Every finding on record at Glen Ridge Health Campus

Based on interview, record review and facility policy review, the facility failed to maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status for all staff members.The findings include:Review of the facility's policy, COVID-19 Health Care Staff Vaccination revised 11/10/2025, revealed under Tracking and Monitoring 1. The facility must develop and maintain a tracking system for facility staff regarding COVID-19 vaccination. 2. Tracking system to include: a. Facility staff member (to include all categories listed above under Facility Staff b. Specific vaccine received including manufacturer and date of each dose or date of next scheduled dose. C. Booster information including date of booster and manufacturer. d. If granted an exemption, include the type of exemption. e. List any temporary delays in vaccination and include when the staff member can safely resume the vaccination. f. And declinations.The facility was unable to provide documentation regarding any staff member who had either accepted or declined the Covid vaccine.In an interview with IP on 06/18/2026 at 9:50AM, she stated staff have not requested the Covid vaccine and she does not track Covid vaccinations for staff members.In a follow up interview with IP on 06/18/2026 at 11:45 AM, she stated she has never offered, tracked or documented staff receiving or declining Covid vaccinations since becoming IP in 2024.In an interview with Director of Nursing on 06/18/2026 at 5:07 PM, she stated it is the Infection Preventionist's responsibility to manage and track Covid-19 immunizations of staff members. She stated the reason for that is to ensure everyone is up to date to prevent the spread of Covid. She stated Covid is a risk if it is not tracked.In an interview with the Administrator on 06/26/2026 at 5:26 PM, he stated it is the Infection Preventionist's responsibility to manage and track Covid-19 immunizations of staff members. He stated the reason for that is to ensure staff are up to date and Covid is kept to a minimum in the facility. He continued stating there was a risk of a wide spread Covid infection in the facility by not tracking.

Based on interview, record review and facility policy review, the facility failed to implement written policies and procedures that prohibited and prevented abuse, neglect, exploitation of residents, and misappropriation of residents' property. The facility failed to run background, Office of Inspector General (OIG) Abuse Registry, and Kentucky Adult Caregiver Misconduct (KACMR) checks prior to start dates for 6 of 10 employees.The findings include: Review of the facility's policy, Abuse, Neglect and Exploitation Procedural Guidelines, revised 12/16/2024, revealed the facility would, screen all potential employees for a history of abuse, neglect or mistreatment of patients during the hiring process. It will consist of but not limited to the following: 1. State licensing authorities 2. State Nurse Aide Registry Verification 3. Reference checks from previous/current employers 4. Criminal background checks of all non-professional staff. Review of the facility's policy, Background Check Screening Policy, revised 10/28/2025, revealed in bold ink letters, The background check must be completed, and results verified before a candidate begins employment. Review of Activity Associate personnel file revealed a hire date of 01/28/2026. However, further review revealed the facility received a background check, the OIG Abuse Registry on 02/13/2026 and KACMR on 02/05/2026. Review of Cook. 1's personnel file revealed a hire date of 02/04/2026. However, further review revealed the facility received the background check, and OIG Abuse Registry on 02/25/2026 and KACMR on 02/05/2026. Review of Environment Services Assistant 1's personnel file revealed a hire date of 03/04/2026. However, further review revealed the facility received background check, OIG Abuse Registry and KACMR on 03/10/2026. Review of Registered Nurse (RN) 4's personnel file revealed her hire date was 04/15/2026. However, further review revealed the facility received background check, OIG Abuse Registry and KACMR on 04/17/2026. Review of Certified Nursing Assistant (CNA) 4's personnel file revealed her hire date was 06/04/2025. However, further review revealed the facility received background check and OIG Abuse Registry on 06/25/2025. The KACMR was performed by facility on 06/06/2025. Review of CNA5's personnel file revealed their hire date was 12/19/2023. However, further review revealed the facility received background check, OIG Abuse Registry and KACMR on 12/27/2023. In an interview on 06/18/2026 at 5:07 PM, the Director of Nursing (DON) stated it was the responsibility of the facility's human resource staff member to perform abuse registry and background checks. She continued that currently, potential employee background and abuse checks were performed offsite at corporate by an employee experience manager because this location currently did not have a human resource staff member in that role; and they have been without since the beginning of June 2026. The DON stated the reason for performing checks was to ensure people we hire are not on those registries. Further, the DON stated a risk of not performing background and abuse checks prior to staff start date was the facility would not know if employees were on the registry or not and that could result in people working with residents who were on the registry. In an interview with the Administrator on 06/18/2026 at 5:26 PM, he stated it was the responsibility of the employee experience manager to perform abuse registry and background checks. He stated the facility does not currently have an employee in that role since June 14, 2026. He stated the reason for performing background and abuse checks was to ensure no one hired was on the registry and they were capable of working with residents. He continued that a risk could be residents are put at risk if someone could potentially be on the registry.

