1 accompanied the surveyor into Resident #102's room. RN (registered nurse) #1 was asked to locate the wheelchair alarm ordered for Resident #102. RN #1 stated, "I don't see it. It's not here." At that point, LPN (licensed practical nurse) #1, Resident #102's assigned nurse, came into the room. LPN #1 was asked to locate the wheelchair alarm ordered from Resident #102. LPN #1 stated, "I transferred him back from the toilet to the wheelchair about an hour ago." When asked if the chair alarm was in place at that time, LPN #1 stated, "I don't know. Maybe not. I don't think so." When asked if Resident #102 should have had a chair alarm in place, both RN #1 and LPN #1 stated, "Yes." On 9/5/13 at 3:30 p.m., RN #1 was asked to define "Falling Leaf Program." RN #1 stated: "It is our fall prevention program. All our new admissions are put on the program for two weeks, and then re-evaluated after that." RN #1 stated that she could not locate the Fall Risk Assessment for Resident #102. She further stated, "I know, though, that he is at high risk for falls because he is so weak. That is why he is on Falling Leaf." ASM (administrative staff member) #1, the facility administrator, ASM #4, the director of nursing, ASM #3, the clinical support specialist, ASM #5, the corporate vice-president for operations, and ASM #6, the regional director of clinical services were informed of this finding on 9/5/13 at 5:45 p.m. No further information was provided prior to exit. *Clostridium difficile is a gram-positive anaerobic bacterium most often associated with antibiotic-associated diarrhea. Symptoms may range from asymptomatic carrier states to severe pseudomembranous colitis and are caused by toxins produced by the organism. Although[DIAGNOSES REDACTED]icile infection can be caused by almost any antibiotic that disrupts the intestinal flora, it's classically associated with clindamycin use. Patients at high risk for this disorder include those that are taking many kinds of antibiotics immunosuppresed individuals, and those in nursing homes. [DIAGNOSES REDACTED]icile may be transmitted directly from patient to patient via contaminated hands of facility personnel (most common) or indirectly through contaminated equipment such as bedpans, urinals, call bells, ...and surfaces such as bedrails, floors, and toilet seats ...because spores of[DIAGNOSES REDACTED]icile are resistant to most commonly used facility disinfectants the patients room may be contaminated even after the patient has been discharged . Springhouse Handbook of Diseases- Causes, Signs and Symptoms, Patient Care- 2007 Springhouse Corporation pages 217-219 3. The facility staff failed to apply a physician-ordered wheelchair alarm for Resident #109. Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS, an admission assessment with ARD (assessment reference date) 7/27/13, Resident #109 was coded as having scored 15 out of 15 on the BIMS (brief interview for mental status), indicating Resident #109 had no cognitive impairment for making daily decisions. Resident #109 was coded as requiring extensive assistance of one person for bed mobility, transferring from bed to chair, and personal hygiene. Resident #109 was coded as being totally dependent on the assistance of one staff member for dressing, toileting and bathing. On 9/4/13 at 4:35 p.m., Resident #109 was observed seated in a wheelchair in his room. No wheelchair alarm was visible. On 9/5/13, Resident #109 was observed at multiple times throughout the morning and afternoon: 8:40 a.m., 10:25 a.m., 11:30 a.m. and 2:50 a.m. At each observation, Resident #109 was seated in a wheelchair in his room. No chair alarm was visible on Resident #109's wheelchair during any of these observations. A review of Resident #109's clinical record revealed the following order, dated 7/31/13 and dated 8/1/13: "Chair alarm when in chair - check for placement every shift and function." A review of Resident #109's MDS Kardex Report Form revealed the following: under the category "Accidents-Fall Risk," the box beside "Bed Alarm" was darkened to indicate this intervention had been selected for Resident #109. A review of Resident #109's care plan with effective date 8/4/13 revealed the following: "At Risk for falls characterized by multiple risk factors related to CVA (stroke), deconditioning, functional problem. Fall prevention program per facility routine. 8/9 continue program. Personal alarm to chair." On 9/5/13 at 3:30 p.m., RN (registered nurse) #1 accompanied the surveyor into Resident #102's room. RN #1 was asked to locate the wheelchair alarm ordered for Resident #102. RN #1 stated, "I don't see it. This one is not here either." When asked if Resident #102 should have had a chair alarm in place, RN #1 stated, "Yes. He should." ASM (administrative staff member) #1, the facility administrator, ASM #4, the director of nursing, ASM #3, the clinical support specialist, ASM #5, the corporate vice-president for operations, and ASM #6, the regional director of clinical services were informed of this finding on 9/5/13 at 5:45 p.m. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure interventions were put in place and implemented to prevent a fall which resulted in a fracture for one of 26 residents in the survey sample, Resident #7. 1. a. Resident #7 had a fall on 11/16/12. The facility staff discontinued fall interventions for Resident # 7 after this fall and failed to implement new interventions to prevent further falls. Resident # 7 fell again on 1/18/13 and suffered a fractured femur. 1. b. Resident #7 had a fall on 4/30/13, with no new interventions put in place to prevent further falls. The findings include: 1.a. Resident #7 was admitted to the facility on [DATE] with a recent readmission on 1/22/13 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/2/13 coded the resident as having the ability to understand others and making himself understood. The resident scored a three on a scale of zero to 15, indicating the resident was severely impaired to make cognitive daily decisions. Resident #7 was not coded as having any behaviors or signs of delirium. The resident was coded as being totally dependent on two staff members for moving in the bed, transferring from one surface to another surface, toileting, personal hygiene and bathing. The resident was coded as requiring extensive assistance of one to two staff members for moving on the unit and dressing. Section G 0400 - Functional Limitation in Range of Motion, coded the resident as having impairment on one side of his lower extremities and as using a wheelchair for mobility. Resident #7 was coded as being incontinent of both bowel and bladder. The resident was coded in Section J199 - Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is most recent, as having had one fall with no injury. Review of the most recent MDS assessment completed prior to the fall of 1/18/13, a quarterly assessment, with an assessment reference date of 12/5/12, coded the resident being able to make himself understood and usually was capable of understanding others, missing some part/intent of a message but comprehends most conversations. Resident #7 scored a four on a scale of zero to 15, indicating he was severely impaired to make cognitive daily decisions. The resident was coded as requiring limited assistance of one staff member for moving in the bed, transferring from one surface to another surface, moving on and off the unit, and dressing. Resident #7 was coded as requiring extensive assistance of one staff member for walking in the room and corridor, toileting, personal hygiene, and bathing. In Section G0400 - Functional Limitation in Range of Motion, the resident was coded as not having any impairment. Section G0300 - Balance During Transitions and Walking - coded the resident as being not steady, only able to stabilize with staff assistance for moving from seated to standing position, moving on and off toilet and surface - to - surface transfer (transfers between bed and chair or wheelchair). Resident #7 was coded as frequently being incontinent of both bowel and bladder. Section J 1900 - Number of Falls Since Admission/Entry or Reentry or Prior Assessment whichever is more recent, coded the resident as having one fall with no injury since the last assessment. The physician order [REDACTED]." The physician order [REDACTED]." A physician telephone order dated, 12/6/12, documented, "D/C (discontinue) Falling leaf program." This order was signed by the physician on 12/14/12. The January 2013 physician order [REDACTED]." The physician order [REDACTED]. " This was signed by the physician on 1/18/13. Review of the "Fall Risk Assessment" forms documented that on 11/1/12, Resident #7 scored a score of 14. "A score of ten or more may represent high risk for falls. Fall interventions should be initiated immediately and documented on the care plan." The "Fall Risk Assessment" dated, 12/5/12, documented the resident scored a score of 14. The form documented on 1/8/13, the resident scored a 12. "A score of ten or more may represent high risk for falls. Fall interventions should be initiated immediately and documented on the care plan." Review of the nurses notes dated, 11/16/12, documented, "Resident noted sitting on floor in bathroom, after having transferred self to toilet on way back to W/C (wheelchair), the chair slid from behind him, as Res (resident) did not lock brakes. Resident educated on W/C safety. (Resident) States understanding. ROM (range of motion) WNL (within normal limits) for resident. Denies pain or discomfort. Assisted to feet with assistance X2 (of two staff members) after skin assessment. No areas noted @ (at) present. Msg (message) left for RP (responsible party). MD (medical doctor) notified. Neuros (neurological checks) initiated. Will con't (continue) to monitor." The nurse's notes dated 1/18/13 at 6:00 p.m. documented, "This writer was called to room by CNA (certified nursing assistant) @ 5 p.m. Resident lying on back (a C with a line over it indicating 'with') knees bent @ doorway of bathroom. Resident stated, 'I was trying to get from the toilet to the W/C.' Resident complained of pain 7/10 (a score of 7 out of 10, 10 indicating