Every finding on record at Fox Run Village

This citation pertains to intake 3152896. Based on observation, interview and record review, the facility failed to supervise a resident with known elopement risk from leaving the facility for one (R601) of three residents reviewed for elopement risk, resulting in the resident leaving the facility unsupervised. Findings include:Review of a facility reported incident (FRI) submitted to the State Agency documented in part: .On 7/30/26, resident (R601) exited a neighborhood stairwell at approximately 7:45pm. Door alarm sounded and resident descended the stairwell. Resident exited the building and returned to independent living.Resident returned to neighborhood at 9:23pm.[R601] has a history of Picks Disease (Pick's disease is a rare form of frontotemporal dementia (FTD) - a neurodegenerative disorder that affects the frontal and temporal lobes of the brain, leading to progressive changes in behavior, personality, and language).She is familiar with her environment and has a BIMS (Brief Interview for Mental Status) score of 5/15 (which indicated severe cognitive impairment). She was admitted to Independent Living in March 2024 and was transferred to [Unit/Floor name of nursing home portion of facility] on July 30, 2026, for additional assistance with activities of daily living and incontinence care. Prior to the transfer, she frequently visited her significant other in the Memory Care neighborhood. Investigation Upon admission to [Unit/Floor name of nursing home portion of facility], [R601] and her family agreed to the use of a (an electric wander management system to protect residents who are prone to wandering) to support her independence while promoting safety in her new environment. Later that evening, staff identified that the resident had exited the neighborhood at 7:39pm. A comprehensive search was initiated, including notification of security, administration, and local law enforcement. [R601] was subsequently located on campus at approximately 9:15pm in the Independent Living area of the community and safely returned to [Unit/Floor name of nursing home portion of facility].[R601] care plan was updated to reflect her needs, including one-to-one supervision and accommodation for her preference to spend time outdoors.On 8/18/26 at 9:32 AM, an interview was conducted with the Unit Clerk/Secretary (Staff 'F'). When asked about where to find the residents identified for elopement risk that was available to staff, Staff 'F' proceeded to the employee hallway and identified a board with three residents (two from the nursing home portion of the facility which included the name and pictures of R601 and of another current resident. Staff 'F' further reported they were responsible for checking the electronic bracelets to make sure they were working properly.On 8/18/26 at 9:40 AM, an interview was conducted with R601's Nurse (Nurse 'G'). When asked about their staffing assignments for today, Nurse 'G' reported there were three nurses, three nursing assistants, and one nursing assistant assigned as a one to one for R601.When asked if they were aware who was an elopement risk, Nurse 'G' reported there were three and provided the names of R601 and two other residents.Further review of R601's clinical record revealed the resident was admitted into the facility on 7/30/26 with diagnoses that included Pick's disease, dementia, cognitive communication deficit, and aphasia. According to the Minimum Data Set (MDS) assessment dated [DATE], R601 had severe cognitive impairment, had wandering behavior which occurred one to three days during this review period of seven days which impacted the resident at significant risk of getting to a potentially dangerous place, and was independent with ambulation without an assistive device.Review of the care plans included: Safety and Exploring.I need to see my partner in Memory Care.Wandering outside the building/residence without notifications.Care Plan Approach(es): Need to have 1:1 companion.Review of a physician progress note on 7/30/26 by Medical Director 'C' read, .Clinical Notes: Moderate dementia with anxiety. Patient has been determined to have a form of primary progressive aphasia in the past and also has had a diagnosis of picks disease. Under the management from neurology at [name of local hospital].In my opinion the patient lacks the ability to make informed medical or financial decisions.On 8/18/26 at 10:58 AM, the Administrator provided additional documentation of their plan of correction regarding R601's elopement on 7/30/26. When asked to recall R601's elopement on 7/30/26, the Administrator recalled the events as documented and reported to the State Agency. When asked about what they had identified as to how R601 was able to exit the facility unsupervised, the Administrator reported the resident was able to access and descend the stairwell and walked over to the independent living area of the campus. When asked if they had identified any issues such as the function of the alarm or elopement procedures, the Administrator reported the alert system was functioning but they did identify an issue with the staff (Nurse 'B') that initially responded to the alerts of R601 near the stairwell did not fully descend and check the stairwell and surrounding area. The Administrator further reported although the stairwell was alarmed and locked, the door was able to be held and the lock would be released within 15 seconds.Review of the staff interviews included with the investigation included:An interview with Nurse 'E' on 7/31/26 documented, in part: On 7/30/26, I was assigned to [R601].Resident admitted to the neighborhood around 5:30 pm, after spending some time with her significant other in memory care. I was completing charting when I was notified that [R601] [electronic alert bracelet] was set off at the stairwell on (northwest unit). Nurse Supervisor was rounding and I assisted in the search for the resident. When [local] police arrived, I provided necessary information requested by Police Officers regarding the resident.Resident was able to recall that she traveled outside and took a beautiful walk. She stated she really enjoyed herself and 'she was able to relax on a bench outside and see other residents'.Companion was present at bedside for the remainder of the shift.updates to care plan included 1:1 companion and a preference to spend time outdoors.An interview with Nurse Supervisor (Nurse 'D' on 7/30/26 documented, in part: At approx. (approximately) 1953 (7:53 PM), this writer was notified by the front desk clerk that the resident's [electronic alert bracelet] was activated, showing a location in [second floor northwest stairwell] and then [first floor northwest stairwell]. At the time, this writer was on the second floor and immediately checked the resident's room as well as her partner's room in [non-nursing home portion of the facility]; but the patient was not present. This writer proceeded to the first floor, went through the stairway up to the third floor and searched the outside area but was unable to locate the resident. The search was then expanded to all floors [other non-nursing home portions of the facility], and all available staff were alerted to assist in searching the resident rooms and common areas. Security was also notified and checked the resident's apartment in IL (Independent Living) but she was not there; security then contacted 911 and when they arrived the assigned nurse stated that she provided patient's birthday, face sheet and medications list to the emergency dispatch. The assistant administrator was notified of the situation and stated she was on her way. This writer continued searching the exterior perimeter of the building, after returning in the building another staff member reported locating resident in [name of an independent living building] neighborhood. The patient was safely returned to the facility.There was no statement for Nurse 'B' included in the documentation provided for review.On 8/18/26 at 12:55 PM, Nurse 'B' was attempted to be contacted by phone and a message was left to return the call. There was no further response from Nurse 'B'.On 8/18/26 at 11:20 AM, an observation of the facility's environment was conducted with the Administrator and Assistant Administrator. At this time, they were asked to show where R601 exited the facility and where they were found. The Administrator reported R601 was last seen by the Afternoon Nurse Supervisor (Nurse 'D') coloring in their room at approximately 7:30 PM on 7/30/26. They further reported R601 exited the stairwell (northwest side of the unit) at approximately 7:53 PM and that was when the alert went off and the front desk staff notified the nursing staff. The Administrator then reported as R601 descended the stairs the alerts picked up the resident.Upon exiting the facility's northwest stairwell on the first floor, there was an employee parking lot and paved sidewalk that surrounded the perimeter of facility. The Administrator reported there were two cameras outside, one to the north of the exit door and one to the south but the north camera was not functional at the time of R601's elopement, but the campus security was able to confirm the south camera was functioning and if the resident had walked that way, it would have been on the camera footage and they felt confident the resident must have walked around the sidewalk path on the northwest side of the facility and across the street to the independent living buildings (not R601's former independent living apartment building). The Administrator pointed to two large multi-level buildings across the street and reported R601 was located by other staff in the independent living facility that was behind the front building.On 8/18/26 at 11:55 AM, an interview was conducted with Medical Director 'C'. When asked about their evaluation of R601 following the elopement on 7/30/26, Medical Director 'C' reported they had followed R601 in the community as well as now and further reported the resident's significant other recently moved to memory care and prior to this, they were always together. Medical Director 'C' reported since R601 had aphasia and some need for more assistance, the idea was to move her to memory care but there was no room available so R601 will stay where they are until that can happen and will remain with a one-to-one caregiver until then.On 8/18/26 at 1:10 PM, an interview was conducted with the Administrator, Assistant Administrator and the Director of Nursing (DON). When asked to confirm the residents at risk for elopement, the Administrator reported there were only two on the nursing home portion which included R601. When asked about a third resident (not previously reported as a risk) as Nurse 'G' reported this resident was also at risk for elopement, the Administrator and DON reported the resident was previously identified as being at risk, but due to decline physically and upon the facility's re-assessment of elopement risk, the resident was no longer considered an elopement risk and confirmed it was currently only R601 and one other resident.According to the facility's policy titled, Missing Resident dated 3/11/2024: .When a resident is suspected to be missing or upon receiving a report of a missing resident, staff will respond timely and investigate the incident in accordance with the procedures defined hereinafter.If resident's elopement deterrent device was triggered or there is evidence of a door alarm or breached egress door, the initial search will focus on the area where the device or alarm was triggered.According to the facility's policy titled, Elopement Risk Assessment dated 03/2024: .Once a resident has been deemed to be at risk for elopement, the resident's name and photograph will be added to a list of at-risk residents kept at the front desk of Continuing Care.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: R601 was placed on one-to-one supervision immediately; the facility's security team physically tested all doors and identified they were functioning properly; Nurse Supervisor conducted a test for functionality of all residents in skilled nursing with electronic alert bracelet; Administrator and Assistant Administrator started education with the staff on facility policy for missing resident, elopement risk and missing resident procedural checklist; Missing resident drills were conducted on all three shifts; Audits were completed for thorough elopement risk assessment, and person-centered interventions; Audits were completed to determine that all staff have [communication device] phones, and they are in working order on all three shifts; Audits were completed on residents who have admitted , readmitted , had a significant change of condition, and quarterly for thorough elopement risk assessment. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review the facility failed to maintain best practices in the food service area resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 9:15 AM during the kitchen tour with Dietary Manager (DM) I and Dietary Services Director (DSD) J observed in the walk-in cooler: two clear deep covered plastic containers of facility made tomato soup. The soup in each container was approximately 6 deep and was labeled as being prepared on 4/27. The temperature of the soup measured at the top of the product was in the range of 45 F-49 F. During this observation, when DM I was queried about the cooling of this product, it was confirmed that it had been cooked and cooled on the previous day more than 6 hours prior. DM I said cooling records are typically kept in the production logs binder referred to as the Red Book, but no monitoring records were logged for this item. Cooling practices described by DSD J were to use an ice wand for stirring product while cooling. DM I indicated the product would be discarded since it had not met cooling parameters and that staff would be re-trained on cooling methods and facility policies.On 04/29/2026 record review of facility policy Cooling Potentially Hazardous Foods dated 10/2025 states: Utilizing a comprehensive cooling log is vital in monitoring a product as it progresses through the cooling cycle. Proper food cooling procedures will be followed and documented in the Red Book. The procedures identify appropriate cooling methods, monitoring, documentation and corrective actions. According to the 2022 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.On 04/28/2026 at 9:20 AM observed small flying insects (drain flies) near clean equipment storage and around the floor drain near the dishwashing area in the main kitchen. When queried during this observation, DM I and DSD J also observed and said they are working with their pest control operator (PCO) and also working to keep this floor area clean and use a drain cleaning product. On 04/28/2026 at 9:45 AM observed small flying insects (drain flies) near the steam table and beverage area in the 2nd floor pantry serving kitchen. Also observed approximately 1/4 of standing water and some food debris in the floor drain insert located in the floor drain near the corner of the steam table. Also observed red sticky substance on the bag-in-box syrup stored on the shelf in the beverage area. On 04/29/2026 at 9:25 AM interview with Maintenance Supervisor (MS) K regarding pest control and any drain management concerns, MS K indicated that dietary staff is responsible for cleaning and maintenance of drains and floor areas in the kitchens. MS K was aware of the presence of small flying insects and confirmed weekly visits from the contracted pest control operator. On 04/29/2026 record review of PCO service record dated 4/27/26 indicated observations from the 4/20/26 visit: RC Kitchen debris present and recommendation to customer: clean and sanitize area. Pest type: (not specified)On 04/29/2026 record review of facility policy Integrated Pest Management dated 3/17/2025 included the following procedures: The community is responsible for . following up on situations noted by the Pro. Also, repairing any leaks and eliminating standing water wherever possible. Work orders must be submitted for repairs. The community is responsible for reviewing sanitation practices and reducing clutter. Sanitation includes areas such as kitchen cleaning and maintenance, waste disposal procedures, and elimination of clutter.According to the 2022 FDA Food Code section 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A)Routinely inspecting incoming shipments of FOOD and supplies; (B)Routinely inspecting the PREMISES for evidence of pests; (C)Using methods, if pests are found, such as trapping devices or other means of pest control .; and (D)Eliminating harborage conditions.

Based on interview and record review, the facility failed to prevent an avoidable fall for one resident, (R36) of three residents reviewed for accidents, resulting in a fall requiring a transfer to the emergency room. Findings include: On 4/27/26 at 11:59 AM, an interview was conducted with R36's family member and they reported R36 had a fall from their bed during incontinence care because there was only one nurse aide present rendering care and R36 was supposed to have the care provided by two staff members. They further reported the fall from the bed required a transfer to the emergency room. On 4/27/26 at 2:04 PM, a review of R36's progress notes revealed a note dated 12/22/25 at 11:43 PM entered into the record by Nurse 'F' that read, Writer was called by staff saying resident just fell out of bed. When I went to resident's room saw {sic} resident laying on the floor on her back by the window side, the bed is on {sic} a waist height position .unable to assess her arms legs due to stiffness and contracted extremities, staffs {sic} got her off the floor with the use of (mechanical) lift and 3 person assist. Dr. on-call notified and ordered to send res. (resident) out to hospital for further evaluation . On 4/28/26 at 1:26 PM, a review of a facility provided document titled, RESIDENT INCIDENT REPORT FORM dated 12/22/25 and signed by Unit Manager 'H' was conducted and read, .Conclusions of the investigation: While the CA (nurse aide) was providing peri care {sic} she turned the resident on her side and resident rolled out of bed .Steps take to Prevent Recurrence (Actions): Staff member educated on following the holistic care plan as written .Continue to use 2 person assistance for transfers per plan of care . On 4/28/26 at 2:55 PM, an interview was conducted with Nurse 'F'. Nurse 'F' indicated CNA (Certified Nurse Aide) 'G' was performing care for R36 without the assistance of a second staff member and when CNA 'G' rolled R36, they fell out of the bed. Nurse 'F' further said they transferred R36 to the emergency room after the fall. Nurse 'F' was asked if R36 required two staff members for bed mobility and said they did because they were difficult to reposition due to contractures. A review of a facility provided policy titled, Fall Management Version Date: 4/2023 was reviewed and read, Policy: To minimize and/or decrease the risk of fall through an interdisciplinary review of guest/resident and to develop individualized care/service plan approaches . On 4/28/26 at 3:10 PM, an interview was conducted with Unit Manager 'H' regarding R36's fall. They were asked about the root cause of the fall and said R36 was a two-person assist and when CNA 'G' provided care without the assistance of a second staff member, R36 rolled out of bed.