Based on observation, interview, record review, facility policy review, and review of manufacturer's information, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 4 medication errors out of 26 total opportunities, affecting 2 of 3 residents reviewed during the medication administration task (Resident (R)54 and R58), which resulted in a medication (med) error rate of 15.38 %. The findings include: Review of the facility policy titled, Medication Administration - General Guidelines, revised 11/2018, revealed medications were to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Continued review of the policy revealed, the FIVE RIGHTS for medication administration revealed the rights included: right resident; right drug; right dose; right route; and right time and were to be applied for each medication being administered. Per policy review, The policy medications were to be administered in accordance with written orders of the prescriber. Further policy review revealed medications were to be administered within 60 minutes of the scheduled time, except before, with or after meal orders, which were administered based on mealtimes. 1. Review of the Resident Face Sheet for R58 revealed the facility admitted the resident on 05/14/2025, with diagnoses that included gastrointestinal hemorrhage and constipation. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 05/16/2025, revealed the facility assessed R58 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident had moderate cognitive impairment. Review of the Active Orders for R58 revealed an order dated 05/19/2025, for polyethylene glycol 3350 powder (a laxative) 17 grams (gms) per dose with instructions to administer one lid full in water twice a day between 6:00 AM and 10:00 AM and between 6:00 PM and 10:00 PM. Observation of medication administration on 06/03/2025 at 8:28 AM, revealed Licensed Practical Nurse (LPN) 1 removed the bottle top from the polyethylene glycol 3350 powder, poured the powder into the bottle top. Continued observation revealed LPN 1 then without placing the top of the bottle on a flat surface and measuring the medication with the provided measurement lines on the inside of the bottle top itself, poured the powder into a drinking glass. Further observation revealed LPN 1 then poured approximately four ounces of red juice into the cup, stirred it, and gave it to R58 with his/her other medications. During interview on 06/03/2025 at 2:24 PM, LPN 1 stated she did not know the proper way to measure the correct dosage of polyethylene glycol 3350 powder. During interview on 06/04/2025 at 9:53 AM, LPN 2 stated powdered medications, such as polyethylene glycol, usually came with a scoop. The LPN reported if the powdered medication did not have a scoop, you should fill the cap of the medication bottle. LPN 2 further stated to make sure the medication was measured correctly, you should shake the lid or tap it on top of the cart to see if it was level. During interview on 06/04/2025 at 10:12 AM, Registered Nurse (RN) 3 stated for powdered medications, such as polyethylene glycol, she used the clear medication cups for accuracy. RN 3 said if a staff member did not level the medication to ensure the correct amount was being administered, it would be a medication error. During interview on 06/04/2025 at 3:11 PM, the Director of Health Services (DHS) stated for a powdered medication, such as polyethylene glycol 3350 powder, there was a line in the bottle top that staff were to utilize when administering the medication. The DHS further stated the medication should be filled to that line and confirmed by the nurse by checking it at eye level. 2. Review of the Resident Face Sheet for R54 revealed the facility admitted the resident on 04/21/2025, with diagnoses that included diagnoses of hypokalemia (low potassium levels) and hypothyroidism (low thyroid levels). Review of the admission MDS Assessment, with an ARD of 04/25/2025, revealed the facility assessed R54 to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the Active Orders for R54 revealed the orders contained the following: - an order dated 04/21/2025 for calcium carbonate 500 milligrams (mg), one tablet once a day between 6:00 AM and 10:00 AM; - an order dated 04/21/2025 for ferrous gluconate 324 mg (38 mg of iron) with instructions to administer with breakfast, once a day between 6:00 AM and 10:00 AM; - an order dated 05/10/2025 for levothyroxine 125 micrograms (mcg) once a day between 6:00 AM and 10:00 AM; and - an order dated 04/21/2025 for potassium chloride extended release 20 milliequivalents (mEq) with instructions to administer with meals, twice a day between 6:00 AM and 10:00 AM and between 4:00 PM and 6:00 PM. Review of the Manufacturer's Prescribing Information for levothyroxine sodium revealed the following instructions: Take UNITHROID [levothyroxine sodium] on an empty stomach at least 30 minutes to 1 hour before eating breakfast or 3 or more hours after dinner or your last meal of the day. Review further revealed to wait 4 hours before or after taking calcium or iron supplements (including prenatal vitamins). During observation of medication administration on 06/03/2025 at 8:42 AM, LPN 1 prepared R54's medications, including calcium carbonate 500 mg, ferrous gluconate 324 mg, levothyroxine 125 mcg, and potassium chloride 20 mEq, and placed them into one medication cup. Observation further revealed LPN 1 administered the medications to R54 with a 5-ounce glass of water. During interview on 06/03/2025 at 2:24 PM, LPN 1 stated medications that were to be administered with food should be given within 15 minutes of consuming food. She confirmed R54's potassium was ordered to be given with food and verified the breakfast trays had not been delivered to the hallway at the time of the medication pass observation. The LPN reported she had not provided food for R54 during the morning medication pass. LPN 1 stated she also administered R54's levothyroxine along with the residents' other morning medications, including his/her calcium and iron. During interview on 06/04/2025 at 9:53 AM, LPN 2 stated a medication that was to be given with food should be given within 30 minutes of the resident consuming food, or a snack could be provided to the resident. She further stated typically, thyroid medications (such as the resident's levothyroxine) were given an hour before all other medications. During interview on 06/04/2025 at 10:12 AM, RN 3 stated if medication was to be given with food, the resident had to be eating when the medication was given. The RN said she usually waited until the resident had eaten before she gave the medication to the resident. RN 3 reported if it was not mealtime, a snack, such as pudding or crackers, could be given with the medication. The RN further stated levothyroxine was a medication that was to be administered separately from other medications and was usually given at 5:00 AM. During interview on 06/04/2025 at 3:11 PM, the Director of Health Services (DHS) stated if medication was to be given with food. She said if a meal was not present at the time of the medication administration, the nurse should provide pudding or crackers during the medication pass to coat the resident's stomach. The DHS explained medications that were to be administered with food should be given to the resident with food. She reported levothyroxine was a medication that was to be given separately from other medications and on an empty stomach. The DHS confirmed R54 had not been asked if it was his/her preference to take all his/her medications together and there was no order for the levothyroxine to be given along with all the other medications. She stated her expectation was for the nurses to follow the physician's orders for medication administration. The DHS further stated all of the above discussed medication administration issues were medication errors. During interview on 06/04/2025 at 4:11 PM, Pharmacist 5 stated the recommendation for levothyroxine was to administer the medication an hour before all other medications and on an empty stomach for the best absorption. Pharmacist 5 said potassium should be given with food to prevent stomach upset and the physician's order should be followed. During interview on 06/05/2025 at 11:02 AM, the Executive Director stated his expectation was for the nurses to administer medications the proper way.