the worst pain) to (L) (left) hip, limited ROM noted. Sheet transfer to bed (a C with a line over it indicating with) 4 assist for safety reasons. MD in building and notified. N.O. (new order) for stat (right away) x-ray of (L) hip & (and) pelvis and Ultram *(pain medication) 50 mg (milligrams) 1 PO (by mouth) q (every) hrs (hours) PRN (as needed) for severe pain. Ultram given (with) relief noted current pain 5/10. Resident eating dinner (with) HOB (head of bed) elevated. (A zero with a line through it indicating 'No') facial grimacing noted. Laughing and joking (with) staff. Neuro checks initiated. RP made aware of incident and new orders." Review of the x-ray report, dated 1/18/13, documented, "Conclusion: There is a displaced fracture of the subcaptial portion of the left proximal femur." The comprehensive care plan dated 4/5/12 documented, " At risk for falls related to: decreased mobility, hx of falls, short and long term memory deficit. " The " Interventions " documented in part the following: ? Assess for altered mental status, provide reality orientation as able, prn (as needed). ? Assess for fatigue and provide rest periods prn ? Assure adequate lighting ? Bed in lowest position ? Call bell within reach ? Keep familiar objects and most used items within reach ? Keep room and hallways clear of clutter ? Keep walker, w/c (wheelchair) within reach ? Bed and chair alarm, check functioning q shift and prn (documented D/C (secondary) non compliance 10/10/12) ? Toileting program. Toilet resident at intervals and as needed throughout day ? 7/25/12 - Neuro (neurological) checks, ROM, outside activities Under "Interventions," dated 12/6/12, was listed, " D/C falling leaf. " Further review of the comprehensive care plan documented as reviewed on 7/5/13, revealed the following: "Focus: At risk for falls related to decreased mobility, weakness, hx of falls, short and long term memory deficit, hx of actual fall, hx of fall with injury." A fall was documented on 3/17/13 and 3/23/13. The "Interventions" documented falling leave program, fall mat x2 on 3/23/13, and fall mats check q shift on 4/29/13." This review revealed no new interventions were implemented until 3/23/13 to prevent Resident # 7 from falling. Review of the October and November 2012 TAR (treatment administration record) documented, "Falling Leaf Program Every Shift." All boxes were signed off. The TAR also documented, "Bed/Chair Alarm - check for placement every shift and function." Next to this was documented, "D/C'd (discontinued) 10-10-12." There was no documentation on the TAR that the resident was non-compliant with the alarm. Review of the September and October nurse's notes did not reveal any documentation of the resident removing or being non-compliant with the bed and chair alarm. The December 2012 TAR documented "Falling Leaf Program Every Shift." Written next to this was "D/C'd 12/6/12." The January 2013 TAR did not document the "Falling Leaf Program Every Shift." The TAR (treatment administration record) documented, " Toileting Program before meals and at bedtime " The times documented, 7:00 a.m., 11:00 a.m., 5:00 p.m. and 8:00 p.m. " All boxes were documented as being completed. During the initial tour with ASM (administrative staff member) #2, the interim director of nursing, on 7/2/13 at approximately at 9:45 a.m., ASM #2 was asked to explain the falling leaves found outside the resident doors. ASM #2 stated, "That's the falling leaf program. Everyone is put on the falling leaf program upon admission for two weeks. Then a re-evaluation is made to determine if they stay on the program or can come off the program. When asked what the falling leaf program entailed, ASM #2 stated, "It's just a reminder for all of the staff to keep a closer eye on these people as they are at higher risk for falls." When asked how often residents on the falling leaf program are checked by staff, ASM #2 stated, "Well at least every two hours but anyone passing the room should look in also." An interview was conducted with LPN (licensed practical nurse) #5 on 7/2/13 at 12:02 p.m. When asked to explain the falling leaf program, LPN #5 stated, "We closely monitor the residents more frequently than others." When asked how often they are checked, LPN #5 stated, "We just do more frequent checks on those residents, ideally it would be that someone, be it a nurse or CNA observe the resident every 15 minutes or so. If the residents are antsy, then we can put them up near the nurse's station to keep a closer eye on them." An interview was conducted with CNA #1 on 7/2/13 at 4:50 p.m. When asked what is entailed if a resident is on the failing leaf program, CNA #1 stated, "We just check on them more frequently." When asked how much is more often, CNA #1 stated, "More than our every two hour checks." On 7/9/13 at 9:10 a.m. the administrator was informed of the concern. This surveyor informed the administrator to present any information regarding the above information. On 7/9/13 at 6:15 p.m. ASM #1, the administrator, ASM #2, the interim director of nursing, ASM #3, the regional director