Based on interview and record review facility staff failed to report an allegation of sexual assault to the Administrator/Abuse Coordinator and State Agency for one (R7) out of two residents reviewed for abuse. Findings include:A review of R7's clinical record revealed the resident was last admitted to the facility on [DATE] with diagnoses that included: subdural hematoma, repeated falls and Parkinsons. A review of the Minimum Data Set (4/13/26) noted the resident had a Brief Interview for Mental Status of 13/15 (cognitively intact cognition).Continued review of R7's clinical record revealed the following:4/26/26: Nursing Note: .I was sexually assaulted by girls last night. (Authored by Nurse D)4/27/26: Physician Note: .On the 23rd reported wandering trying to leave the facility.later in the day he reported that some of the female aides helping him last night was messing with him. He said there were 3-4 of them and he was tied down and unable to defend himself as they were overpowering him.Seen today up in a wheelchair.later at night reported that a few female aides were messing with him. He was unable to defend himself. (Authored by Medical Director E)On 4/28/26 at approximately 11:22 AM, a request was made for any Incident/Accident (IA) and/or grievances for R7. Documents provided did not include any details pertaining to R7's allegation of sexual assault.On 4/28/26 at approximately 3:17 PM, a phone interview was conducted with Nurse D. Nurse D was asked about the allegation reported by R7. Nurse D noted that R7 was in the hall and not acting himself and reported the allegation of sexual assault by the Certified Nursing Assistants (CNAs). Nurse D was asked if the allegation was reported to the Abuse Coordinator/Administrator and they replied that they only reported it to the Social Worker and the Charge Nurse.On 4/28/26 at approximately 3:52 PM, an interview was conducted with the Abuse Coordinator/Administrator. The Administer was asked if they reported and/or investigated R7's allegation of sexual abuse to the State Agency. They reported that they were not aware of the allegation and as such did not report it to the State Agency.The facility's policy titled, Abuse Reporting & Investigation (5/2021) was reviewed and noted, in part: .(facility) is committed to providing an environment where resident's rights are protected and residents remain free from abuse.To this end (facility) has adopted a standard of ZERO TOLERANCE of each incidents.and will assure that all allegations of abuse.are reported as required by federal, state and local laws and investigated promptly.Allegations involving abuse.are reported immediately, but not later than two hours after the allegation is made.to the administrator of the facility and to other officials (including the State Survey Agency).Although a resident may have cognitive impairment (mild or severe) allegations of abuse received from these residents should be taken seriously.If the abuse allegation is not substantiated, but a failure to follow appropriate policies and procedures occurred, staff should be counseled as indicated.If an allegation of sexual abuse is made: Immediately contact the appropriate law enforcement officials and the residents attending physician.

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices for residents on droplet precautions during an influenza outbreak, and implementation of Enhanced Barrier Precautions (EBP) affecting multiple residents reviewed for infection control, including R93, R21 and R15. This deficient practice has the likelihood to result in cross-contamination and the continued development and spread of infection and disease. Findings include: R93 On 3/11/25 at 10:09 AM, R93's door was closed and the resident was heard coughing very loudly from the hallway. There were several signs taped to the outside of the door which included: a rehab treatment schedule, a sheet that read, STOP PLEASE SEE NURSE, a sheet that showed the sequence of putting on personal protective equipment (PPE) for a gown, mask or respirator, goggles or face shield, and gloves, and a sheet that showed the sequence of removing PPE. There was no signage to identify what type of precautions the resident was on, or what specific PPE to use. There was no Nurse or Care Assistant (CA) observed in the hallway for approximately 10 minutes. On 3/11/25 at 10:19 AM, CA 'D' was observed exiting R93's room wearing only a black KN95 mask (no gown, face shield/goggles, or gloves). CA 'D' was not observed to wash their hands, or use hand sanitizer, and proceeded to exit the room into the hallway. On 3/11/25 at 10:20 AM, an interview was conducted with CA 'D'. When asked about why R93 was on isolation precautions, CA 'D' pointed to the signs on the door, confirmed there was nothing specific posted and stated they thought it was for the flu. When asked what PPE was required to be worn, CA 'D' reported a gown and a N95 mask. When asked why they had not donned PPE when they were in R93's room, CA 'D' reported they just went into the room to give the resident their meal tray and acknowledged the meal was delivered later than usual. When asked if again what PPE should be worn upon entering the room, CA 'D' stated when they touched the resident or do something in the room they put on N95 mask, gloves, and gown. CA 'D' confirmed there were no N95 masks available in the PPE cart outside the room. CA 'D' then went to go find the Nurse to inquire about the N95 masks. On 3/11/25 at 10:27 AM, Nurse 'E' was observed in the hallway coming from the central dining area. When asked about the specific isolation precautions for R93, Nurse 'E' reported the resident was on droplet precautions. When asked what PPE should be donned prior to entering the room, Nurse 'E' reported anyone entering the room should be wearing an N95 mask. When informed there were no masks available on the PPE cart outside the room, Nurse 'E' reported the N95 masks were kept in the nursing station. When asked how visitors would know to go there to obtain those, or what specific PPE needed to be donned/doffed, Nurse 'E' reported that was a good question and most visitors usually approached them. When informed that they were not observed as available for approximately 10 minutes, Nurse 'E' acknowledged they were doing medication administration at this time. When asked if the PPE carts should have all required PPE available, they reported they should. On 3/11/25 at 10:45 AM, CA 'D' was observed outside of R93's room wearing a disposable gown, the same black KN95 mask as observed earlier, as well as a N95 mask over the KN95 mask. When asked about the donning of both masks, they reported that was ok, so they could continue to use the KN95 mask. They were requested to follow-up with nursing administration regarding that practice. CA 'D' then removed the black KN95 mask and put it into their pocket. On 3/11/25 at 10:48 AM, upon CA 'D' entering R93's room, Nurse 'E' was observed exiting the resident's room with the entire nursing pushcart that contained several items including: disposable straws, spoons, cups, a laptop, a sharps container, and an opened container of yogurt. Nurse 'E' was not observed to use hand sanitizer upon exiting the room, nor sanitizing any of the items on the push cart. Nurse 'E' then immediately proceeded to go into R21's room (which was not currently on any precautions as there was no signage or PPE cart at/near the resident's room but should have been on enhanced barrier precautions for an open wound per physician orders as of 2/27/25). Nurse 'E' was overhead asking the resident if they were ready for their medications. Review of the clinical record revealed R93 was admitted into the facility on [DATE] with diagnoses that included influenza A. There was no Minimum Data Set (MDS) assessment completed at this time. According to the physician's orders in the hard chart, R93 was on droplet precautions for influenza A since admission on 3/7/25. Review of the care plans revealed there were none for resident's diagnosis of influenza A or what specific isolation precautions to follow. R21 On 3/11/25, multiple observations were made of R21's room. There were no signs posted identifying R21 was on any precautions, or PPE carts made available until the morning of 3/12/25. On 3/12/25 at approximately 9:30 AM, R21's room now had signage that indicated they were on enhanced barrier precautions (EBP) and a PPE cart was in the hallway outside of their room. Review of the clinical record revealed R21 was admitted into the facility on [DATE] with diagnoses that included: chronic systolic heart failure, dementia without behavioral disturbance, chronic kidney disease, sarcoidosis, chronic obstructive pulmonary disease, and Alzheimer's disease. According to the MDS assessment dated [DATE], R21 had severe cognitive impairment (scored 5/15 on BIMS) and no skin/wound concerns. Review of the physician orders revealed no orders included in the hard chart identified R21 had wound care orders to the left heel which started on 2/29/25. Additionally, R21 had orders for enhanced barrier precautions due to a wound on 2/27/25, but this was not observed as implemented during the survey until 3/12/25. Further review of the progress notes revealed R21 was on droplet precautions for +influenza A starting on 3/4/25, tested positive on 3/7/25 and was removed off droplet isolation on 3/11/25. It should be noted there were no isolation precautions observed in use via either signage or PPE cart on 3/11/25. R15 On 3/11/25 at 10:52 AM, the resident was observed working with therapy staff in their room. There was no EBP signage posted, or PPE cart available and/or in place at that time. On 3/12/25 at 8:15 AM, R15's room was now identified as the resident being on EBP. Observation of the PPE cart revealed there were only disposable yellow gowns available. There were no gloves or hand sanitizer available for use. Review of the clinical record revealed R15 was admitted into the facility on [DATE] with diagnoses that included: hypo-osmolality and hyponatremia, influenza due to other identified influenza virus with other respiratory manifestations (onset date 2/26/25), presence of right artificial knee joint, aftercare following joint replacement surgery, and acute posthemorrhagic anemia. According to the MDS assessment dated [DATE], R15 had intact cognition. Review of the physician orders revealed orders for EBP were not written until 3/12/25. Review of the progress notes revealed changes to the resident's right knee on 3/10/25 which included: An entry on 3/10/25 at 4:25 PM by Nurse 'I' read, Blister filled with pus to right knee noted 1x1cm (centimeter), open, not warm to touch and it is not affected per [Physician 'K']. The wound cleansed with NS (Normal Saline). TAO (Treatment As Ordered) applied and covered with Opti foam daily until healed. After treatment the blister open and purulent discharge noted . An entry on 3/10/25 at 1:16 PM by Nurse 'I' read, .the wound to right knee, open, has purulent drainage, not warm to touch and it is not affected <sic> per [Physician 'K']. Ordered placed to change the dressing daily . Additional review of the care plans revealed there were none implemented to address the resident's use of EBP or droplet precautions for when they were identified as positive for influenza A on 2/26/25. On 3/12/25 at 3:47 PM, an interview was conducted with the infection Preventionist who also performed duties as the Assistant Director of Nursing (ADON). They reported they just took over the infection control program about a month ago. At that time, the ADON was informed of the concerns regarding the facility's infection control practices as observed, including interviews with staff. The ADON reported the staff had recently received multiple education and training including what to don/doff, how to ensure supplies were available, and the specific requirements including what and how to don/doff for residents on droplet precautions and EBP. When asked if staff should be bringing the nursing pushcart into rooms that were on droplet precautions, the ADON reported the WOW (Workstation on Wheels) should be disinfected upon leaving an isolation room. They further reported the observations and interviews with staff were not reflected of their training. When asked if the facility's decision to not post specific signage of the type of precaution and what specifically to don and doff, how were staff and/or visitors to know exactly what to do, the ADON reported they should see the nurse or also should be on the care plan. When asked how staff and/or visitors would access the care plans given those were kept in binders inside the rooms and would have to enter those rooms, without following appropriate infection control practices, the ADON reported that was a good question and was not able to offer any further explanation. On 3/13/25 at 10:40 AM, an interview was conducted with the Director of Nursing (DON). At that time, the same concerns were reviewed as with the ADON. The DON confirmed the reported observations and interviews were not in accordance with appropriate infection control practices and also was not what staff were educated to do. In regard to Nurse 'E' bringing the WOW into a droplet precaution room, the DON reported there is no reason that should have been brought into the room. Review of the documentation provided for the specific isolation precautions included: A facility document titled, Continuing Care Isolation Precautions Resource Tool which included: .Enhanced Barrier Precautions .PPE Requirements .Gloves and gown prior to the high-contact care activity .PPE to be changed before caring for another resident .Make PPE, including gowns and gloves available and accessible to staff before performing high contact activities .Ensure access to alcohol-based hand rub is available . .Droplet Precautions All residents infected with a disease which spreads through droplets during coughing, sneezing or talking. Examples include Influenza .When PPE Used .Any Room Entry .PPE Requirements .Gloves, Gown, Mask (Surgical or N95 Masks), Protective eyewear, (Don prior to room entry, doff prior to room exit) .PPE to be changed before caring for another resident .Isolation Cart at entryway .Appropriate Signage in place . 48680 On 3/11/25 there were three rooms that were noted to have a posting stating STOP SEE NURSE. There was instruction for how to don and doff personal protective equipment (PPE), but no information on what PPE to put on. On 3/13/25 at 10:00 AM, an infection control meeting was conducted with the Assistant Director Of Nursing (ADON) / Infection control preventionist (ICP). They were asked about the rooms that had the signage STOP SEE NURSE and asked how visitors and staff members would know what PPE to wear or what's required if the type of isolation nor the instructions for what to wear is not available on the posting. The ADON explained that individuals are supposed to see the nurse and they should be able to tell individuals what is required. The ADON was then asked what if a nurse is not present, how would one know what to do or what isolation is present. The ADON replied, that it was being discussed with corporate, because this facility is very big on homelike environment and making sure the residents are dignified, but understood the safety in having the correct information present so employees and visitors could properly protect themselves. No additional information was provided by the exit of survey.

Based on interview and record review, the facility failed to ensure medications were available for administration for one resident (R143) of one resident reviewed for new admissions. Findings include: On 03/11/25 at approximately 11:17 a.m., R143 was observed to be in their room, laying in their bed. R143 was observed to have a catheter draining amber colored urine into a drainage bag. On 3/12/25 the medical record for R143 was reviewed and revealed the following: R143 was initially admitted to the facility on [DATE] and had diagnoses including Retention of Urine and Encounter for fitting and adjustment of urinary device. A review of R143's March 2025 Medication Administration Record (MAR) revealed R143 was not administered the following medications on 3/11/25 (a day after being admitted on [DATE]): 1. doxycycline hyclate 100 mgcapsule (1) CAPSULE Oral Two Times Daily for Two Days Starting 03/10/2025 .(10:00 AM dose-med on order) .2. midodrine 5 mg tablet (1tab) (TABLET) Oral Three Times Daily Starting 03/11/2025 .(9:00 AM dose-Med on order and 1:00 PM dose-med on order) .3. famotidine 20 mg tablet (1) TABLET Oral One Time Daily Starting 03/11/2025 .(9:00 AM dose-on order) .4. ascorbic acid (vitamin C) 500 mg tablet (2) TABLET Oral Two Times Daily Starting 03/11/2025 .(9:00 AM dose-on order) . 5. Banatrol Plus oral powder packet (1 packet) POWDERIN PACKET (EA) Oral Three Times Daily Starting 03/11/2025 .(9:00 AM dose-on order and 1:00 PM dose-on order) .6. ferrous sulfate 324 mg (65 mg iron) tablet, delayed release (1 tab) TABLET,DELAYED RELEASE (ENTERICCOATED) Oral One Time Daily Starting 03/11/2025 .(9:00 AM dose-on order) .7. alphaA lipoicA acidA 600A mgA tablet (1 tab) TABLET Oral One Time Daily Starting 03/11/2025 .(9:00 AM dose-med on order) . On 3/13/25 at approximately 9:00 a.m., during a conversation with the Assistant Director of Nursing (ADON), the ADON was queried regarding the process for ensuring medications were available for administration the following shift for newly admitted residents. The ADON reported that the admitting Nurse ensures the medication orders are entered into the EMR (electronic medical record) and reconciles the medications with the medical provider during their admission assessment. The ADON was queried regarding R143 not having their medications available the day after their admission and the ADON indicated that the admitting Nurse should have implemented a STAT (ASAP) delivery to be made from the pharmacy as a drop ship which arrives in 2-4 hours or the Nurse should have checked the backup box to ensure the medications were administered timely and according to Physician orders. At that time the ADON indicated they would have to look into the issue. No further information was provided before the end of the survey as to why R143 did not have their medications available the following day for administration.