Based on interview, record review, and facility document and policy review, the facility failed to protect a resident's right to be free from mental abuse perpetrated by a staff member for 1 of 2 sampled residents reviewed for abuse, out of the total sample of 16. The findings include: Review of the facility policy titled, Abuse and Neglect Procedural Guide, reviewed 08/29/2019, revealed the facility was to protect residents from abuse. Further review revealed Mental/Emotional Abuse was defined as the use of verbal or nonverbal conduct which caused or had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of the Resident Face Sheet for Resident (R)214 revealed the facility admitted the resident on 03/11/2025, with diagnoses of emphysema, acute respiratory failure with hypoxia, acute kidney failure, and acute on chronic diastolic heart failure. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/17/2025, revealed the facility assessed R214 to have a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident had severe cognitive impairment. Review of the facility's Final Report/5 Day Follow-Up dated 04/18/2025, revealed in response to resident behaviors, Certified Resident Care Aide (CRCA) 6 directed an inappropriate hand gesture (middle finger gesture) toward R214. Per review, R214 reported the CRCA's action to the nurse on duty, who immediately obtained a statement from CRCA 6 and suspended the CRCA. Further review revealed after completion of its investigation, the facility determined, Findings of the investigation were verified as employee admitted to the hand gesture toward resident. Continued review of the facility's investigation information revealed a Statement of Witness Form, from CRCA 6 dated 04/18/2025, which noted the CRCA admitted she gave the middle finger at R214 before turning to walk down the hallway, with the resident following behind her in his/her wheelchair. During interview on 06/04/2025 at 12:07 PM, CRCA 6 stated that although she knew the hand gesture could be perceived as abuse, she had not considered it in that manner at the time. During interview on 06/05/2025 at 4:30 PM, CRCA 7 stated she recalled being at the nurses' station with CRCA 6 when R214 activated his/her call light, and CRCA 6 went to answer it. She stated after a few minutes, CRCA 6 returned to the nurses' station, followed by R214. The CRCA reported R214 notified the Assistant Director of Health Services (ADHS) that CRCA 6 had demonstrated an inappropriate hand gesture at him/her. She explained that although she was not present when CRCA 6 made the gesture, she was present when CRCA 6 admitted to the ADHS that she made the gesture towards R214. During interview on 06/05/2025 at 10:43 AM, the ADHS stated she was on duty on the morning of 04/18/2025, when R214 approached the nurses' station and notified her that CRCA 6 made an inappropriate hand gesture towards him/her. The ADHS stated following R214's allegation, she questioned CRCA 6, who admitted making the hand gesture towards the resident. During interview on 06/05/2025 at 12:56 PM, the Director of Health Services (DHS) stated on 04/18/2025, around 3:00 AM, she received a telephone call from the ADHS who notified her that R214 alleged CRCA 6 made an inappropriate hand gesture towards him/her. She said the ADHS informed her CRCA 6 admitted to making the gesture towards the resident. The DHS further stated the hand gesture was inappropriate and was considered mental abuse. During interview on 06/05/2025 at 1:34 PM, the Executive Director (ED) stated CRCA 6's employment was terminated following R214's allegation, because the CRCA admitted the allegation had occurred.

Based on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) within two hours for 1 of 2 sampled residents reviewed for abuse (Resident (R)214). The findings include: Review of the facility policy titled, Abuse and Neglect Procedural Guide, reviewed 08/29/2019, revealed Mental/Emotional Abuse was defined as using verbal or nonverbal actions which caused or had the potential to cause a resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of the section of the policy titled, Identification, revealed the Executive Director (ED) was responsible for notification to the State Department of Health (per State guidelines) and other agencies, which include the Ombudsman, Adult Protective Services (APS) and/or local law enforcement agencies, as indicated. Continued review of the policy revealed under the section titled, Reporting/response, revealed the facility was to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made if the event, that caused the allegation involved abuse or resulted in serious bodily injury. Further review revealed the alleged violation was to be reported to the Administrator of the facility and to other officials (including to the SSA and APS where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of the Resident Face Sheet for R214 revealed the facility admitted the resident on 03/11/2025, with diagnoses of acute on chronic diastolic heart failure, acute respiratory failure with hypoxia, acute kidney failure, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/17/2025, revealed the facility assessed R214 as having a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating the resident had severe cognitive impairment. Review of the facility's Initial Report, dated 04/18/2025, revealed an initial report was submitted to the SSA related to an allegation of abuse involving Certified Resident Care Aide (CRCA) 6 having made an inappropriate hand gesture towards R214. Continued review of the Initial Report revealed the incident occurred on 04/18/2025 at 3:25 AM, and the ED was notified of the incident on 04/18/2025 at 3:42 AM. Further review revealed the facility had not submitted the report to the SSA until 7:48 AM on 04/18/2025, more than two hours after the allegation was reported. However, review of the facsimile (fax), Communication Result Report, included with the facility's documentation of the allegation, revealed a fax transmission of the Initial Report was attempted on 04/18/2025 at 9:02 AM. Per review of the fax, the transmission had been unsuccessful, due to an error code of E-3), which indicated there was no answer. Continued review revealed comparison of the number listed on the Communication Result Report to the fax numbers and contact numbers listed on the Initial Report revealed the facility attempted to submit a fax to a SSA telephone number, instead of a fax line number. Review of an electronic mail (email) correspondence from the ED to the SSA, dated 04/18/2025, revealed the initial report of the incident was submitted to the SSA on 04/18/2025 at 9:07 AM. In interview on 06/05/2025 at 4:30 PM, CRCA 7 stated she recalled being at the nurses' station with CRCA 6 when R214 activated their call light, and CRCA 6 left the nurses' station to answer the light. CRCA 7 stated few minutes later CRCA 6 returned to the nurses' station, with R214 following. The CRCA said R214 notified the Assistant Director of Health Services (ADHS) that CRCA 6 had demonstrated an inappropriate hand gesture towards him/her. In interview on 06/05/2025 at 10:43 AM, the ADHS stated the morning of 04/18/2025, R214 approached the nurses' station and notified her that CRCA 6 had made an inappropriate hand gesture towards him/her. The ADHS reported she immediately notified the Director of Health Services (DHS) via telephone call of the allegation and was instructed to suspend CRCA 6 pending an investigation of the allegation. In interview on 06/05/2025 at 12:56 PM, the DHS stated on 04/18/2025 around 3:00 AM, she received a telephone call from the ADHS who notified her R214 had alleged CRCA 6 made an inappropriate hand gesture towards him/her. The DHS said the ED was immediately notified. The DHS further stated she was aware the initial report of the incident must be submitted to the SSA within two hours. In interview on 06/05/2025 at 1:34 PM, the ED stated he was notified of R214's allegation made on 04/18/2025 between 3:45 AM and 4:00 AM. He said he was aware notification to the SSA must occur within two hours. After reviewing the initial report, the ED stated the report was submitted to the state on 04/18/2025; however, not within the required two hour timeframe. He further stated he was not aware the report had not been received by the SSA during the first transmission (fax) attempt or that the attempt had been made to fax the document to a telephone number instead of a fax number. The ED additionally stated he expected the initial report of an allegation to be sent to the SSA within the two-hour timeframe.