of operations, and ASM #4, the regional director of clinical services were informed of the above concern. On 7/10/13 at 8:25 a.m. ASM #1 was interviewed. ASM #1 stated on 11/16/12; the resident did not lock the brakes on his wheelchair and fell . When asked where it was on the care plan and what new interventions the facility put in place, ASM #1 stated, "No, it's not on the care plan and I can't find the incident report for that fall." When asked for the decision making documentation to discontinue the bed and chair alarm, ASM #1 stated, "I don't have it." ASM #1 stated the decision to discontinue the falling leaf program was made during a meeting with the team, the unit manager, the physician and the administrator. When asked for the documentation of that meeting, ASM #1 stated, "I did not document it." The facility policy, "Fall Prevention and Fall Management" documented, "Falling Leaf Program: The Falling Leaf Program is designed to facilitate recognition of residents who are at high risk for falls and to decrease the number of resident falls in the facility. Each resident will be assessed to be placed in the Falling Leaf Program if their initial fall risk assessment score is ten or more and /or they have had a fall or if determined by the interdisciplinary team to be at risk for falls. The program entails placing a colored leaf outside the resident's room on the door frame." The policy further documented, " Steps for Fall Review: The facility will review each resident fall when they occur by following these steps: 1. Assess the resident for any injury......2. Establish new interventions and place on the fall care plan... " In Fundamentals of Nursing, 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates. " 1. b. Resident #7 had a fall on 4/30/13, with no new interventions put in place to prevent further falls. A nurse's note dated, 4/20/13 at 7:45 a.m., documented, "Resident seen on floor on (L) side of bed on floor mat, alarm was in place and functioning. Resident stated he was going for a walk. Resident told to use call bell to summons help (with) all transfers. Resident said he would use call bell for help and would not attempt to get OOB (out of bed) alone again. Moved extremities (without) difficulty or pain. (L) hand skin tear noted, tx (treatment) rendered. Resident assist back into bed X2 nursing staff. Alarm in place, fall mat in place. Resident resting in bed (with) eyes closed, call bell within reach. RP aware." The "Fall Risk Assessment" completed 3/23/13, documented the resident with a score of 16. A score of ten or more may represent high risk for falls. Fall interventions should be initiated immediately and documented on the care plan." Review of the March and April 2013 TAR documented, "Bed alarm - check for placement every shift and function. Chair alarm - check placement and function every shift." "Floor mats @ bedside; check for placement when in bed." The fall mats were not documented as being in place until 4/29/13. Review of the "Incident/Accident Report" dated 4/20/13 at 6:00 a.m. documented the resident had been toileted at 5:30 a.m. The physician order [REDACTED]. " The review of the April 2013 TAR (treatment administration record) documented, " Toileting Program before meals and at bedtime " The times documented, 7:00 a.m., 11:00 a.m., 5:00 p.m. and 8:00 p.m. " All boxes were documented as being completed. The TAR also documented the "Falling Leaf Program Every Shift" as being in place for all shifts of every day. Review of the comprehensive care plan dated, 4/5/12 and documented as reviewed on 7/5/13, revealed the following: "Focus: AT risk for falls related to decreased mobility, weakness, hx of falls, short and long term memory deficit, hx of actual fall, hx of fall with injury." A fall was documented on 3/17/13 and 3/23/13. The "Interventions" documented falling leave program, fall mat x2 on 3/23/13, and fall mats check q shift on 4/29/13." An interview was conducted with LPN #6 on 7/8/13 at 2:00 p.m. When asked who is responsible for updating the care plan and initiating new interventions after a resident has a fall, LPN #6 stated, "The charge nurse can update the care plan and put new interventions in place but mostly the unit managers update the care plans." An interview was conducted with ASM #2, the interim director of nursing, on 7/8/13 at 3:02 p.m. When asked who is responsible for putting new intervention in place after a resident falls, ASM #2 stated, "The nurse should put safety prevention interventions in place at the time of the fall." An interview was conducted with ASM #1, the administrator, on 7/10/13 at 8:25 a.m. When asked if the fall of 4/20/13 was on the care plan, ASM #1 stated, "No, it's not there." When asked what interventions were put in place after the fall, ASM #1 stated, "We assessed him for injury, placed him back in bed and re-educated him on using the call bell for assistance to get out of bed." When asked if it is appropriate to re-educate a resident with a cognitive score of 3 or 4, ASM #1 did not respond. No further information was provided prior to exit.