Based on observation, interview and record review, the facility failed to ensure Nursing standards of practice were followed for medication administration for one resident (R5) of five residents reviewed for medication administration. Findings include: On 03/11/25 at approximately 10:52 a.m., R5 was observed in their room, laying in their bed. R5 was observed to have eye drops and a medication cup with three white pills in it without a Nurse in the room providing supervision. R5 was queried how they received their pills in the cup, and they reported the Nurse had given it to them to take and did not wait for them to take them all, left the room and never returned. At that time, R5 was observed to take their hand and grab the pills one by one out of the cup and swallow them. On 3/12/25 at approximately 9:29 a.m., during a medication administration observation, Nurse E was observed to administer a Cyancobalamin (vitamin B-12) 1,000 mcg tablet in a medication cup with multiple other medications in together in the cup at the same time. A review of the pharmacy instructions for the administration of the Cyancobalamin revealed the Cyancobalamin was to be administered sublingually (under the tongue). Further review of the pharmacy instructions revealed the following: dissolve under tongue only. On 03/12/25 at approximately 9:49 a.m., during a review of the medication administration observation with Nurse E, Nurse E was queried why they administered the cyancobalamin with the rest of the medications in the medication cup to R5 instead of following the pharmacy instructions and administering it sublingually, and they indicated that they usually do administer it sublingual but had forgotten that morning. On 3/11/25 the medical record for R5 was reviewed revealed the following: R5 was last admitted to the facility on [DATE] and had diagnoses including Congestive heart failure and Polyneuropathy. A review of R5's MDS (minimum data set) with an ARD (Assessment reference date) of 1/3/25 revealed R5 needed assistance from facility staff with their activities of daily living. A Physician order revealed the following: Refresh Tears 0.5 % eye drops (2 drops) DROPS Both Eyes Notes: Indication: for dry eyes (Dispense as written) OK to SELF ADMINISTER/LEAVE AT BEDSIDE., Instructions: . Further review of the medical record did not reveal any other Physician orders for the self-administration of any other medications On 3/13/25 at approximately 9:00 a.m., during a conversation with the Assistant Director of Nursing, (ADON), the ADON was queried regarding both of the medication observations pertaining to R5's medication administration and they indicated that it was the responsibility of the Nursing staff to follow the rights of medication administration including clarifying the pharmacy instructions vs the orders and ensuring residents have successfully ingested all the medications that were administered by providing supervision during administration.

Based on observation, interview and record review, the facility failed to consistently provide assistance with oral hygiene for one (R34) of two residents reviewed for activities of daily living (ADLs). Findings include: On 3/11/25 at 10:18 AM, R34 was observed lying in bed. When asked if they had any concerns with the facility's care R34 reported they had concerns with staff not always assisting them with brushing their teeth most of the time. R34 reported oral care had not been done yet today. On 3/11/25 at 12:39 PM, R34's call light was lit up in the hallway and the door was closed. Upon entering the room, the resident was observed lying in bed on their back with a lunch meal on an overbed tray in front of them. When asked if they had pressed their light for help, R34 reported their bed controller fell to the floor and they couldn't reach it. The bed remote controller was observed on the floor under the bed. When asked if they had received any oral care yet, R34 reported not yet. The resident further reported they were used to doing that by themselves when they were in their apartment before coming here. R34 stated, I'm dependent on them to do it when I can't get out of bed in my chair. They reported they required a mechanical lift with a sling and two people to get them out of bed. When asked if they were having any mouth/tooth pain, they stated no but also reported they had a dental appointment next week for a routine cleaning and that seemed to be when they got their teeth cleaned. They further reported they took pride in the fact they always took good care of their teeth and now was worried it wasn't being done like it should. On 3/11/25 at 12:43 PM, the Care Assistant (CA 'D') who was assigned to R34 entered the room to inquire about the activated call light. R34 reported the bed remote had fallen. At that time, CA 'D' was asked about what care had been provided to R34 earlier this morning. They reported they had only given them their meal trays. When asked if they had provided any oral care to R34 this morning, CA 'D' reported they had not. When asked about why not, such as if their assignment was too much, CA 'D' reported they were busy and had eight residents in their assignment. When asked if they had reported to the Nurse they were not able to complete any of the resident care needs, they reported they did not. Review of the clinical record revealed R34 was admitted into the facility on [DATE] with diagnoses that included: displaced bimalleolar fracture of right lower leg, other fracture of right lower leg, pleural effusion, and unspecified injury of head. According to the Minimum Data Set (MDS) assessment dated [DATE], R34 scored 7/15 on Brief Interview for Mental Status Exam (BIMS) which indicated severe cognitive impairment (however the resident was able to recall specific details during this survey that were correct) and required setup or clean-up assistance in which the helper sets up or cleans up and the resident completes the activity for oral hygiene. According to the resident's holistic care plans, R34 required one-person limited assistance with grooming, and had natural teeth. There was no specific care plan for the resident's oral hygiene status, however the care plan for assistance in bathroom identified they required total dependence of one-person physical assist. Review of the oral care documentation provided by the facility included documentation that staff were to provide documentation of the level of assistance required for all ADL (which covered section GG of the MDS assessment for all three shifts: 7:30 AM-3:30 PM; 3:30 PM-11:30 PM; and 11:30 PM-7:30 AM). The documentation provided revealed several shifts and dates from 3/1-3/12/25 that were left blank and others varied from R34 being dependent, requiring supervision, to being independent. There were no refusals of care documented. On 3/12/25 at 4:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON). When informed of the observation and interview of R34 with CA 'D', the ADON reported oral care should be included as part of the morning care and CA 'D' had received routine training about that. The ADON further reported the staffing assignments were well within reason to be able to provide care and that should not have been an issue. When asked if they were aware if R34 had any behaviors of refusal of care, the ADON reported they were not aware of any refusal of care, but that from time to time the resident liked to stay in bed. On 3/13/25 at 9:00 AM, the facility was requested to provide any dental consultations since admission for R34. On 3/13/25 at 9:50 AM, the Administrator reported they didn't have any notes regarding dental, but reported R34 did have an appointment on 3/19/25 at 2:00 PM with the dentist on campus. Review of the documentation provided by the facility for Oral Care was an excerpt from the [NAME] Procedure which read, .Oral care promotes patient comfort, nutritional intake, and oral health, and reduces dental plaque, oral colonization, and mucosal inflammation . On 3/13/25 at 9:57 AM, an interview was conducted with the MDS Coordinator (Nurse 'F'). When asked about the ADL documentation provided for R34, Nurse 'F' reported that was how the facility documented oral care. They reported they had reviewed the same documentation provided to this surveyor and confirmed the blank entries, fluctuations in assistance required, and lack of any noted refusals.

Based on observation, interview and record review the facility failed to ensure Physician orders were in place and appropriate catheter care was provided for one resident (R143) of two residents reviewed for indwelling catheters. Findings include: On 03/11/25 at approximately 11:17 a.m., R143 was observed to be in their room, laying in their bed. R143 was observed to have a catheter tube draining amber colored urine into a drainage bag. On 3/12/24 at approximately 2:44 p.m., R143 was observed in their room, walking around in their hospital gown, dragging their catheter tubing and urine collection bag on the floor without any privacy bag in it. R143's catheter tubing was not observed to be secured and was observed to be pulling away from their body as they were walking. On 3/12/25 the medical record for R143 was reviewed and revealed the following: R143 was initially admitted to the facility on [DATE] and had diagnoses including Retention of Urine and Encounter for fitting and adjustment of urinary device. A review of R143's holistic assessment 7.0 revealed the following: Continence-Urine Retention .I use a(n): suprapubic catheter .Catheter size 18Fr .Diagnosis Urine Retention Urine: [NAME] . A review of R143's Physician orders did not reveal any active Physician orders for the instruction/care or monitoring of R143's Suprapubic catheter On 3/12/25 at approximately 2:41 p.m., the medical record for R143 was reviewed with Nurse E. Nurse E was queired if R143 had any Physician orders addressing the care and monitoring of their catheter. Nurse E was observed reviewing the record and reported that R143 did not have any orders for the care of their catheter and that the Nurse who admitted them should have place them in the record. At that time, Nurse E reported that they would have to put in the orders for R143's catheter care including orders for their dressing change every day and general catheter care per shift. On 03/13/25 at approximately 9:00 a.m., during a conversation with the Assistant Director of Nursing (ADON), the ADON was queired regarding the admitting physician orders for R143's catheter care. The ADON indicated that the orders for catheter care should be entered by the admitting nurse when the initial evaluation is completed, so that documentation of the care can be done. The ADON indicated they would review the concern and return if they had any further information. No further information regarding the lack of Physician orders for R143's catheter was provided by the end of the survey.

This citation pertains to intake # MI00144708 Based on interview and record review, the facility failed to ensure services met professional standards for medication administration and documentation of controlled substances and medication documentation according to order changes for one resident (R901) of one reviewed for professional standards, resulting in R901 not receiving medication in accordance with the physician order. Findings include: Review of a complaint filed with the State Agency (SA) alleged a physician order for Morphine was ordered around 2:00 PM on 5/8/24 and the facility failed to administer for many hours later in the day resulting in R901 to .suffer for hours without ordered Morphine . A record review revealed that R901 was admitted to the facility on [DATE] for physical therapy rehabilitation and aftercare for spinal surgery from a fractured vertebrae. A comprehensive assessment for R901 was not available due to the short-term stay. A clinical record review documented R901 was alert, orientated, and capable of making their needs known. A medication record review identified a request was sent from the facility to the pharmacy via fax for removal of controlled medication Morphine Sulfate (an opioid pain relieving medication) from the contingency supply-controlled medications on 5/8/24 at 1:42 PM. The Controlled Substances Proof of Use worksheet documented the first dose of ordered Morphine was administered on 5/8/24 at 8:26 PM. The Director of Nursing (DON) was interviewed and indicated when the request for removal form is faxed, the medication is in general available to pull from the PYXIS (an automated machine used for dispensing medications) within 15 minutes. The DON acknowledged nursing should have identified the delay and if the medication was not available, then a follow up call to the pharmacy should have been done. The DON further clarified if the medication is not made available after a call to the pharmacy, the DON should have been made aware. The DON confirmed nursing should have followed up on the order soon after it was sent to the pharmacy and administered the morphine to R901 timely to when originally ordered. Review of the facilities policy title; Medication Administration, Receipt, Storage & Disposal dated 10/2023 documented: .When the licensed nurse determines that an ordered medication is unavailable .Call the pharmacy and let them know which medication is needed as soon as possible . Further review of the original order transcribed on Controlled Substances Proof of Use form documented: Morphine Concentrate20 mg/ml (milligram/milliliter) 0.25ml/5mg PO (by mouth) SL (sublingual) Every 6 hours. The Resident medication profile was reviewed and on 5/8/24 at 10:19 AM the order was changed from administering every six hours, to every three hours. On 5/9/24, the order was changed to administer every two hours. On 5/10/24, the dose was increased from 5mg, to 10 mg every three hours, and on 5/10/24, the ranges changed again from every three hours to every two hours. The DON was questioned when narcotic changes are made, does the controlled substance worksheet have to be updated. The DON confirmed every time a change is made, whether it be dose or timing, a new worksheet must be produced. The DON was provided the only worksheet identified with the original transcribed order (Morphine 20mg/ml 0.25/5mg PO.SL Every 6 hours) and the DON acknowledged a new worksheet should have been completed for every change. Review of the facilities policy title; Medication Administration, Receipt, Storage & Disposal dated 10/2023 documented: .Medication management in Continuing Care (CC) will include ordering, transcribing, receiving, proper storage, accurate documentation .Medications are administered in accordance with Nursing Standards of practice .