Based on interview, record review, and review of the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility, Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) Assessment for 1 of 16 sampled residents (Resident (R)54). The findings include: Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, Version 1.19.1, dated 10/2024, revealed under section O0110: Special Treatments, Procedures, and Programs, O0110C1, Oxygen therapy specified, Code continuous or intermittent oxygen administered via [by way of] mask, cannula, etc. [et cetera], delivered to a resident to relieve hypoxia in this item. Review of the Resident Face Sheet for R54 revealed the facility admitted the resident on 04/21/2025, with diagnoses to include pulmonary embolism, acute respiratory failure with hypoxia, pulmonary fibrosis, pulmonary hypertension, and atelectasis (complete or partial collapse of a lung or a lobe of a lung). Review of the admission MDS Assessment, with an Assessment Reference Date (ARD) of 04/25/2025, revealed the facility assessed R54 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Further MDS review revealed the use of supplemental oxygen was not reflected under Section O0110 Special Treatments, Procedures, and Programs of the MDS. Review of the Active Orders for R54 revealed an order, dated 04/23/2025, for nursing to manage oxygen administration in coordination with physician to prevent respiratory acidosis. Further review of the Active Orders revealed however, no physician's order specifying when the supplemental oxygen should be administered or a prescribed supplemental oxygen flow rate. Review of a nursing Progress Note, dated 04/22/2025 at 10:09 PM, revealed R54 had an oxygen saturation (O2 sat) level of 91 percent on room air. Further review revealed supplemental oxygen was administered to R54 at a rate of two liters per minute (2 LPM) by way of nasal cannula. Review of the physician Progress Note, for R54 dated 04/23/2025 at 8:04 PM, revealed, Assessment: S/p [status post] acute hypoxia respiratory failure, on oxygen. Further review of the physician Progress Note revealed the Plan was to Continue oxygen. During interview on 06/04/2025 at 8:59 AM, R54 stated he/she used supplemental oxygen at night because his/her oxygen level dropped whenever he/she laid down. R54 further stated he/she had used the supplemental oxygen every night since his/her admission to the facility. During interview on 06/03/2025 at 2:32 PM, Licensed Practical Nurse (LPN) 1 stated R54 wore supplemental oxygen at nighttime. During interview on 06/04/2025 at 9:53 AM, LPN 2 stated R54 wore supplemental oxygen at nighttime. During a telephone (phone) interview on 06/04/2025 at 1:01 PM, LPN 4 stated she worked on the nightshift and had taken care of R54 several times. LPN 4 said she had observed the resident wearing supplemental oxygen. She further stated R54 had been wearing oxygen at night since his/her admission to the facility. During interview on 06/05/2025 at 9:22 AM, the MDS Coordinator stated when gathering data for an MDS Assessment, she looked at the resident's orders, progress notes, observations, events, therapy notes, and the initial admission assessment. She reported the oxygen administration for R54 should have been caught in the many audits that had been done; however, it had not been. The MDS Coordinator further stated that had been an error on the resident's MDS Assessment. During interview on 06/04/2025 at 3:11 PM, the Director of Health Services (DHS) stated her expectation was that MDS assessments were completed accurately and timely. During interview on 06/05/2025 at 11:02 AM, the Executive Director (ED) stated his expectation was for staff to use the audits the facility had in place and to be thorough in completing the residents' MDS Assessments.

Based on interview, record review, and facility standard operating procedure review, the facility failed to obtain orders for supplemental oxygen use for 1 of 1 resident reviewed for respiratory care, out of the 16 total sampled residents (Resident (R)54). The findings include: Review of the facility's standard operating procedure (SOP) titled, Administration of Oxygen, last reviewed 12/13/2024, revealed, OVERVIEW Guidelines to properly Administering Oxygen and any Respiratory procedure. SOP DETAILS 1. Verify physician's order for the procedure. Review of R54's Resident Face Sheet revealed the facility admitted him/her on 04/21/2025, with diagnoses to include: pulmonary embolism, acute embolism and thrombosis of unspecified deep veins of left lower extremity, acute respiratory failure with hypoxia, atelectasis (complete or partial collapse of a lung or a lobe of a lung), pulmonary fibrosis, and pulmonary hypertension. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/25/2025, revealed the facility assessed R54 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of R54's Care Plan, revealed the facility identified included a problem, dated 04/30/2025, that indicated the resident had the potential for shortness of breath while lying flat. Further review revealed the interventions directed staff to administer supplemental oxygen per physician's order and as needed (dated 04/30/2025). Review of R54's Active Orders revealed an order dated 04/23/2025, for nursing to manage the resident's oxygen administration in coordination with the physician to prevent respiratory acidosis. Review of the Active Orders further revealed however, no physician's order specifying when R54's supplemental oxygen was to be administered or a with a prescribed supplemental oxygen flow rate. In interview on 06/04/2025 at 8:59 AM, R54 stated he/she used supplemental oxygen at night as his/her oxygen level dropped whenever he/she laid down. The resident further stated he/she had used supplemental oxygen every night since being admitted to the facility. Review of the nursing Progress Note, dated 04/22/2025 at 10:09 PM, revealed R54 had an oxygen saturation (O2 sat) level of 91 percent on room air. Review further revealed supplemental oxygen was administered to R54 at a rate of two liters per minute (2 LPM) by way of nasal cannula. Review of the physician Progress Note dated 04/23/2025 at 8:04 PM for R54, revealed under a section titled, Assessment it was noted the resident was status post (s/p) acute hypoxia respiratory failure, and was on oxygen. Review of the Progress Note further revealed under a section titled, Plan, it was noted to Continue oxygen. Review of the nursing Progress Notes, dated 04/27/2025, 05/02/2025, 05/04/2025, 05/05/2025, 05/08/2025, 05/12/2025, 05/14/2025, 05/15/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/29/2025, and 05/31/2025, revealed it was documented R54 used supplemental oxygen. Further review of those nursing Progress Notes revealed staff should refer to physician's orders for the oxygen flow rate and delivery method for R54. In interview on 06/03/2025 at 2:32 PM, Licensed Practical Nurse (LPN) 1 stated R54 wore supplemental oxygen at night. LPN 1 further stated there should have been an order for R54's supplemental oxygen administration and a place to record the resident's oxygen saturation level. In interview on 06/04/2025 at 9:53 AM, LPN 2 stated R54 wore supplemental oxygen at night. She further stated there should have been an order for R54's supplemental oxygen. In a telephone (phone) interview on 06/04/2025 at 1:01 PM, LPN 4 stated she worked on the nightshift and had cared for R54 several times. LPN 4 further stated she had observed R54 wearing supplemental oxygen when she cared for the resident. In interview on 06/04/2025 at 3:11 PM, the Director of Health Services (DHS) stated a physician's order was needed for the administration of supplemental oxygen. The DHS said it was her expectation for nurses to obtain an order if a resident needed to use supplemental oxygen. She reported nurses could provide supplemental oxygen in an emergency situation and then immediately notify the physician for an order and parameters to follow. The DHS reviewed R54's physician orders and verified there was no order for supplemental oxygen for the resident. She further verified R54 wore supplemental oxygen nightly and had since being admitted to the facility.

Based on observation, interview, record review, and facility policy review, it was determined, the facility failed to ensure personal privacy for one (1) of six (6) sampled residents reviewed for dignity (Resident #32). Observation revealed staff obtained Resident #32's blood glucose level and administered insulin in the resident's abdomen while he/she was seated at a table in a common area with five (5) other residents. The findings include: Review of the facility policy titled, Resident Rights Guidelines, revised 05/11/2017, revealed the purpose of the policy was To ensure resident rights are respected and provide an environment in which they can be exercised. Further policy review revealed facility residents had the right to be treated with dignity and respect and privacy. Review of Resident #32's Resident Face Sheet revealed the facility admitted the resident on 10/03/2022 with diagnoses which included type 2 diabetes. Review of Resident #32's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/23/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident had severe cognitive impairment. Per MDS review, the facility assessed Resident #32 to have medically complex conditions and diabetes. Further review of the MDS revealed the facility assessed Resident #32 to have received insulin injections in the last seven (7) days of the assessment period. Review of Resident #32's Care Plan, dated 10/10/2022, revealed the facility care planned the resident as at risk for hypo/hyperglycemia related to diabetes mellitus. Further review revealed the facility developed interventions that included staff to administer medication per physician orders. During an observation on 03/12/2024 at 8:33 AM, Resident #32 was seated at a table in a common area with five (5) other residents. Continued observation revealed Licensed Practical Nurse (LPN) #4 checked Resident #32's blood glucose level and administered the resident's insulin in his/her abdomen. Further observation revealed Resident #32 was not able to answer any questions related to privacy or dignity. In an interview on 03/12/2024 at 8:53 AM and 2:51 PM, LPN #4 stated she should not have obtained Resident #32's blood glucose level and administered his/her insulin in the resident's abdomen at a table where other residents were present. She stated she should have taken Resident #32 to his/her room to perform those procedures in privacy for the resident. In interview on 03/14/2024 at 3:53 PM, the Director of Health Services (DHS) stated she expected staff to treat all the residents with respect. The DHS stated the nurse should have taken Resident #32 to his/her room before checking the resident's blood glucose level or administering an insulin injection. In interview on 03/15/2024 at 1:36 PM, the Executive Director stated he expected staff to provide treatments, such as an insulin injection, in a private area. He further stated he expected staff to provide privacy during medication administration.