This citation pertains to intake #MI00144708. Based on interview and record review, the facility failed to ensure adequate, and accurate assessment, investigation, and monitoring of a resident post fall with injury for two (R901 and R904) of three residents reviewed for accidents. Findings include: R901 A complaint filed with the State Agency alleged concerns regarding R901's fall and post-fall investigation. Review of the clinical record revealed R901 was admitted into the facility for skilled therapy on [DATE] around 6:15 PM with diagnoses that included: wedge compression fracture and multiple fracture of ribs. R901 was signed onto hospice following a fall with injury within a few hours of admission on [DATE], which resulted in likely traumatic head injury per Physician evaluation, subsequent significant decline in overall status, and the resident died on [DATE]. According to the Minimum Data Set (MDS) assessment for death in facility dated [DATE], there were no details of the resident's cognition, or falls. However, documentation upon admission on [DATE] indicated the resident was alert with some confusion. Review of the progress notes included: An entry on [DATE] at 12:26 AM for [DATE] at 9:00 PM by Licensed Practical Nurse (LPN 'D' - who was R901's assigned nurse) read, Resident arrived at neighborhood approx. (approximately) 6:15pm via ambulance/stretcher and accompanied by two EMTs (Emergency Medical Technicians). She appeared to be in pain during the transfer process. She had been hospitalized on [DATE] following multiple falls in her independent apartment. Hospital records indicate multiple acute and chronic compression fractures, moderate to severe lumbar stenosis, rib fractures, traumatic ecchymosis .She is alert and responsive, with some confusion .She had a large BM (Bowel Movement) at the time of transfer and staff performed incontinence care. Observed at that time that resident had foley catheter in place draining clear straw colored urine. Her daughter followed behind ambulance to assist mother and is a good historian .Skin assessment indicates extensive bruising related to multiple falls. Bruising observed on scalp, around both eyes and cheeks, down both upper extremities, including dark purple ecchymosis on bilateral hands, with small skin tear or ruptured ecchymosis to back of L (Left) hand. Very large dark purple traumatic ecchymosis to left flank, hip and lower back, as well as smaller, but widespread bruising down bilateral thighs, shins and ankles. Observed pink rash-like appearance under abdominal fold from hip-to-hip. Large area of what appeared to be surgical bandaging down the center spine from cervical through the thoracic area. Nurse did not remove these dressings at that time, as resident wanted to eat and rest. No open areas observed on her coccyx/buttocks area, heels or bony prominences. The next entry on [DATE] at 2:25 AM for [DATE] at 11:00 PM, by LPN 'D' read, Approx 9:00pm, CENA (Certified Nursing Assistant) alerted this nurse that [R901] was found on the floor in her room. Upon entering the room, nurse observed resident lying face down on her bathroom floor with her head near the base of the toilet. Her walker was tipped over and her foley catheter and drainage tubing was observed wound around the leg of the walker, having become dislodged from resident's body. Also observed that resident had experienced a BM (bowel movement) incontinent episode .neurochecks initiated, and the afternoon supervisor was alerted to come to the neighborhood to assist. While the resident had extensive periorbital bruising upon arrival, it appears that new, fresh periorbital bruising evident, particularly beneath the L eye and above the R (Right) brow. Supervisor notified the resident's daughter, who is staying in the resident's independent living apartment .and the provider on call. Orders obtained for neurochecks, and bladder scans q (every) 6 hours r/t (related to) the removed foley, with ISC for volumes >300ml (milliliters) . An entry on [DATE] at 7:56 AM by Registered Nurse (RN 'E') read, New admit. AO x 3 (Alert and Oriented to person, place and time) with confusion . An entry on [DATE] at 2:34 PM by LPN 'G' read, received in bed resting. Alert and able to make needs known .Around lunch time resident had a change in condition. Resident respirations were 24 with an audible wheeze and distended upper abdomen. SpO2 (blood oxygen level) ranging between ,d+[DATE]% on RA (Room Air). Resident had a fixed stare. Provider was notified of change in condition. Orders given for a hospice consult. Social worker notified of orders and comfort medications put in place. Resident in bed resting with daughter at bedside. An entry on [DATE] at 8:31 AM by RN 'I' read, .Resident observed grimacing and moaning when care provided. Scheduled morphine & ativan given per orders .Resident noted to have blue tinge around her mouth when head of bed is lowered . An entry on [DATE] at 9:19 PM by LPN 'J' read, Writer received resident in bed sleeping, daughters at bedside .Scheduled medication administered, resident tolerated. At 6:30 pm writer observed no signs of life, daughters at bedside .Hospice Nurse arrived to unit, resident pronounced at 8:06 pm . Review of the facility's fall investigation included an incident report completed by RN 'F' documented multiple inconsistencies which conflicted with other documentation following the fall incident on [DATE]. The report documented, in part: Incident Date: [DATE] .9:00 PM .Fall .Found on floor .Fall involved the following device .Walker .Resident used the walker when getting out of her bed, tripped on her call light, and fell .Level of Injury: Minor .Other type of injury .scar to the underside of her left eye .Pain Scale .0 .Is this a new onset of pain? No .Mental Status: Any change in Baseline Condition .No Change from Baseline (Alert and Oriented at the resident's baseline) .Musculoskeletal Function: Any change in Baseline Condition .No Change from Baseline .Health condition post incident .No Change from Baseline .Post incident, were Neuro Checks initiated by nursing staff .Yes .At the time of the event, was resident transferred to acute care hospital .No .Person completing the Incident Report form .[Name of RN 'F'] [DATE] 10:33 PM .Conclusions of the Investigation: Patient got out of bed, used the walker, and tripped over the call light . This report conflicted from other documentation from R901's assigned nurse (LPN 'D') who was the nurse that responded to the resident being on the floor and identified the resident's catheter tubing was caught around the legs of the walker, not a call light. This report failed to identify any specific details of existing injuries and only identified a scar to the underside of her left eye. There was no other details included of any interviews with staff, or details of an investigation. Additional conflicted documentation was identified upon review of R901's Neurological Check Flow Sheet which documented the first 15 minute neurocheck was done on [DATE] at 8:00 PM (approximately 1 hour prior to the actual fall), then continued for every 15 minutes at 8:15 PM, 8:30 PM, 8:45 PM, then every 30 minutes on [DATE] at 9:00 PM, then 9:30 PM, then 10:00 PM, then 10:30 PM, then every 1 hour on ,d+[DATE] at 11:30 PM and [DATE] at 12:30 AM. The next section of times to monitor for neurochecks every eight hours on [DATE] at 8:30 AM, 4:30 PM, ,d+[DATE] at 12:30 AM, and ,d+[DATE] at 8:30 AM were all blank (incomplete). There was no additional documentation of neurocheck monitoring available for review (or provided by end of the survey) to show any additional monitoring was completed as required by facility policy. Review of follow-up documentation by nursing administration revealed no identification of concerns regarding documentation discrepancies on the incident report, or neurochecks. On [DATE] at 12:55 PM, a phone interview was completed with RN 'F'. When asked to recall the events of R901's fall on [DATE], RN 'F' reported they had recently started working at the facility on [DATE]th as an afternoon Nurse Supervisor for the facility, including the assisted living and independent living communities. They further reported if there was a call for help, they would fill out the report. They recalled one of the nurses needed help, believed R901 was a new resident and had just gotten admitted , LPN 'D' was swamped with her med pass and the resident fell . RN 'F' stated, I said I'd do the incident report. I didn't find her on the floor, [LPN 'D'] did. Not sure who the CNA was. When asked if they had received any training or education on what the facility's process was for completing post-fall assessments, they reported they were not sure. When asked about their conflicting documentation of the fall occurring due to the call light wrapped around the walker, and LPN 'D' who documented it was a foley catheter tubing that had also been pulled out, RN 'F' reported they were not sure. RN 'F' further reported LPN 'D' said R901 fell and needed help filling out the paperwork because she was so busy. When asked how the resident's neurocheck assessments were initiated prior to the fall occurrence, RN 'F' reported they were not able to offer any further explanation. On [DATE] at 1:23 PM, a phone interview was completed with LPN 'D'. When asked to recall the events of R901's fall on [DATE], LPN 'D' reported a nursing assistant came to them to let them know they found R901 on the floor. LPN 'D' reported they went to her room and observed the resident on the bathroom floor, face down on the floor with their head toward the toilet. She had a tipped over walker, and she had come in with a foley catheter and the foley catheter tubing was wrapped around the legs of the walker and she had had another episode of bowel incontinence. LPN 'D' the explained the fall occurred around 9:00 PM and after they had assessed the resident, she was awake, alert, responding and moving all of her extremities. She didn't complain of pain and said help me. LPn 'D' stated, I couldn't really lift her myself not safely. There were four of us who helped roll her onto her back, then we got her up in the wheelchair, then into bed. LPN 'D' further reported because R901 had fallen unwitnessed and appeared she had hit her head, they did an initial set of vitals and started neurochecks. When asked how RN 'F' became involved, LPN 'D' reported they had contacted RN 'F' as the nurse supervisor and did another assessment because it appeared she had more bruising. It appeared there was new bruising around her eyes. When asked who should be completing the actual fall report, LPN 'D' reported they were completing R901's admission assessment at that time, so RN 'F' completed the fall report. When asked about the discrepancy of when the neurochecks were started and why they weren't completed as required, LPN 'D' reported RN 'F' had initiated the neurocheck flowsheet and re-confirmed R901 fell around 9:00 PM. When asked if they had provided care to R901 following this incident, they reported they did not. On [DATE] at 3:00 PM, an interview and record review were completed with the Director of Nursing (DON). At that time, the DON confirmed the discrepancies in the documentation on the fall report by RN 'F' and the documentation in the progress notes by LPN 'D'. When asked about the conflicting time of how the neurochecks would've been started an hour prior to the fall, and why they weren't completed as indicated on the neurocheck flow sheet, the DON was unable to offer any further explanation. R904 Review of the clinical record revealed R904 was admitted into the facility on [DATE] with diagnoses that included: acute on chronic diastolic heart failure, chronic diastolic heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and osteoarthritis. According to the MDS assessment dated [DATE], R904 had short term memory problems with moderately impaired decisions and had no falls since entry or prior assessment. Review of the facility's roster matrix identified R904 had a fall. Review of the incident report provided by the facility documented R904 had an unwitnessed fall on [DATE] at 6:09 PM and was found on the floor in the bathroom, with a laceration to his head (right) with moderate amount of blood present. R904 was sent out to the hospital and returned just after midnight (on the night of the fall) since R904 was also on Aspirin. There was no neurocheck flowsheet initiated for R904 available for review in the clinical record. On [DATE] at 3:10 PM, the DON was asked why neurochecks were not initiated for R904 following their fall with head laceration and they reported they might not have since he was sent to the hospital. The DON also reported that the facility staff would go off of any new orders received if the provider wanted neurochecks completed. When asked whether the provider (Physician) had been notified upon R904's return to the facility a few hours after the fall, the DON confirmed the documentation indicated the physician was notified only by writing in the log book. The DON was asked if the physician should've been notified by phone of the resident's return, specifically following a head injury post fall, the DON reported the nurse should've called the physician or on-call provider and neurochecks should've been completed per facility's process/policy. According to the facility's policy titled, Neurological assessment dated ,d+[DATE]: .Unless otherwise indicated by the provider, a Neurological Assessment is performed using the Neurological Check Flow Sheet (located in the EMR [generate Assessment] .Utilizing the directions and codes on the Neurological Check Flow Sheet, observe and document neurological assessment findings .Significant changes in the neurological assessment, notification of the Provider and notification of family are documented in the nurses' notes by the licensed nurse .

Based on observation and interview, the facility failed to ensure proper storage of medications in two of two medication carts reviewed resulting in the potential of dispensing expired medications and storing unidentifiable medications in the narcotic cart. Findings include: On 5/29/24 at 9:20 AM, An unlocked medication cart was observed containing multiple bottles of Senna (stool softener medication) which had expired in 2023. Registered Nurse (RN) B acknowledged the cart serves as dual purpose as the unit treatment cart and as an overflow medication cart. RN B confirmed medications located in the cart are retrieved if needed and administered. When asked who is responsible for reviewing expiration dates within the cart, RN B responded the nursing staff on midnights should be. At 9:30 AM, The Director of Nursing (DON) arrived on the unit and was informed of the observation of expired Senna medication bottles in the first cart reviewed. The DON acknowledged expired medications are not to be stored and or administered. The DON remained present as the first drawer of the narcotic cart was opened by Licensed Practical Nurse (LPN) K and three loose pink colored pills were observed in the back left corner of the drawer placed in between two medication cups. The DON removed the medications and acknowledged unidentifiable medications are not to be stored within the narcotic storage cart. Review of the facilities policy title; Medication Administration, Receipt, Storage & Disposal dated 10/2023 documented: .Medication management in Continuing Care (CC) will include proper storage .expired medications shall be destroyed within 30 days or sooner per state regulations, in the facility .All medications will be kept in their original containers .

Based on observation, interview and record review, the facility failed to ensure food items were stored, dated, and discarded appropriately, failed to maintain the kitchen in a sanitary manner, and failed to ensure the dry storage room was free from pests. This deficient practice had the potential to affect all residents in the facility. Findings include: On 2/5/24 from 10:27 AM to 11:00 AM, an initial tour of the kitchen was conducted with the General Manager (GM 'E'). The following concerns were observed: 1) The flooring in the dry storage room was littered with debris (plastic utensils, unidentified food crumbs, and dried stains on the floors underneath the metal storage racks). 2) The dry storage room had three separate cardboard boxes of dry food items (one box with real semi-sweet chocolate chips, one box with cran-raisins, and one box with walnuts). Each of these food items were stored in a blue plastic bag inside the cardboard box. These blue plastic bags were not adequately sealed and were left open to air. When GM 'E' turned these boxes around on the metal shelving unit, there were several small, black, flying insects released. When asked about the storage of the items, GM 'E' reported their staff needed to make sure those were pulled closed, and proceeded to attempt to re-close the bags. They did not remove the items and when the flying insects were pointed out, GM 'E' offered no response. 3) The ceiling exhaust vent in the chemical storage room was observed to have a thick layer of dust accumulation. 4) The kitchen flooring near the ovens and hood vent were observed to have debris scattered throughout and underneath the counters. 5) There was a large white bin with cornmeal located underneath one of the meal prep counters. The label was difficult to read but documented it had been placed on 4/25/22 with a use by date of 4/25/23. When asked about the labeling, GM 'E' attempted to peel off the label and reported they would have someone put today's date. When asked why they were putting today's date if they label indicated it was to be used by 4/25/23, GM 'E' reported the facility rarely used the cornmeal and likely it wasn't from that long ago. When asked how could they label and date today if they were unable to identify when it was opened/used, GM 'E' reported they will see when they got the last bag of cornmeal and since they didn't use the whole lot, it would be that date. 6) The walk-in fridge had a large, clear, plastic container without a lid, which exposed the inside contents which was a large quantity of sliced zucchini. The container had a sticker label with a prepared date of 2/4 and a use by date of 2/7. When asked about how the sliced zucchini should be stored, GM 'E' reported they should be covered and reported they were going to be used today. When asked if they were still going to be used since they were not stored properly, GM 'E' reported Actually no and removed the container from the walk-in fridge. 7) There was a plastic bag stored on the top shelf of the walk-in fridge, next to other food items. When asked to verify the contents, GM 'E' reported that was an employee's lunch, more specifically drinks and proceeded to move it to a lower shelf. When asked if any employee items should be stored in the facility's fridge, GM 'E' reported they thought it was ok if it was on a different area, not with other food items. 8) The walk-in fridge had a push cart that had a box of pre-made brownies and caramel apply cheesecake slices that had broken plastic wrap and an unsealed box that exposed these food items. When asked about the uncovered food items, GM 'E' did not respond and proceeded to remove the items from the fridge. 9) The walk-in freezer was observed to have a very thick layer of ice build-up on the ceiling and the flooring in the one side of the freezer. There were many food items stored directly beneath. When asked if the food items should be stored underneath the ice-build up, GM 'E' reported they didn't think that was a problem as there was no visible ice observed on the food items and began moving some of the food around on the shelving unit and exposed a box with a layer of ice particles on the outside of the cardboard box. GM 'E' reported having an issue with the ice-build up and had someone come out a few times but wasn't able to fix it from happening and they usually had someone come in to chip away at the ice on the floor and ceiling. They further reported they were not sure if it was the heating element, but the drips and ice build-up occurred when the defrost mode kicks in, which happened several times a day. 10) The shelving unit close to the ice-build up was observed to have a cardboard box of pre-made brownies that had a broken plastic covering which exposed the contents and a cardboard box of meal cutlets was stored directly on top, which came into direct contact with the exposed brownies. When asked about the storage of these items, GM 'E' reported they would be removed and discarded. 11) At 10:55 AM, upon exiting the walk-in fridge, the same large container of sliced zucchini was now observed on the meal prep table with a blue lid on top. When asked why those were still in use when GM 'E' indicated they would be disposed earlier, they offered no response and went over the move the container to the other side of the kitchen and stated they would be discarded. On 2/7/24 AT 9:00 AM, an interview was conducted with the Administrator. At that time, they were informed of the concerns identified during the kitchen and reported they would follow-up. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) FOOD shall be protected from cross contamination by: .(3) Cleaning EQUIPMENT and UTENSILS as specified under 4-602.11(A) and SANITIZING as specified under S 4-703.11 According to the 2017 FDA Food Code: Section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .(B) Routinely inspecting the PREMISES for evidence of pests; .and (D) Eliminating harborage conditions. Section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. Section 7-209.11 Storage, Except as specified under SS 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles can not occur.

Based on observation, interview and record review, the facility failed to properly store, secure, and/or dispose medications, including controlled drugs in one of two medication carts and one of two medication rooms, resulting in increased potential for diversion and misappropriation. Findings include: According to the facility's policy titled, Narcotics/Controlled Substances dated 5/2021: .All controlled substances/medications are kept under double lock . On 2/6/24 at 8:02 AM, observation of the medication cart on the Cardinal unit revealed one of the two medication carts positioned on the outside of the nursing station was unlocked without any nursing staff present or in direct supervision. The cart was able to be opened without a key and contained various blood glucose monitoring supplies as well as a locked compartment in which controlled drugs were stored. On 2/6/24 at 8:04 AM, an employee (Nurse 'Q') was observed to slowly pull the cart around the corner of the nursing station. When queried about the unlocked cart, Nurse 'Q' reported they just saw that and proceeded to lock it. Nurse 'Q' further reported it should always be locked and reported they were not the nurse assigned, but was moving the cart to stock additional supplies. The assigned nurse (Nurse 'L') was in a resident's room with the door closed. On 2/6/24 at 8:14 AM, Nurse 'Q' was asked about the unlocked medication cart and reported they had already heard about that and it should've been locked. They also clarified the regular meds were kept in the individual rooms and the narcotics were kept in the cart that had been unlocked. 49272 On 2/7/24 at 10:20 AM, the medication storage room on the Tulip Wing was observed to be unlocked. Nurse R stated that the medication storage room was not normally used to store medications and was a general storage area. This Surveyor observed a bin of resident medications in the unlocked storage room. Nurse R reported that the medications were for a resident that had been discharged . Nurse R was asked how medications for discharged residents should be handled. They stated they should be placed into a sealed bag to return to pharmacy and should be stored in a locked room until that time. On 2/7/24 at 12:12 PM DON (director of nursing) was notified of the previously mentioned medications that were found in the unlocked storage room. When asked how discharge medications should be handled DON stated once a resident has been discharged , medications should be scanned and bagged immediately for return to the pharmacy and medication storage units should always remain locked.

Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified and respectful manner. This deficient practice had the potential to affect multiple residents that resided on the Cardinal unit. Findings include: According to the facility's policy titled, Resident Rights - Continuing Care dated 6/6/2023 documented: .The facility will promote and protect the rights of each resident and places and strong emphasis on individual dignity .The facility will adhere to state and federal regulatory requirements pertaining to Resident Rights .Residents have a right .to be treated with respect and dignity . On 2/5/24 at 2:02 PM, an observation was made from the inside the nursing station which revealed three employees talking in the main hallway of the Cardinal unit, in direct view of open resident rooms and residents in the lounge area, loudly discussing their concerns with not being able to have a break. One of the three employees was then observed to swear loudly, stating F*** this multiple times. When one of the employees attempted to tell this employee to be quiet, the same employee responded with F*** this and proceeded to walk by resident rooms and beyond the double doors to a staff only area. On 2/5/24 at 2:10 PM, an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). When informed of the observation of the staff interactions and responses, the DON asked if this was in view of residents and was informed this was in front of opened resident rooms and the lounge area. The DON indicated that should not have occurred and would address it immediately.

Based on observations, interviews, and record reviews the facility failed to ensure the required assistance level for bed mobility was provided to one (R18) of four residents reviewed for accidents. Findings include: On 2/5/24 at 1:19 PM, R18 was observed sitting in their wheelchair in their room. A limited interview was conducted with the resident at that time. Review of the medical record revealed R18 was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease and dementia and required a two person staff assistance for bed mobility. Review of a Nursing note dated 12/17/23 at 10:24 PM, documented in part . Staff was attempting to change resident, while turning res. (resident) towards staff res. Started to pull on the fame <sic> of the bed, and res. fell . Staff nurse assessed res. And noted an abrasion on the left side of the lower back measuring 10 cm (centimeters) by 1 cm, and redness noted to the back of the head slightly raised . Review of the medical record confirmed R18 required a two person assist for bed mobility. Review of a Resident Incident Report Form dated 12/17/23, documented in part . Staff was attempting to change resident. ADON (Assistant Director of Nursing): Staff member assisted resident for incontinence care, resident began having actions and expressions, grabbing onto bed rail, staff member tried to intervene to prevent fall, but resident pulled weight over, resulting in fall. Resident is a two person assist for bed mobility. Abrasion noted to L (left) side of back, no pain upon palpation . Counseling for staff involved regarding bed mobility safety, care plan direction and actions and expressions management . On 2/6/24 at 2:52 PM, the ADON A was interviewed and asked about R18's fall on 12/17/23 and the ADON A stated the care associate breached the care plan and performed R18's care alone. ADON A stated R18 required a two person assist at the time of the fall.

Based on observations, interviews, and record reviews the facility failed to ensure a level one OBRA screening (Omnibus Budget Reconciliation Act) was submitted to the Community Mental Health Services Program (CMHSP) for a level two evaluation for two (R's 7 and 2) of two residents reviewed for PASAR (Preadmission screening/resident review). Findings include: R7 On 2/5/24 at 10:35 AM, R7 was observed lying on their back in bed and an interview was conducted with the resident at that time. Review of a Level I OBRA screening dated 7/24/23, documented the resident to have diagnoses of anxiety and bipolar and documented the resident to have been prescribed antipsychotic, antidepressant, and antianxiety medications. Further review of the medical record revealed no documentation of a Level two evaluation to have been completed. Review of the medical record revealed R7 was admitted to the facility on [DATE], with diagnoses that included: anxiety disorder and bipolar disorder. Review of the physician orders documented the following orders: Rexulti 1 mg for depressive disorder Cymbalta 30 mg for depressive disorder Lamotrigine 25 mg for bipolar On 2/6/24 at 1:09 PM, the Social Worker (SW) I was interviewed and asked if the level one assessment on 7/24/23 was submitted to CMHSP for a level two evaluation to be completed or if the facility had documentation to provide that a level two assessment was completed for R7 and SW I stated they would look into it and follow back up. On 2/7/23 at 10:39 AM, SW I returned and stated the Level one screening was not submitted and they were unsure on how that got missed. SW I stated they have now submitted the Level one screening to CMHSP for review. 49272 R#2 Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included: dementia and hallucinations. An MDS (Minimum Data Set) dated 11/6/23 documented severely impaired cognition and required staff assistance for all activities of daily living (ADLs). Review of the medical record revealed a PASARR (Preadmission Screening and Resident Review) level I was completed on 8/17/23 and no PASARR II. On 2/6/24 at 3:03PM requested either a PASARR II or completed exemption from SW I. On 2/7/24 at 10:39AM SW I stated that they did a screening, level II was never submitted, and it was now submitted. SW I did not recall why it got missed.

Based on interview and record review the facility failed to effectively collaborate with the hospice agency for one resident (R2) of one resident reviewed for hospice services. Findings include: On 2/5/24 at 10:06 AM, R2 was observed laying on her back with her breakfast on her chest, asleep, with pillows under both arms. Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included: stroke, hallucinations, dementia. On 2/6/24 at 10:28 AM Nurse S was queried regarding how the facility collaborates care with the hospice agency, Nurse S reported that she was unsure and that she had only worked at the facility for a short time. They stated that they began working October of 2023. When asked where the hospice care plan is she again reported that she was unsure. They referred me to the facility visit and collaboration sheet in the hospice binder, which was found to be blank. Nurse S stated that their (hospice) visits are sporadic and not care planned. On 2/6/24 at 12:34 PM, CNA T was asked if they knew how hospice services were communicated to facility staff caring for the residents, they stated the nurses would know that answer. CNA T was unable to provide any additional details. On 2/5/24 a review of the hospice binder for R2 was completed, a log of the hospice aide visits was found, which included dates/times for the visits and the associated hospice aide's names only. On 2/7/24 at 8:59 AM an interview with the DON (director of nursing) was conducted. The DON was queried about how the facility collaborates with hospice, the DON stated that the hospice nurse is usually at the facility 5 days per week. They were unable to provide a clear answer to how the services are communicated and if they collaborate. They stated that ADON A communicates with hospice the most and may be able to provide a more clear answer. On 2/7/24 at 9:24 AM ADON (assistant director of nursing) A, stated that the nurse is at the facility Monday through Friday and communicates verbally with clinical staff and the hospice nurse will document in the residents hard chart (not in the designated hospice binder). When asked if there was any clear communication to the facility staff on when, how often and what types of hospice services will be provided, ADON A stated the services are sporadic, is communicated verbally on a weekly basis and to her knowledge, there is not communication done in print for the facility staff to reference. On 2/7/24 at approximately 11 AM, Hospice nurse U was queried on how the hospice care team collaborates with the facility staff in regards to what time of care will be provided, when, what and how often. Nurse U stated that they see residents Monday through Friday, the facility staff know who she is and to call her if they need anything. Nurse U was not able to provide a record or process that was in place to collaborate and communicate care regularly with the facility staff.

Based on observation, interview and record review the facility failed to consistently provide a rationale for declination of the pharmacist's monthly medication regimen review for two residents (R2 and R15) of the two residents reviewed. Findings include: R2 On 2/5/24 at 10:06 AM, R2 was observed laying on her back with her breakfast on her chest, asleep, with pillows under both arms. Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included: stroke, hallucinations, dementia. Pharmacy consultation report dated December 18, 2023, indicated that Physician C chose to decline the pharmacist recommendation to consider attempting a GDR (Gradual dose reduction) from Seroquel (a psychiatric medication) 25 mg (milligrams) twice daily to Seroquel 25 mg at bedtime. The rationale provided on the consultation report deferred the decision to behavioral health services with no further supporting information. On 2/7/24 at 11:28 AM an interview was conducted with the DON (director of nursing) and ADON (assistant director of nursing), A. A request was made for supporting documentation of declination of the pharmacy recommendation for December 18, 2023. On 2/07/24 at 03:20 PM, Physician C stated that for psychiatric medications and for potential GDR's they defer to Behavioral Health services. Physician C also reported that Behavioral Health services do not see hospice residents and R2 was receiving Hospice services, therefore no provider was providing a supporting rationale for the declination of the pharmacy recommendation. R15 On 2/5/24 at 11:46 AM R15 was observed laying on her back, asleep with their spouse at their bedside. Review of the medical record revealed R15 was admitted to the facility on [DATE] with diagnoses that included: dementia, anxiety, and delusions. A pharmacy consultation report dated December 18, 2023, indicated that Physician C chose to decline the pharmacist recommendation to consider changing R15's Olanzapine from 2.5mg twice per day to 5mg at bedtime, due to the medications long half-life and the increased risk for potential adverse events. The rationale provided on the consultation report deferred the decision to behavioral health services with no further supporting information. On 2/7/24 at 11:28 AM, an interview was conducted with the DON (director of nursing) and ADON (assistant director of nursing), A. Request was made for supporting documentation of declination of the pharmacy recommendation for December 18, 2023. On 2/07/24 at 03:20 PM, Physician C stated that for psychiatric medications and for potential GDR's they defer to Behavioral Health services. Physician C also reported that Behavioral Health services do not see hospice residents and R15 was receiving Hospice services, therefore no provider was providing a supporting rationale for the declination of the pharmacy recommendation.

Based on interview and record review, the facility failed to justify the use of antibiotics in according with current practice/guidance for one (R8) of four residents reviewed for antibiotic medication use. Findings include: According to the Centers for Disease Control (CDC) and Prevention NHSN (National Healthcare Safety Network) updated January 2024: Healthcare-associated Infection Surveillance Protocol for Urinary Tract Infection (UTI) Events for Long-Term Care Facilities .Criterion For residents with an indwelling catheter in place .One or ore of the following (Signs and Symptoms and Laboratory and Diagnostic Testing) .4. New onset confusion/functional decline with no alternate diagnosis AND Leukocytosis [defined by NHSN as > 10,000 cells/mm^3, or Left shift (> 6% or 1,500 bands/m^3)] .AND A positive urine culture with no more than 2 species of microorganisms, at least one of which is a bacterium of =105 CFU (Colony Forming Units)/ml . According to the facility's policy titled, Antibiotic Management dated 5/2021, approved on 3/20/23: .Antibiotic prescribing will be done in a manner that optimizes safe and appropriate use of antibiotics, enhances clinical outcomes while minimizing unintended consequences of antimicrobial use (e.g., toxicity, resistance), and reduce healthcare costs without adversely affecting quality of care . This policy did not include the updated CDC requirements in regard to antibiotic use. Review of the clinical record revealed R8 was admitted into the facility on [DATE], and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, neuromuscular dysfunction of bladder, and benign prostatic hyperplasia without lower urinary tract symptoms. According to the Minimum Data Set (MDS) assessment dated [DATE], R8 had impaired communication, short and long term memory were ok with modified independent cognitive skills for daily decision-making, and had an indwelling urinary catheter. Review of R8's physician orders included an antibiotic medication order for Cipro 250 MG (Milligrams) tablets two times a day for seven days that was started on 1/30/24 for UTI by Physician 'C'. Review of R8's urine cultures revealed the most recent culture obtained on 1/24/24 resulted in Escherichia coli (E.coli). (The urine culture from 10/16/23 also indicated a result of Escherichia coli.) Further review of the clinical documentation revealed there was no physician/provider assessment for for R8 since the urine test was ordered and antibiotic was started, nor were any labs ordered/obtained as required with the current practices for justification for antibiotic use for resident with catheters and suspected UTI. The most recent lab work completed for R8 was on 11/13/23. The most recent physician assessment was on 1/16/24 which indicated no concerns with the resident's urine and/or catheter. On 2/7/24 at 8:19 AM, an interview was conducted with the Infection Preventionist (IP 'O'). IP 'O' was asked to explain the facility's process for monitoring and ensuring justification for antibiotic medication use to ensure medications were not being prescribed unnecessarily. IP 'O' reported they pulled a medication report on a daily basis that shows what's ordered, also reviews the 24 hours report, and they would go into the chart, review nursing notes, provider notes, what the symptoms were and why the antibiotic was initiated. IP 'O' further reported they utilized an electronic system in which the information that was entered would prompt if criteria was met or not met and that was based off of McGeer's criteria (a set of infection surveillance definitions adapted from existing surveillance definitions such as the Centers for Disease Control and Prevention (CDC) with input from consensus discussions among infectious disease physicians, geriatricians, and infection control nurses to provide standardized guidance for infection surveillance and research studies in nursing homes). IP 'O' reported if not met, they would reach out to the providers and get their clinical rationale. When asked what the clinical rationale was for R8, IP 'O' reviewed their documentation and reported It was foley and agitation, so it met criteria. Also experienced mental decline. IP 'O' was queried about whether that was different from the actual baseline as the documentation reviewed indicated R8 had episodes of non-compliance/agitation due to limited speech and they deferred to the provider for further explanation. When asked if there was any lab work ordered, IP 'O' reported there was not and lab work was not always needed. When asked if there had been any consideration that R8 may have a colonized infection given the same urine results, IP 'O' reported they didn't think that was the reason, because the resident usually had hematuria and had history of UTIs. When asked when their electronic program had last been updated, IP 'O' reported they weren't sure but thought it was regularly updated. When queried about the software documentation of being reviewed in 2017, IP 'O' was unable to offer any further explanation. When asked how they became informed of any changes/revisions to requirements with infection control practices, they received updates from CDC (Centers for Disease Control). On 2/7/24 at 9:01 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of the concerns with R8 being prescribed an antibiotic medication without obtaining all required diagnostics and they reported they had not been aware of the recent CDC changes, but would follow-up. On 2/7/24 at 9:31 AM, an interview was conducted with Nurse Practitioner (NP 'D') who works with Physician 'C'. When asked about why R8 was started on an antibiotic on 1/30/24 and what was the clinical rationale, NP 'D' reported the resident had been hospitalized for urine and typically presented with hematuria. They further reported on clinical presentation, R8 had altered mental status, pain (arm for another issue), and very agitated. When asked about the lack of provider assessment, NP 'D' reported they typically provided a visit not, but was not able to circle back to do that this time. When asked if they had considered lab work if they suspected a UTI, NP 'D' reported they don't order labs every time someone had a UTI and reported they knew R8 had based on presentation. NP 'D' was informed of the recent McGeer/CDC requirements for prescribing antibiotics for residents with catheter and suspected UTI and they reported they had not been aware of the need requiring lab work.