Based on interview, record review, and review of facility documents and policy, it was determined the facility failed to ensure resolution of a grievance for one (1) of twenty (20) sampled residents, (Resident #9). Interview with staff revealed they were aware Resident #9 did not sleep well at night due to his/her roommate's yelling/screaming out, and reported everyone knew about that information. However, the facility failed to make prompt efforts to resolve the resident's complaint/grievance and ensure he/she received the care and treatment necessary to achieve adequate rest/sleep at night. The findings include: Review of the facility policy titled, Resident Concern Process, effective 11/13/2019, revealed, the purpose of the policy was To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service. Continued review revealed the facility was to provide an open and customer friendly atmosphere for residents and their families/representatives to voice concerns and problems to ensure their concerns were heard and acted upon. Per review, the facility was committed to the on-going education of their employees on immediately responding to and resolving customer concerns. Further review revealed the facility was to follow its Resident Concern Process flow chart when any concern or complaint was voiced. Additionally, policy review revealed the facility staff were to take steps to correct the problem, ensure the problem was resolved, and the Executive Director was to review and manage the follow up of the concerns. Review of Resident #9's Resident Face Sheet revealed the facility admitted the resident on 07/05/2022, with diagnoses that included atrial fibrillation, chronic pain syndrome, fatigue, muscle weakness, and a history of falling. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/23/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), which indicated he/she had moderate cognitive impairment. Review of Resident #9's Care Plan revealed a Problem statement, last edited on 02/26/2024, that indicated the resident had the potential for experiencing symptoms of fatigue, weakness, and confusion related to anemia. Further review revealed the Care Plan interventions directed staff to encourage Resident #9 to take rest periods during episodes of fatigue. During an interview on 03/11/2024 at 10:52 AM, Resident #9 stated his/her roommate kept him/her up at night screaming and yelling. Resident #9 stated he/she had discussed the problem with the Executive Director (ED), who stated he would fix the problem; however, the problem had not been resolved. Review of the facility's resident complaint log for the timeframe of 03/02/2023 through 02/19/2024, revealed no documentation noting Resident #9's issues of not being able to sleep at night due to his/her roommate's screaming/yelling. During an interview on 03/13/2024 at 10:12 AM, the Director of Social Services (DSS) described Resident #9 as able to make his/her needs known however, at times, did not accurately recall events. The DSS stated she did not know Resident #9 as well as other residents, and had not received any concerns from staff, or the resident regarding his/her relationship with his/her roommate. The DSS further stated if Resident #9 was having difficulty with his/her roommate, she expected staff to have notified her of that information. During an interview on 03/13/2024 at 10:53 AM, Registered Nurse (RN) #10 stated Resident #9 had told her and everyone else that his/her roommate screamed and yelled at night which kept the resident awake and was unable to sleep. RN #10 stated she had not notified anyone of Resident #9's concern because everyone knew about it. She further stated she was not aware of whether a room change had ever been offered to Resident #9, or whether the facility's grievance process had been completed as required. During an interview on 03/13/2024 at 12:09 PM, Licensed Practical Nurse (LPN) #5 stated Resident #9 had reported his/her inability to sleep at night due to his/her roommate's yelling and screaming. LPN #5 stated she had documented that information in Resident #9's medical record and had reported the resident's concerns to the Director of Health Services (DHS). The LPN stated the DHS told her she would report the resident's concerns to the ED. She further stated she had not completed a written grievance regarding Resident #9's concerns, but felt she had done her part by reporting the resident's concerns to the DHS. During a telephone interview on 03/14/2024 at 1:10 PM, Certified Resident Care Associate (CRCA) #17 stated she worked at the facility on the 6:00 PM to 6:00 AM shift or on the 10:30 PM to 6:30 AM shift. She stated she knew Resident #9 well and confirmed the resident had reported his/her roommate keeping him/her awake at night. The CRCA stated Resident #9's roommate yelled and screamed at night, keeping Resident #9 awake. She stated when staff from the night shift went into Resident #9's room, the resident begged the staff to do something about his/her roommate's behaviors. CRCA #17 stated she had not reported that information however, because everyone knew about it, including the ED, who was also well aware of the issue. She stated the ED changed Resident #9's shower time from 5:00 AM to 7:00 AM, due to the resident not being able to sleep at night. CRCA further stated however, the DHS and the ED changed Resident #9's shower time back to 5:00 AM because the first shift did not consistently assist the resident as he/she needed. During an interview on 03/14/2024 at 3:13 PM, RN #19 stated Resident #9 complained about his/her roommate yelling and screaming at night, keeping Resident #9 awake. RN #19 stated Resident #9's complaints regarding his/her roommate keeping him/her awake at night had been occurring since she was hired in May 2023. She stated she reported Resident #9's concerns to the DHS and knew several other staff members had also reported the resident's concerns to the DHS. RN #19 further stated however, she had not completed a grievance form. During an interview on 03/15/2024 at 9:13 AM, the DHS stated sometimes Resident #9 and his/her roommate got along fine, and sometimes they argued about the heat, and Resident #9's roommate yelled. She stated no one had reported any recent problems occurring between the roommates. The DHS stated staff had offered Resident #9 earplugs. She stated if there was not a record of a written grievance regarding Resident #9's concerns, then a grievance had not been filed. The DHS further stated she had not completed the grievance process because they handled the resident's concerns at the time of occurrence. During an interview on 03/15/2024 at 1:37 PM, the ED stated a couple of months ago, he had given Resident #9 earplugs to use (when the roommate was yelling). He stated he had followed up with Resident #9 about a month later and found out the earplugs were not working. The ED stated he offered Resident #9 a larger set of earplugs, and the resident declined. He further stated no other interventions were attempted. According to the ED, staff had not notified him of the lack of sleep for Resident #9 being an on-going problem.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to assist one (1) of seven (7) residents sampled for review of activities of daily living (ADL) care, (Resident #3). Observation revealed Resident #3's feet were dry with a buildup of black, dry, and flaky skin between and under the toes. Additionally, the skin on the resident's heels was also observed as dry and flaky with a buildup of callused skin on the right heel. The findings include: Review of the facility policy titled, Guidelines for Pressure Prevention, last reviewed on 12/31/2023, revealed to moisturize residents' skin with lotion or cream (if applicable) to keep skin soft and pliable. Continued review of the policy revealed to pay special attention to bony prominences and Keep skin clean, dry and free of body wastes, perspiration, and wound drainage. Review of Resident #3's Resident Face Sheet revealed the facility originally admitted the resident on 12/24/2022, and most recently readmitted him/her on 03/25/2022, with diagnoses that included chronic kidney disease with heart failure, chronic respiratory failure with hypoxia (inadequate oxygen supply at the tissue level), chronic obstructive pulmonary disease (COPD), and unspecified dementia. Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/21/2023, revealed the facility completed a Staff Assessment for Mental Status (SAMS) for Resident #3 which indicated the resident had short- and long-term memory impairment with moderately impaired cognitive skills for daily decision-making. Continued review of the MDS Assessment revealed Resident #3 had expressed no rejection of care, and was dependent on staff to put on and take off his/her footwear. Further review revealed Resident #3 was also dependent on staff for showering/bathing and required substantial to maximal assistance from staff for completion of personal hygiene. Review of Resident #3's Care Plan revealed the facility identified a problem area that indicated the resident had impairment in his/her ADL functional status in regards to bed mobility, transfers, toileting, and eating. Per review, the problem start date was noted as 12/10/2021, and a date of last edit of 02/26/2024. Continued review revealed the interventions were for staff to encourage the resident to be as independent as safely possible. Further review revealed however, there was no evidence of an intervention that addressed Resident #3's bathing or hygiene. In addition, review further revealed an additional problem with a last edit date of 02/26/2024, which identified Resident #3 as at risk for skin breakdown related to reduced mobility, with an interventions directing staff to keep the resident as clean and dry as possible. During a concurrent observation and interview on 03/13/2024 at 11:00 AM, of Certified Resident Care Assistant (CRCA) #14 and CRCA #16 in the resident's room to provide care to Resident #3, who was lying on his/her bed. CRCA #14 and #16 both stated they were not assigned to care for Resident #3 that day; however, had been asked by the Director of Health Services (DHS) to provide any needed care for the resident at that time. Per observation, Resident #3's feet were observed to be dry with a buildup of black, flaky skin between and under the toes. Further observation revealed the skin on Resident #3's heels was observed as dry and flaky with a buildup of callused skin on the right heel. During a concurrent observation and interview on 03/13/2024 at 11:25 AM, Registered Nurse (RN) #10 entered Resident #3's room and stated the resident's feet were dry and flaky. RN #10 was observed to take a warm, wet washcloth and passed the washcloth between Resident #3's toes and underneath the resident's toes. Continued observation revealed the RN removed black-brown, dry skin that was approximately 0.5 inches in diameter from the resident's feet. In interview, after providing care of Resident #3's feet, RN #10 stated the resident's feet did not appear to have been washed During a follow-up interview on 03/13/2024 at 12:38 PM, RN #10 stated she did not think Resident #3's feet had been washed due to how dirty the resident's feet appeared. During a concurrent observation and interview on 03/14/2024 at 10:23 AM, CRCA #13 and CRCA #14 were observed providing Resident #3 with showering assistance. Per observation, when CRCA #14 washed Resident #3's feet, CRCA #14 removed a large amount of brown/black dried skin from between the resident's toes. CRCA #14 stated at that time, based on what she had seen the day prior and the amount of black, flaky skin she had just removed during the shower, she would say Resident #3's feet had not been washed in weeks. During an interview on 03/15/2024 at 9:24 AM, the DHS stated she expected Resident #3's feet to be clean. During an interview on 03/14/2024 at 11:53 AM, the Medical Director stated he had nothing to say about the condition of Resident #3's feet since the State Survey Agency (SSA) Surveyor and multiple staff members had seen the resident's feet with the buildup of dried skin. The Medical Director stated he did not expect Resident #3's feet to have been left in that type of condition. During an interview on 03/15/2024 at 1:45 PM, the Executive Director (ED) stated residents should be presentable at all times. The ED further stated he expected all residents' feet to be washed and kept clean.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the bowel protocol in accordance with physician's orders for one (1) of one (1) sampled resident for bowel management (Resident #213) out of the total sample of twenty (20) residents. The facility failed to implement the bowel protocol for Resident #213, when the resident exceeded 72 hours with no bowel movement (BM). The findings include: Review of the facility policy titled, Bowel Protocol Guidelines, reviewed on 12/31/2023, revealed its purpose was to provide guidance for the use of bowel stimulants for residents with constipation. Per policy review, the procedures included upon admission, an order might be obtained to 'Utilize Bowel Protocol as needed for the newly admitted resident. Continued review revealed if the resident needed to utilize the bowel protocol, the 'Bowel Protocol' order set might be opened and orders entered from the order set for the affected resident. Review of the policy revealed the Ineffective Bowel Pattern Event should be initiated for any resident not having a BM within 72 hours (unless that had been determined to be a usual bowel pattern for the individual). Policy review revealed a progress note associated to the initiation of the Ineffective Bowel Event, was to be completed until the resident had a BM or the bowel pattern returned to normal for that resident. Further review revealed the progress note was to include (assessment for) abdominal distention, pain, and bowel sounds, and nursing staff to assess for effectiveness. Additional policy review revealed orders might be written to administer a Natural Laxative if a resident had no BM within 72 hours; if no results within twenty-four (24) hours after the natural laxative, give Milk of Magnesia (MOM) q [every] day and PRN (as necessary) for constipation. Review of the policy further revealed if no BM resulted within approximately twelve (12) hours after the MOM, administer a Dulcolax suppository, and if no satisfactory BM resulted after the suppository within two (2) hours give a Fleets enema. In addition, the policy further noted nursing staff were to enter residents' bowel movements, in the resident's electronic medical record [EMR] each shift. Review of the Resident Face Sheet for Resident #213 revealed the facility admitted the resident on 01/04/2024, with diagnoses that included unspecified