This citation pertains to Intake # 0 Based on observation, interview and record review, the facility failed to ensure 1:1 supervision was provided and ensure a mechanical lift was utilized to prevent falls for three residents (R#15, R#1 and R#172) out of three residents reviewed for falls/accidents, resulting in R#15 sustaining laceration to the head, transfer to the hospital emergency department and three staples to the head, R#1 sustaining multiple falls and head injury, and R#172 sustaining a skin tear when not transferred per their care plan, and the potential for continuous falls. Findings include: R#15 On 9/15/20 at approximately 9:30 AM, R#15 was observed sitting in a wheelchair in their room. The resident was alert, but unable to answer most questions asked. A review of R#15's clinical record documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive one and two person assist for Activities of Daily Living (ADL). The MDS indicated that the resident had sustained a fall prior to admission. Continued review of R#15's clinical record documented, in part, the following: An initial Admission Holistic Form (8/6/20): These are mood and expressions I may or have been exhibiting Dementia/confusion Combative Assist to bathroom .Supervision . I do wander .FALLS .I have had no injuries from falls .Date of last fall 8/2/20 .This is what I believe may have caused me to fall .poor balance .My Falls Risk Assessment .History of falls Dizziness/[MEDICAL CONDITION] unsteady gait Assistive devices. Unsafe transfer impaired vision/blind Cognition/Memory Hypertension Use of Diuretics.I will need help to maintain a safe environment to allow me to ambulate freely to minimize injury or falls daily. I will need encouragement to use adaptive equipment to minimize falls or injuries from falls daily. I will need assistance with [MEDICAL CONDITION] precautions I will have a home that promotes safety. Progress note (8/7/20) authored by Nurse D . R#15 noted trying to ambulate without call light use and or walker and/or w/c (wheel chair) and to place on call light, resident stated, get the (expletive) away and started hitting at writer writer unable to assist writer and CNA (certified nursing assistant) address client together resident sitting on toilet noted smeared BM (bowl movement) in sink .and rails of bathroom. Resident refused staff to assist and swing soiled tissue at staff staff left in order not to agitate resident. Progress Note (8/7/20) authored by Social Worker (SW) F: Writer notified by nursing management to arrange for a companion for R#15 starting at soonest availability. Writer reached out to companion service (name redacted) who will start services today at 8 PM and will be continuous until writer notified to discontinue. Writer notified nursing of arrangements . Progress Note (8/8/20): Sitter at bedside the whole shift . Progress Note (8/10/20): .Resident quietly rested in bed with a sitter near the bedside . Progress Note (8/14/20) authored by Nurse D Writer standing in hallway when heard thump and someone yelling ouch. Writer went to distress call when noted resident on floor of room (# redacted). Resident noted dressed with skid free foot wear and hoyer lift in w/c resident head in bathroom and legs extended out of bathroom near w/c against wall noted in lock position, laying on right side of body. Sitter from (name redacted) companion service (name redacted) not in room. Resident alert and verbal at time of occurrence. Resident glass on floor told writer I just loss my balance that's all. Head to toe reveals laceration to right 5x2.5 with bleeding applied pressure to stop bleeding, bleeding stopped after 3.5 minutes noted indentation with swelling to back of head side of head no further skin concerns with occurrence. Writer retrieved two staff members (names redacted) resident assisted off floor x 3 person .noted blood alongside wall of bathroom .sitter from (name redacted) monitoring service after assist with transfer. Sitter educated to not leave client side without informing staff when leaving .Ice pack applied to head x 10 minutes MD (medical doctor) notified of occurrence .notified daughter and recommends resident have cat scan Bleeding has stopped. Patient last seen by staff at 1 PM in room with sitter . ambulance arrived on campus at 3 PM to take patient to (name redacted) Hospital . Progress Note (8/14/20) 10:48 PM: .patient alert oriented, came from the (name redacted) Hospital via ambulance around 7:30 PM .Dr. (name redacted) was informed if it is ok to remove staples in 5-7 days. Patient has 3 new staples on the top of head .from 7:30 PM will continue to monitor. Progress note (8/16/20): sitter was asleep as well tried to wake sitter x3 sitter woke up on the 3rd time, writer gave sitter instruction not to sleep on duty d/t res being high risk for falls. A Resident Incident Report Form (I/A) dated 8/14/20 documented, in part, the following: Detail Event Type: Found on floor .Fall involved the following device: wheelchair .Event observed: No .Event Description (see progress notes dated 8/14/20 authored by Nurse D (as documented above) .Steps taken to Prevent Recurrence (Actions) Companion Service sitter not to leave client side unattended .res transported to (name redacted) Hospital vial EMS for further testing, res returned 3 hours later with 3 staples to rt side of .scalp, 24/7 sitter in place, Companion Service manager notified of their staff leaving res alone in the room without notifying our staff first . On 9/16/20 at approximately 12:50 PM an interview was conducted with Nurse D. Nurse D indicated that they had worked in the Facility for [AGE] years. When queried about the incident involving R#15 that occurred on 8/14/20, Nurse D reported that the resident had been transferred from the Memory unit and was showing behavioral issues when they first arrived. As such, the resident was assigned a 1:1 companion 24/7 to ensure the resident remained safe. Nurse D indicated that Social Worker (SW) F arranged the service and a 1:1 companion(s) came from (name redacted) companion service. Companion G (name redacted) was assigned to R#15 on 8/14/20. Nurse D reported that she heard the resident yelling from their room and when she went to see what was wrong she found the resident on the floor, half inside their bathroom and half in their room. Noticed blood and a laceration to the head and indicated that the resident was sent to the hospital and had three staples. Nurse D stated that Companion G was not in the room and did not provide any notice that they were leaving and stated, had she done so, we would have made sure someone else was with the resident as they needed 1:1 care. Nurse D stated she contacted the Companion Service to report the incident. On 9/16/20 at approximately 1:16 PM, a phone interview was conducted with SW F. SW F was queried as to their involvement when scheduling private Companions for the residents. SW F indicated that they usually receive notice from nursing staff that a resident needs 1:1 supervision and then they contact (name redacted) Companion Service to schedule. SW F also indicated that they arrange payment with the resident and/or family. When asked for the Policy pertaining to outside Companions that enter to provide 1:1 supervision, SW F reported that they are to remain with the resident and if, for any reason, they need to leave the resident's room, they are to inform nursing staff. On 9/16/20 at approximately 4:20 PM, an interview was conducted with the Administrator pertaining to R#15's fall on 8/14/20. The Administrator recalled the event and indicated that the Facility utilizes (name redacted) Companion Service that provides private pay supervision to residents. The Administrator stated that due to Covid-19 the Facility was primarily using (name redacted) Companion Service for its residents. When asked if the Facility had a policy and/or contract that would define the expectation of private companions that employed by a service selected by the Facility, the Administrator reported that there was not a specific policy. The Administrator further indicated that if any facility resident, including R#15, receives 1:1 supervision from an outside source selected and scheduled by the facility, they should be supervised 100% of the time and if they need to leave the resident for any reason they are advised to inform the facility so that a staff member can assist the resident. R#1 On 9/14/20 at approximately 10:00 AM, Resident #1 was observed in their room sitting on a wheelchair. The resident was alert, but had difficulty answering many questions asked. The resident was able to ask for assistance to adjust their pants. A review of R#1's clinical record documented the resident had been admitted to the facility on [DATE], readmitted [DATE] through 6/23/20 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A MDS (4/30/20) documented that the resident had a Brief Interview for Mental Status (BIMS) score of 8/15 (moderately impaired) and required extensive two person assistance for all transfers and bed mobility. Continued review of the resident's clinical record documented, in part, the following: Entry note (2/17/20) 11:09 AM: Resident admitted with confusion. Observed not following simple instruction. Resident attempting to get in and out of bed multiple times. Resident hospitalized due to fall. Contacted Home Support and DPOA (Durable Power of Attorney) DPOA in agreement to Home Support, 24 hours 1:1 supervision for 2 days. Caregiver informed to start tonight at 10:00 PM, relief will arrive at 7 am and stay till 3 PM. An I/A (dated 2/18/20) documented, Date reported 2/18/2020: Incident date: 2/19/20 .Incident Time: 3:16 PM Event Description and Presence of Injury: At approx 3:16 Staff approached nursing station and stated, (name redacted) needs to know if patient is on blood thinners .Upon arrival into room, Afternoon aide sitting with resident in room resident laying on right side of body with pillows surrounding neck .Resident stated, 'I don't know what happened one minute I am in chair and the next I am on floor' Resident did state 'I hit my head right side and both my shoulder hurts,' Staff reports her sitter left at approx 3:10 PM. Resident alert and noted some confusion which is usual state. This occurrence was unwitnessed .No available units in area for ambulance .first responders arrived on campus and placed on cervical collar .resident left via stretcher at 4 PM .Steps taken to Prevent Recurrence: Agency will inform staff and give verbal report to staff when coming and leaving facility .Staff was immediately inserviced that res with scheduled 24 hr sitter is not to be left alone in the room at anytime, CNA is not to sign (Companion Service) paperwork at the end of their shift they are to inform sitter to find the nurse for signature .manager notified of incident to reeducate his staff that they are not to leave the room until their replacement is in the room for face to face report, if replacement is not available a CNA is to be pulled to sit with the resident until one is available, nursing has been informing .sitter as they come on to their shift that they are not to leave the room to use the bathroom or get a drink unless staff is in the room to monitor the resident . A hospital record (date of evaluation 2/18/20) documented, in part: Patient .presenting to emergency department due to a fall she had been just here in the hospital where she was admitted for several days due to old rib fractures .she was discharged to (name redacted) facility yesterday according to the staff and family they report they got was that she was found on the floor and states that she stood up and lost balance and fell forward .she states she hit her head on the right side she did not lose consciousness she said the headache was improving .she is having some right shoulder pain and right hip pain . An I/A form dated 3/5/20 documented, in part, the following: Incident date: 3/5/20 .Incident time: 1:05 PM .Fall: chair (out of) .Event description: Writer was walking by the dining room and noticed resident was laying on the floor with nurse educator .resident verbalized that she noticed that several others were leaving the dining room and she was trying to leave as well . An I/A form dated 4/13/20 documented, in part, the following: Incident Date: 4/13/20 .Incident time 12:05 PM .Fall: Chair (out of) .Event Description: Writer was coming out of another resident's room when she heard resident shout I fell .She verbalized that she had hit her head .She denied having pain .no bruising, skin tears .She verbalized she didn't know why she stood up . An I/A for dated 4/23/20 documented, in part, the following:Incident Date: 4/23/20 .Incident Time: 12:15 AM .Fall: found on the floor Event Description: Resident found sitting on the floor near bed, resident transferred from wheelchair to bed by self w/o (with out) assistance, did not use call light .Steps taken to Prevent Recurrence (Actions) .Encourage resident to use call light for assistance CC (name redacted) Manager H offer assistance with transfers and getting ready for bed, continue with safety checks while res is in the room, engage the res in conversation . An I/A dated 4/30/20 documented, in part, the following Incident Date: 4/26/20 .Incident Time: 6:00 PM .Fall: ambulating (while) .Event Description: Resident is going to be sent to hospital due to fall with head injury .per supervisor res fell and sustained a big laceration on the left side of her head with bleeding .transferred resident to (name redacted) Hospital .Conclusion of Investigation: CNA was collecting dinner trays when she went into room .aid told her to take her time and she would be back to get tray .by the time the aid got to the end of hall she heard a loud boom .resident uses w/c but can ambulate with unsteady gait, resident uses 02 .and does not always remove it when she gets up from chair .recently had private sitter discontinued, poor safety awareness . Steps taken to Prevent Recurrence .continue with plan of care .CC (name redacted) Manager H res returned from Hosp. on 4/30/20 with 24/7 sitter x14 days for strict isolation precautions, sitter to provide companionship and safety, staff to monitor for room safety frequently . A Hospital record (4/29/20) documented, in part: .patient does have a left frontal scalp hematoma with laceration with sutures .:. A care plan dated 2/27/20 was provided by the Facility and documented, in part, the following: Goals .need help to maintain a safe environment to allow me to ambulate freely to minimize injury or falls daily .Care Plan Approaches to address risks check .24 hr continuous sitter at bedside throughout day/night (on hold 4/10/20), Non skid foot wear for transfer/ambulation, assistance provided for all needs. Monitor vitals and pain assessment frequently .hand written notes fall mats .no low bed .3/5/20: fall in dining room, ice pack to rt forehead .4/13/20 (word not legible) for sitter 4/23/20: Fall in bedroom .continue to use non-skid for transfer and ambulation .provide assistance to all needs .continue to remind res to use call light assistance and wait for help,. On 9/17/20 at approximately 11:20 AM, a phone call was made to the Manager H of (name redacted) Companion Service. A voicemail was left. No further communication was made prior to the end of the survey. On 9/17/20 at approximately 11:40 AM, an interview was conducted with the DON. When queried as to the incidents pertaining to R#15 and R#1 who were left in their rooms unsupervised, the DON stated that ultimately the facility is responsible for residents in need of 1:1 supervision. On 9/17/20 at approximately 12:15 PM, an interview was conducted with the Administrator regarding R#1's falls. The Administrator reported that R#1 initially was provided 1:1 supervision via the Companion Service and later the service was removed as the resident was noted to have improved. It should be noted that the resident care plans document the service was place on hold on 4/10/20. R#1 had continued falls on 4/13/20, 4/23/20 and 4/26/20. R#172 A review of R172's clinical record was conducted and revealed R#172's Minimum Data Set assessment dated [DATE] indicated R172 had mild cognitive impairment and required total assistance of two staff members for transferring. On 9/16/20 at 2:08 PM, a review of a facility reported incident investigation file for R172 was conducted. The file contained an untitled document dated 9/24/19 at 10:15 PM that read, .Incident Summary: Staff member allegedly transferred Resident with a gait belt resulting in her being lowered to the floor. Resident was discovered to have a superficial skin tear following the incident . Investigation Summary/Actions Taken: On 9/24/19 at approximately 10:15 PM, care associate was unable to move a hoyer (mechanical lift used for transferring residents) lift to the Resident's room for a transfer from Resident's wheelchair to her bed. Resident requires extensive assist and the use of a hoyer lift for transfers per her care plan. Care associate returned to Resident's room, used a gait belt and attempted a one person transfer. Resident's feet began to slide during the transfer and care associate lowered Resident to the floor .and went to get help. Care Associate returned with another care associate and two lifted Resident into her bed. After transfer, care associate noted skin tear to the back of Resident's right upper arm/shoulder .Care associate was interviewed and stated she was aware of Resident's care plan and the need for a hoyer lift. Care associate acknowledged she did not ask for assistance prior to lowering Resident to the floor. Care associate acknowledged that she transferred the Resident improperly .Care associate was given corrective action for failing to follow the facility's transfer policy and inservice education on the community's policy on Lifting, Transfer, and Bed Mobility before returning to work . A review of a document titled, Staff Notes contained in the investigation file was reviewed. The notes were dated 9/24/19 at 10:15 PM, and revealed a hand written statement from Certified Nursing Aide/Care Associate (CNA) 'B' that read: I was getting Hoyer lift to proceed to (room # redacted, resident name redacted). I was pushing the lift. It kept on stopping, not allowing it to be pushed. So I went to resident's room attempted to transfer her myself from wheelchair to bed. Resident started to slide, so I lowered resident to the floor .and went to get help. Then my co-worker and I lifted her off the floor and put her in bed. After that I noticed a skin tear on her right shoulder. I went to tell the nurse what happened. Continued review of the investigation file included a signed interview with Certified Nursing Assistant (CNA) 'B' that read, What happened yesterday? I was getting the Hoyer to transfer (R172) but the Hoyer kept stopping. I went down to her room and put a gait belt on her and attempted to transfer her from the wheelchair to the bed .When I lifter <sic> her she started to slide and I lowered her to the floor .I left the room and got (CNA 'C') to help get her from the floor to the bed .When you got the Hoyer and was <sic> bringing it down the hall way <sic> you knew she was a 2 person with a Hoyer. Why didn't you get a second person? I don't know. Why didn't you go to another floor and get another Hoyer? I've worked on the 3rd floor and they don't have a Hoyer up there. I assumed going to get one from another floor wasn't an option. We just in-serviced about this 2 weeks ago what happened. I don't know I made a mistake. A review of a signed interview from CNA 'C' contained in the file was reviewed and read, What happened on Tuesday, September 24, 2019? .I didn't do nothing but help her get the resident off the floor. (CNA 'B') told me that the Hoyer was broke. She said she tried to transfer (R172) with the booties on and she started to slide and she lowered her to the floor. She asked me to help get the resident off the floor. Then she came out and told (Licensed Practical Nurse (LPN) 'D') that the resident had a skin tear on her back .Did (CNA 'B') ask you to help lift the resident prior to you assisting (CNA 'B') when the resident was on the floor? No. A review of R172's care plans included in the investigation file were conducted and hand written on the care plan was the following: .Resident will now transfer (with) Hoyer lift as of 5/3/19 . A review of Licensed Practical Nurse (LPN) 'D's progress note dated 9/24/19 was conducted and read, Per (CNA) the hoyer lift is not working so she just transferred res. (resident) by herself from wheelchair to bed but resident's socks start <sic>to slide (CNA) lowered res. down on the floor and went to ask for another (CNA) to put res. in bed, then she noticed that res. got a skin tear on her right upper arm, I assessed the skin tear, it is superficially open skin, thin skin is rolled open, tried to unrolled <sic> it and covered back on, with slight bleeding, cleansed with NS, (normal saline) pat dry, TAO (wound treatment) applied and covered with .non-adherent strips and 4x4 gauze, secured with Kerlix, no c/o pain during the procedure family notified, logged in Dr.'s log book . On 9/16/20 at 4:40 PM, an interview with the facility's Administrator was conducted regarding R172's improper transfer. The Administrator indicated R172 was a two person mechanical lift and CNA 'B' attempted to transfer her by herself using a gait belt. The Administrator further indicated CNA 'B' had been suspended pending the investigation, been given one-to-one inservice and received a written warning regarding the incident. A review of a facility provided policy titled, Fall Management version dated 2/2020 documented, in part, the following: Policy: To minimize and/or decrease the risk of falls through a interdisciplinary review of guest/resident and to develop individualized care/service plan approaches .3. Guest/resident with identified 1 or more risks will be considered at risk for falls and the Falls Prevention protocols will be initiated .10. DON and/or designee will review 24 Hour Report and audit falls documentation to ensure it is complete and accurate, to include completion of investigative protocols, review of care plan and updating of Holistic Assessment .DON and/or designee will report fall trends any action plans developed to keep guest/residents safe from falls and/or decrease frequency of falls . A review of a facility provided policy titled, Lifting Transfer Bed Mobility Local Review version dated 2/2018 was conducted and read, .2-person Total Body Lift is used the resident Cannot bear weight or Offers minimal or no assistance with the lift/transfer .2 individuals (trained staff persons) are required when using the Total-Body lift .Procedure: .7. Each guest's/resident's care or service plan will address care approaches if a mobility need is identified to include type of lift .8. Type and level of assistance required for a guest's/resident's transfer mobility will be communicated to staff. Information will include device to be utilized, number of staff required for bed mobility and/or transferring assistance.

Based on observation, interview and record review, the Facility failed to provide adequate supervision and implementation of fall safety interventions for one (#505) of four (4) sampled residents reviewed for falls from a total of 24, resulting in multiple falls, bruises, hematomas, a fracture to the hip and pain. Findings include: On 10/24/17 at 12:00 p.m., Resident #505 was observed in the large dining sitting in a wheelchair. The Resident was alert, but not able to answer all questions asked. On 10/24/17 at 1:30 p.m., a review of the Resident's clinical record was conducted and documented that the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Resident's MDS (medical data set) completed 9/17/17 revealed that the Resident had a BIMS (brief interview for mental status) score of six (cognitively impaired) and required extensive two person assistance for transfers and extensive one person assistance for ambulation and personal hygiene. Continued review of the Resident's clinical record documented the following fall risk Assessments: 8/5/17 - Score 16 (High Risk) 5/3/17 - Score 13 (High Risk) 2/12/17 -Score 9 (Moderate Risk) A review of the Resident's Incident Report Forms (I &A) was conducted on 10/24/17 at 3:00 p.m. and documented, in part, the following: Incident date 3/27/17 (9:20 p.m.): Per Pt (patient) she was trying to get out of bed and lost her balance. Then she crawl to the door (was closed) to alert someone for help, where she was found by staff. Incident date: 3/29/17(8:00 a.m.): HHA (certified nursing assistant) walked by res(resident)room and saw her on the floor flat on her back in her bedroom, res head was facing the bathroom door and her feet were towards the window. Res had on a shirt, brief and no socks, the walker was across the room, NP (nurse practitioner) was notified and did neuro check. res c/o (complained of) pain to her rt (right) hip and her head, she had a large bump on the back of her head Conclusions of the Investigation: Res had dementia and very poor short term memory, res has been reminded to use the call light and ask for help to get up in the room, res got herself out of the bed to go to the bathroom and slipped falling to the floor landing on her back . Steps taken to Prevent Recurrence: res is to wear a gripper socks when put in bed, door to be room to be left half open so staff can watch her, limit resident's time alone in room Incident date: 4/13/17 (12 p.m.): Nurse walked into res room to check on her and found her kneeling in front of the sink holding on with both hands, res had feces on towel in the sink and feces on her bottom and lower back, res stated she was at the sink washing and felt her legs give out no injury noted Conclusion of investigation: Res got up without using her call light Steps taken to Prevent Recurrence: Door is left open, call light attached to res clothing, continue to toilet as previously stated . and monitor. Incident date: 5/5/17 (11 a.m.): Staff was walking past residents room and saw her kneeling by the side of the bed trying to get up, res did not know how she got to the floor, walker and w/c (wheelchair) out of reach by her dresser, res was sleeping prior to her being on the floor . Conclusion Res woke up and tried to get out of bed she slide to the floor and to her knees but could not pull herself back up. Steps taken to Prevent Recurrence: Staff to have resident up by 11 am (that is when she likes to get up usually) help with morning hygiene keep walker next to her bed. 6/28/17 (11:15 p m.): Nurse assessed patient 45 min prior to fall. Patient was busy, backing her belongings. Nurse offered patient to go to bed, patient stated she was not ready. After 45 min nurse observed patient on her bil (bilateral) knees on the floor and body above waist, .pt could not give any explanations about what happened. Conclusions of Investigations: cont. current care plan. Treatment to bil knees. Pt uses black rubber sole shoes during the day with nylon socks under and non skid sock during the night when in bed. Res was wearing black shoes earlier, but took them off and had black nylon socks (slippery) .Resident often experiencing sundow[DIAGNOSES REDACTED] . Steps taken to Prevent Recurrence: .staf to monitor residents activity closely and distract resident when she starts packing her things .make sure she had proper foot ware on (shoes or non-skid socks) 6/30/17 (6:15 p.m.): Resident stood up from wheel chair and preceded to walk in dining room and fall onto her buttocks and hit head. Conclusions: Resident was walking in dining room without assistive device . Steps taken to Prevent Recurrence: Make sure resident is using assistive device at all times . 7/16/17 (6:30 p.m.): Per resident heard a knock on the door and went to answer it. Resident observed on bedroom floor on the other side of threshold in seated position. Walker was located in front of her behind door. Resident observed barefoot .injury hematoma to back of head (small egg) Conclusions: .due to resident ambulating barefoot in room (shoes and socks were on the floor) lost balance Steps taken to Prevent Recurrence: Resident to keep non skid socks on at all times if not wearing proper footwear .Reminders to ask for assistance via call button within reach. Keep door open at all times 8/2/17 (7:00 p.m.):It appears to be that resident pushed her w/c outside her room using it as a walker, left it outside the room door with few books piled on w/c, then it appears that she walked back to her room without the device. Before she reached to the walker that was in her room, she fell . Was found on her R (right) side, c/o R hip/groin pain . Conclusions: Resident with Hx (history) of sundown at around 6-8 pm where she looses her reality orientation and she starts packing/re arranging thinks in believe that she is moving out .Resident asked *HHA to take her back to her room (resident was in her w/c which she uses at times ) Resident was helped to the bathroom, in her w/c per her request (with the door open) . It appears to be that resident got up and using her w/c as a walker, pushed it out of the room, where it was found at the time of the fall, with a few books that she placed on the w/c seat. After that, per resident's statement, when asked how did you fall she said, I was trying to get back to my walker and fell . Steps taken to Prevent Recurrence: Patient was transferred to the Hospital (name redacted). Will evaluate upon return, Resident, her family *It should be noted that no documented interview statements were provided by the Facility with reference to the incident above. No information was provided in the I&A above as to who the HHA was that helped take the Resident back to the room and to the bathroom prior to the fall. A clinical note (authored by Nurse M ) dated 8/2/17 at 7:20 p.m. documented, Writer was called in resident's room, she was on the floor, on her R side, reported severe pain to her R hip/groin .she was transferred to bed .resident was sent 911 due to severe pain to Hospital ER (name redacted) .unable to perform ROM (range of motion) to RLE (right lower extremity) A Physician order [REDACTED].primary Diagnosis: [REDACTED]. Continued I & A reports were reviewed: 9/6/17 (4:15 p.m.) Res was observed siting in the wheelchair in her room, per HHA they just saw her room door is closed so I knocked the door and when I opened it I saw her on her left side on the floor by the bed .go up with 2 person assist and she got up without complaint of pain. Conclusions of the Investigations: Res is alert and oriented x2 with confusion and forgetfulness, she was left by therapist in room sitting in wheelchair, she was alone in the room after HHA went and check on her . Steps taken to Prevent Recurrence: Offer and assist resident to bed Limit being alone in her room times, unless resident is sleeping/napping . 10/3/17 (11:50 a.m.) Resident observed in the BR (bathroom) near the living room on the floor. Resident tried to toilet herself and fell . There was no staff member that witnessed this fall . Conclusions of the Investigation: Resident was sitting in her w/c in the living room watching TV. Resident decided to take herself to the bathroom near the (name redacted) living room. Resident tried to transfer herself onto the toilet and fell on to the BR floor On 10/26/17 at 12:00 p.m., an interview and record review was conducted with Nurse M pertaining to the significant number of falls sustained by Resident #505. Nurse M reported that the Resident resided on the second floor through September 2017 and then was transferred to the third floor. When queried as to what interventions were in place to protect Resident #505 from sustaining falls, Nurse M reported that the Resident was confused and liked to be in her room and do things on her own, but they tried to keep her door open and make sure she wore non-skid socks or shoes. Nurse M stated, We did begin to see she was having increased confusion and sundowning ( a symtom of Alzheimer's disease and other forms of dementia. It's also known as late-day confusion). We would attempt to distract her and let our CNA's know to keep her occupied, but if she wanted to do something like go in her room, we would let her. Nurse M was queried as the fall incident that occurred on 8/2/17 leading to the Resident sustaining a fracture to the right hip. Nurse M reported that CNA N was assigned to work with the Resident that evening. Nurse M was queried as to whether Resident #505 should have been left in her room and/or bathroom in a wheelchair alone. Nurse M stated, Again, she let us know that she wanted to be in her room. On 10/26/17 at 1:44 p.m, a phone interview was conducted with CNA N. CNA N was queried as to the fall sustained by the Resident on 8/2/17 resulting in a fall. CNA N stated, I remember working with the Resident. I remember that she needed to be transferred with assistance. She was confused and liked to do things on her own. I did push her in the room and bathroom in her wheelchair. She wanted to stay in her room, so I left her in her wheelchair. I did write a statement about what happened. I can't remember everything. If I'm not mistaken we always write a statement about what happened. On 10/26/17 at 2:30 p.m., an interview was conducted with the Administrator. The Administrator was queried as to the Facility's Fall Investigations policy specifically pertaining to Resident #505 fall resulting in a fracture to the right hip. The Administrator stated, I remember the event. I know Resident #505 was not making good decisions. I do remember getting a statement from CNA N. I know it was not attached to the I&A. I remember that CNA N felt that she fell because of her. Again, we do not have the documented statement. We need to work on doing better at that. On 10/26/17 at 1:00 p.m., a review of the Facility's Policy titled Fall Management revealed, in part, the following: Purpose/Scope: To minimize the risk of falls, reduce injury and ultimately improve the quality of the life of our residents. Policy: The preventative management of falls is a priority for the continuing care resident(s) . The Fall management policy outlined in this policy will be used to ensure .that the resident receives adequate supervision . Procedure: 3. The following residents will be considered at high risk for falls. a. score of 10 or greater on the Falls Risk Assessment. b. Fall within the past 6 months .

Based on interview and record review, the facility failed to implement safety interventions based on assessed needs, which included a motion sensor room light, to limit the potential for falls for one (#702) resident of two reviewed for falls of a total sample of three residents, resulting in a fall with fractures of the left flank eighth, ninth and tenth chest ribs, which required emergency hospital care. Findings include: During an interview on [DATE] at 4:30 pm, a family member of Resident #702 alleged that the resident had fallen at the facility and was transferred to the hospital on [DATE] for uncontrollable pain. The family member stated that Resident #702 was diagnose at the hospital with fractures of the left flank eighth, ninth and tenth chest ribs. Resident #702 expired at the hospital on [DATE]. On [DATE] at 9:00 am, review of the closed clinical record for Resident #702 revealed the following. Resident #702 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #702 was transferred to the hospital on [DATE] for uncontrollable pain. Resident #702 expired at the hospital on [DATE]. According to the quarterly minimum data set resident assessment, dated [DATE] for Resident #702, Resident #702 had severely impaired cognitive skills for decision making and required one person assistance for transfer and ambulation. The 'Falls Risk Assessment,' dated [DATE], for Resident #702, reflected Resident #702 had a score of '10' which indicated high risk for falls ('high risk if score is 10 or above'). A 'Resident Incident Report Form', dated [DATE], 5:45 am, for Resident #702, reflected, ' CA (care assistant) reports she heard a loud thump coming from resident's room. Upon investigating resident was noted sitting on the floor of his room behind the bedroom door. His back was against the wall and his legs were stretched out in front of him. His walker was next to his bed .Steps taken to prevent recurrence(actions): 30 min. safety checks initiated, referred to rehab, will add a motion sensor light in addition to the night light installed in the room has been ordered .' The 'Fall Risk Care Plan' updated [DATE], reflected, 'Lack of safety awareness, requires motion sensor night light'. A 'Resident Incident Report Form', dated [DATE], 7:45 am, for Resident #702, reflected, 'res was found sitting on floor next to his walker in his room calling for 'help' while writer was doing rounds at end of shift. Room was dark, his walker was laying on the floor next to the dresser .Steps taken to prevent recurrence (Actions): Monitor frequently, place a sensor night light in room if possible. Keep door slightly open while in bed to provide some outside light ' A clinical note, dated [DATE], 7:45 am, reflected, ' .res was examined for injury, none found rom (range of motion) was wnl (within normal limits) on all extremities .a reddened area aprox (approximately 4x4 cm was seen on his L (left) flank area .' A subsequent note, dated [DATE], 1:24 pm, reflected, 'pt (patient) complains of left flank/rib pain when sitting against area on chair .stat Xray ordered .conclusion: no acute rib fracture identified. Chest AP/LAT (anterior posterior lateral aspect) conclusion: cardiomegaly without acute pulmonary process. A 'Resident Incident Report Form,' dated [DATE], 3:40 am, reflected, 'Upon entering Mr. (NAME REDACTED) #702 room, writer observed him kneeling, holding onto the front of his recliner. He was moaning and grimacing whenever he tried to move 4 staff assisted him into his w/c (wheel chair). He displayed ,[DATE] on pain scale .Steps taken to prevent recurrence (Actions): Continue 30 safety checks for 72 hr .motion sensor lights installed in room .' A clinical note dated [DATE], reflected ' Approximately 4:30 pm resident sitting in wheel chair not saying much and wincing in pain when trying to reposition himself. Pain medication given, then he went to dinner .Was assisting resident into chair to play bingo upon standing he began to yell in pain. Provider on call notified. Orders given to transport to hospital for uncontrollable pain .' During an interview on [DATE] at 1:00 pm, the medical director of the facility reported that Resident #702 was diagnosed at the hospital with left flank fractures to the eighth, ninth and tenth ribs and stated ' .no doubt he got the fractures from the fall .' On [DATE] at 3:00 pm, during an interview, the unit manager for the dementia unit confirmed that the Falls Care plan included the intervention dated [DATE] 'motion sensor night light. The unit manager explained the motion sensor night light was on back order from the supply company and was not installed until [DATE]. The unit manager further stated that the use of motion sensor night lights with two other residents had been successful in reducing falls. The unit manager stated ' . The brightly lit room is so much more safe for the ambulatory residents .' On [DATE] at 4:30 pm, during an interview, the Director of Nursing (DON) confirmed that the Fall Care plan, updated [DATE] included the intervention motion sensor night light. However, the motion sensor night light was on back order. The DON further confirmed that all interventions on the care plan should have been implemented. According to the facility policy Fall Management, ,[DATE], The preventative management falls is a priority for the continuing care residence (s). The Fall management plan outlined in this policy will be used to ensure the resident environment remains as free of accidental hazards as is possible and that the resident receives adequate supervision and assistive devices to prevent accidents.' ( )

REFERS TO INTAKE MI 243 AND CONTAINS MULTIPLE DEFICIENT PRACTICE STATEMENTS. BASED ON INTERVIEWS AND CLOSED RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY ASSESSMENTS, CLOSE MONITORING, AND PREPARATION FOR DISCHARGE FOLLOWING A FALL FOR 1 (#500) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 4, RESULTING IN RESIDENT #500'S hospitalization FOR A SUBDURAL HEMORRHAGE. FINDINGS INCLUDE: RESIDENT #500, [AGE] years OLD, WAS admitted to the facility on [DATE] PER THE FACILITY FACE SHEET. A HOSPITAL TRANSFER FORM DOCUMENTED THAT RESIDENT #500 HAD CABG (CORONARY ARTERY BYPASS GRAFT) SURGERY ON 7/25/11. SHE HAD [MEDICAL CONDITION] FIBRILLATION (CARDIAC ARRHYTHMIA), AND TREATMENT INCLUDED [MEDICATION NAME] (ANTICOAGULANT) AND ASPIRIN (DECREASES PLATELET AGGREGATION). A SIDE EFFECT OF THIS TREATMENT INCLUDES BLEEDING. A LABORATORY TEST, AN INR (INTERNATIONAL NORMALIZED RATIO), MONITORS THE THERAPEUTIC LEVEL OF [MEDICATION NAME]. THE TRANSFER ORDERS INDICATED THAT THE GOAL OF INR THERAPY WAS 2 TO 3 (THERAPEUTIC LEVEL). ACCORDING TO THE ANTICOAGULANT FLOW SHEET, RESIDENT #500'S INR ON 8/4/11 WAS 1.3. THE [MEDICATION NAME] DOSE ON 8/4/11 WAS 3 MG. THE FOLLOWING CHANGES IN THE DOSE OF [MEDICATION NAME] WERE MADE DEPENDING ON THE INR IN AN EFFORT TO REACH THE THERAPEUTIC LEVEL OF [MEDICATION NAME]. 1) ON 8/6/11, THE INR LEVEL WAS 1.6 AND THE [MEDICATION NAME] DOSE WAS 3 MG. 2) ON 8/8/11, THE INR LEVEL WAS 1.9 AND THE [MEDICATION NAME] DOSE WAS 2 MG. 3) ON 8/11/11, THE INR WAS 1.9 AND THE [MEDICATION NAME] DOSE WAS 2 MG. 4) ON 8/15/11, THE INR LEVEL WAS 1.5 AND THE [MEDICATION NAME] DOSE WAS 2.5 MG. 5) ON 8/18/11, THE INR LEVEL WAS 1.9 AND THE [MEDICATION NAME] DOSE WAS 2.5 MG. 6) ON 8/19/11, THE INR LEVEL WAS 2.0 AND THE [MEDICATION NAME] DOSE WAS 2.5 MG. 7) ON 8/22/11, THE INR LEVEL WAS 2.5 AND THE [MEDICATION NAME] DOSE WAS 2.5 MG. 8) ON 8/25/11, THE INR LEVEL WAS 3.0 AND THE [MEDICATION NAME] WAS HELD (NOT GIVEN). ACCORDING TO AN MDS (MINIMUM DATA SET) ASSESSMENT ON 8/29/11, RESIDENT #500 HAD NO COGNITIVE IMPAIRMENT. A PHYSICAL THERAPY SUMMARY, DATED 8/24/11, DOCUMENTED THAT RESIDENT #500 HAD MET ALL THERAPY GOALS. THE RESIDENT WAS TO RETURN TO HER HOME ALONE WITH HOME CARE AND FAMILY SUPPORT. THE RESIDENT WAS ABLE TO AMBULATE 200-300 FEET INDEPENDENTLY, AND SHE WAS INDEPENDENT IN HER ACTIVITIES OF DAILY LIVING (ADLS). ON 8/24/11 THERE WAS A physician's orders [REDACTED]. AN INCIDENT REPORT, DATED 8/25/11, INDICATED THAT RESIDENT #500 fell WHILE INDEPENDENTLY TOILETING HERSELF AT APPROXIMATELY 12:00 A.M. THE RESIDENT, ACCORDING TO THE REPORT DID NOT TELL ANYONE ABOUT THE FALL. A NURSE'S NOTE, ON 8/25/12 WRITTEN AT 7:31 A.M., DOCUMENTED THAT EARLIER IN THE SHIFT, BUT NO TIME GIVEN, WHEN THE RESIDENT WAS BROUGHT INTO THE SHOWER ROOM, SHE (#500) WAS OBSERVED WITH "SWELLING" AND "MINIMAL DISCOLORATION" TO THE HER LEFT EYEBROW AREA. THE INJURY WAS CLEANSED WITH NORMAL SALINE. AN ANTIBIOTIC OINTMENT AND STERI STRIPS WERE APPLIED. THE RESIDENT DENIED PAIN, DIZZINESS, OR DISCOMFORT. ICE WAS APPLIED. THE PHYSICIAN WAS NOTIFIED. NEUROLOGICAL CHECKS WERE INITIATED. NEUROLOGICAL CHECKS INCLUDED ASSESSMENTS OF VITAL SIGNS, LEVEL OF CONSCIOUSNESS, PUPILS, MOTOR FUNCTION, HAND GRASPS, HEADACHE, [MEDICAL CONDITION], EAR OR NOSE DRAINAGE, AND PRESENCE OR ABSENCE OF VOMITING. CHANGES IN NEUROLOGICAL CHECKS ALERT THE HEALTH CARE PROVIDER TO BLEEDING INSIDE THE HEAD. NEUROLOGICAL CHECKS, ACCORDING TO FACILITY PROTOCOL WERE TO BE DONE EVERY 15 MINUTES TIMES (X) 4, EVERY 30 MINUTES X 4, EVERY HOUR X 2, AND EVERY 8 HOURS X 4. NEUROLOGICAL CHECKS WERE DONE AT 6:30 A.M. AND 6:45 A.M. THE DAY SHIFT NURSE (NURSE #4) DID NOT DOCUMENT ANY NEUROLOGICAL CHECKS FOR RESIDENT #500 ON HER SHIFT, WHICH BEGAN AT 7 A.M. AT THE TIME OF DISCHARGE, 10:28 A.M., THE NURSE DOCUMENTED VITAL SIGNS, DOCUMENTED THAT THE RESIDENT WAS ALERT AND ORIENTED X3 (PERSON, TIME, AND PLACE), AND DOCUMENTED THAT THE RESIDENT HAD NO PAIN. THERE WAS NO DESCRIPTION OF THE INJURY. THERE WAS NEVER A FULL DESCRIPTION OF THE LACERATION, INCLUDING A MEASUREMENT. IN AN INTERVIEW ON 6/4/12 AT 2:45 P.M., NURSE #4 SAID SHE DID NOT REMEMBER RESIDENT #500 AND COULD NOT REMEMBER THE CARE SHE PROVIDED ON 8/25/11. A PHYSICIAN'S ASSISTANT (PA) SAW RESIDENT #500 ON 8/25/11, AND THE VISIT WAS DOCUMENTED IN A PHONE NOTE. THE NOTE DOCUMENTED THAT THE RESIDENT "SLIPPED ON THE FLOOR STRIKING HER LEFT EYEBROW. . .THE CUT WAS CLOSED BY NURSING WITH (2) STERI STRIPS. INR IS 3.0 AND BLEEDING WAS EASILY CONTROLLED. THERE HAVE BEEN NO NEURO (NEUROLOGICAL) CHANGES, NO CHANGE IN VISION, AND NO REPORTED PAIN. VERBAL D/C (DISCHARGE INSTRUCTIONS TO THE PT (PATIENT) AND DAUGHTER-IN-LAW INCLUDED HOLD [MEDICATION NAME] TONIGHT AND RESUME TOMORROW NITE/HC (HOME CARE) RN (REGISTERED NURSE) WILL MONITOR INR. D/C ALSO INCLUDED VERBAL WOUND CARE INSTRUCTIONS." THE PA WAS NOT AVAILABLE FOR INTERVIEW, PER DIRECTOR OF NURSING (DON) #3, INTERVIEWED ON 6/1/12 AT 2:30 P.M. ACCORDING TO DON #3, INTERVIEWED ON 6/4/12 AT 2:30 P.M., THERE WERE NO WRITTEN INSTRUCTIONS IN THE DISCHARGE PACKET ADDRESSING THE SIGNIFICANCE OF THE FALL AND THE POTENTIAL FOR A CRANIAL BLEED. THERE WERE NO SIGNS OR SYMPTOMS THAT WOULD ALERT TO A BLEED. THERE WERE NO INSTRUCTIONS ABOUT WHAT TO DO IF SIGNS AND SYMPTOMS OCCURRED. THERE WERE NO INSTRUCTIONS ABOUT THE FREQUENCY OF THE INRS. IN AN INTERVIEW ON 6/7/12 AT 9 A.M., FAMILY MEMBER #1, PRESENT WITH RESIDENT #500 AT THE TIME OF HER DISCHARGE SAID SHE RECEIVED NO INFORMATION FROM THE NURSE ABOUT SIGNS AND SYMPTOMS TO BE MONITORED AFTER THE FALL. THE FAMILY MEMBER SAID SHE DID NOT REMEMBER ANY INSTRUCTIONS ABOUT [MEDICATION NAME] EXCEPT TO HOLD THE 8/25/11 DOSE AND TO RESUME THE MEDICATION ON 8/26/11. THE FAMILY MEMBER SAID SHE DID NOT REMEMBER ANYTHING ABOUT A HOME CARE NURSE. FAMILY MEMBER #1, INTERVIEWED ON 6/1/12 AT 10:20 A.M., SAID SHE SAW RESIDENT #500 ON 8/25/11 AT 9:30 A.M. SHE SAID THE RESIDENT "LOOKED TERRIBLE." HER EYE WAS STARTING TO GET BLACK AND BLUE AND STARTING TO SWELL. THE FAMILY MEMBER SAID SHE VOICED HER CONCERNS ABOUT THE DISCHARGE TO THE PA AND THE NURSES, BUT THEY ASSURED HER THAT THE RESIDENT COULD RETURN HOME. THE FAMILY MEMBER SAID SHE STAYED WITH THE RESIDENT UNTIL 4:30 P.M. AT 5 P.M. THE RESIDENT CALLED TO SAY SHE HAD A TERRIBLE HEADACHE, AND TYLENOL WAS INEFFECTIVE. AT 5:30 P.M. WHEN THE FAMILY MEMBER RETURNED TO THE RESIDENT'S HOME, THE RESIDENT WAS ON HER COUCH WITH A BASIN IN HER LAP. SHE WAS NON-RESPONSIVE. EMERGENCY MEDICAL SERVICES (EMS) WERE CALLED AND THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL. HOSPITAL RECORDS WERE REVIEWED ON 8/5/12 AT 3:45 P.M. A HOSPITAL EMERGENCY DEPARTMENT HISTORY & PHYSICAL DOCUMENTED THAT RESIDENT #500 WAS BROUGHT TO THE hospital on [DATE] AT 6:55 P.M. THE RESIDENT PRESENTED TO THE HOSPITAL UNRESPONSIVE. SHE WAS diagnosed with [REDACTED]. THE RESIDENT WAS INTUBATED (BREATHING TUBE PLACED IN AIRWAY). A LEFT SIDED CRANIOTOMY (CUT THAT OPENS THE SKULL TO ACCESS THE BRAIN) AND HEMATOMA (BLOOD CLOT) EVACUATION WAS DONE ON 8/25/11. AT DISCHARGE FROM THE ACUTE CARE HOSPITAL THE RESIDENT HAD A [MEDICAL CONDITION] AND REMAINED VENTILATOR DEPENDENT. ( ) BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO COMPLETE NEUROLOGICAL CHECKS FOR THE 3 (#501, #502, #503) OF 4 SAMPLED RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 4, PLACING THEM AT RISK FOR DELAYED DETECTION OF AN INTRACRANIAL BLEED. FINDINGS INCLUDE: RESIDENT #501 RESIDENT #501 HAD A FALL ON 5/29/12, ACCORDING TO AN INCIDENT REPORT. A DESCRIPTION OF THE EVENT INDICATED THAT THE RESIDENT SLIPPED AND fell WHILE WALKING TO THE BATHROOM UNASSISTED. SHE fell on HER RIGHT HIP AND TAILBONE, AND ALSO HIT HER HEAD. ACCORDING TO THE NOTE, NEURO CHECKS WERE INITIATED. THE NEUROLOGICAL CHECK FLOW SHEET INCLUDED ASSESSMENTS PER FACILITY PROTOCOL THROUGH THE TWO "EVERY ONE HOUR CHECKS." THE EVERY 8 HOUR CHECKS X4 WERE NOT DONE. ( ) RESIDENT #502 RESIDENT #502 SUSTAINED A FALL ON 5/22/12, ACCORDING TO AN INCIDENT REPORT. A DESCRIPTION OF THE EVENT STATED, "RESIDENT STATES HE REACHED FOR WHEEL CHAIR TO SIT, CHAIR WAS UNLOCKED AND MOVED, RESIDENT fell , HIT HEAD AND BOTH ELBOWS, HOUSEHOLD ASSOCIATE FOUND PT (PATIENT) ON THE BEDSIDE FLOOR, VITALS STABLE, NEURO CHECKS INITIATED." THE NEUROLOGICAL CHECK FLOW SHEET DOCUMENTED THAT THE FINAL TWO "8 HOUR" CHECKS WERE NOT DONE. ( ) RESIDENT #503 ACCORDING TO A HOSPITAL TRIAGE REPORT ON 3/9/12, RESIDENT #503 HAD A FALL ON THAT DATE AND HIT HER HEAD. THE RESIDENT WAS TRANSFERRED BACK to the facility on [DATE] AT 10:30 P.M. ACCORDING TO THE NEUROLOGICAL CHECK FLOW SHEET, THE NEUROLOGICAL CHECKS WERE NOT RESUMED WHEN THE RESIDENT RETURNED TO THE FACILITY. ( ) IN AN INTERVIEW ON 6/4/12 AT 2 P.M., DON #3 COULD NOT EXPLAIN WHY THE NEUROLOGICAL CHECKS WERE NOT COMPLETED FOR RESIDENTS #501, #502, AND #503. ( )