constipation, chronic pancreatitis, unspecified severe dementia, and gastroesophageal reflux disease (GERD) without esophagitis. Further review of the Resident Face Sheet, revealed Resident #213 was discharged from the facility on 02/14/2024. Review of the Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/05/2024, revealed the facility assessed Resident #213 to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating the resident had severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident #213 as dependent upon staff for toilet use and was always incontinent of bowel. Review of Resident #213's Care Plan revealed the facility developed a Problem area, with a start date of 01/12/2024, that noted the resident had inflammatory bowel disease and colon polyps. In addition, review of the Care Plan revealed the facility developed another Problem area, with a start date of 01/12/2024, regarding Resident #213 having a diagnosis of hypothyroidism and was at risk for complications. Continued review of the care plan revealed interventions which included staff to observe the resident for signs of hypothyroidism, including constipation, and to notify the physician as needed. Further review of the Care Plan revealed the facility also developed a Problem area, with a start date of 01/18/2024, regarding Resident #213 to receive high risk medications, including a diuretic, with an intervention for staff to observe and report signs of dehydration, including constipation. Review of Resident #213's Order History revealed an order dated 01/04/2024 that specified, May utilize bowel protocol as needed .enter bowel protocol order set. Continued review of the Order History also revealed the following orders were started on 01/05/2024, as part of the bowel protocol order set: - If no bowel movement within 72 hours; 2 Tablespoons (30 cc) of 'Natural Laxative' Special Instructions: assign to bowel protocol flow sheet Once A Day - PRN [as needed]; - If no results within 24 hours, after 'natural laxative' give 30 cc of Milk of Magnesia Special Instructions: q [every] day/PRN for constipation; - If no results within approximately 12 hours of above MOM administration give Dulcolax suppository per rectum Special Instructions: q day/PRN if no results from MOM; and - If results of suppository are not satisfactory within 2 hours give Fleets enema per rectum once a day - PRN. Review of Resident #213's BM record, for the duration of his/her stay at the facility, revealed the resident had a medium BM on 01/05/2024 at 9:02 PM. Continued review of the BM record revealed the next BM recorded for Resident #213 was noted on 01/10/2024 at 8:08 AM. Per review of the documentation, Resident #213 exceeded 72 hours with no documented BM. Continued review of the BM record revealed BMs were then recorded every one (1) to three (3) days until 01/19/2024 at 2:03 PM, when a large BM was noted. Further review of the record revealed however, Resident #213 did not have another BM documented until 01/26/2024 at 9:54 PM, seven (7) days later. Review of Resident #213's January 2024 Medication Administration History revealed no documented evidence the bowel protocol medications were administered when the resident exceeded 72 hours with no BM, during the timeframe from 01/05/2024 to 01/10/2024 and from 01/19/2024 to 01/26/2024. Review of Resident #213's Resident Progress Notes for the timeframe of 01/05/2024 to 01/10/2024, when the resident first exceeded 72 hours with no BM, reflected no documented evidence of Ineffective Bowel Pattern Event documentation or an assessment of the resident's abdomen or bowel sounds until 01/10/2024 at 1:49 AM. Review of the 01/10/2024 at 1:49 AM documentation revealed staff noted Resident #213's abdomen was soft and non-tender and bowel sounds were active. Review of Resident #213's Progress Notes for the timeframe of 01/19/2024 to 01/26/2024, when the resident again exceeded 72 hours with no BM, revealed staff documented his/her abdomen was soft and non-tender and bowel sounds were active on 01/19/2024 at 1:15 AM, 01/20/2024 at 8:47 AM, 01/21/2024 at 1:14 AM, 01/22/2024 at 8:02 PM, 01/24/2024 at 11:07 PM, 01/25/2024 at 9:37 PM, and 01/26/2024 at 8:05 PM. Further review revealed however, no documented BMs, nor documentation related to the implementation of the facility's bowel protocol. During an interview on 03/13/2024 at 12:18 PM, Licensed Practical Nurse (LPN) #5 stated the facility utilized a BM protocol that instructed staff to initiate the protocol if a resident had no BM for three (3) days. LPN #3 stated the facility's EMR was not designed to flag the nurse after a resident had no BM for three (3) days, and the nurse would have to check the vital sign section of the EMR to know when a resident had their last BM. She further stated she remembered assisting Resident #213 to the bathroom, and as far as she knew, the resident was having regular BMs. During an interview on 03/14/2024 at 11:37 AM, the Medical Director was unable to recall Resident #213. The Medical Director stated he expected staff to intervene if a resident had no BM for 72 hours unless that was the resident's normal BM routine. He stated staff should increase fluids, add fiber to the resident's diet, and implement the bowel protocol after 72 hours of no BM. He further stated if a resident had no BM for three (3) days he also expected to be notified of that information. During an interview on 03/14/2024 at 1:35 PM, LPN #3 stated if a resident had no documented BM for three days, the nurse was expected to open a bowel pattern event in the EMR; assess for hard stool in the resident's rectum; check for nausea and vomiting; and check to make sure the resident had active bowel sounds. LPN #3 reviewed Resident #213's BM record, and stated when the resident went without a BM for five (5) days and then again for seven (7) days, the Medical Director should have been notified, an ineffective bowel pattern event opened, and the bowel protocol implemented. During an interview on 03/14/2024 at 3:17 PM, Registered Nurse (RN) #19 stated the BM protocol was initiated if a resident had no BM for three (3) days. RN #19 stated the protocol started with use of MiraLAX (a laxative), and if the resident had no BM within four (4) hours, the resident was to be given MOM. She stated if the resident still had no BM within twelve (12) hours of the MOM; a suppository was to be given; and if the resident continued to have no BM within two (2) hours of the suppository; an enema was administered. RN #19 stated if the resident still had no BM the physician was called. She stated prior to starting the bowel protocol for a resident, an abdominal assessment was needed to listen for bowel sounds and to determine if the resident's abdomen was hard or distended. She stated if a resident had no BM for a period of five (5) days or seven (7) days, she would ask the physician for an X-ray to rule out a bowel obstruction or ileus (inability of the intestines to contract normally). RN #19 reviewed Resident #213's BM record and then further stated the resident should have been assessed and the bowel protocol should have been implemented. During an interview on 03/15/2024 at 8:25 AM, LPN #2 stated the bowel protocol was to be initiated when a resident had no BM for 72 hours. LPN #2 said the facility's bowel protocol had been approved by the Medical Director and was included in the orders for a newly admitted resident. She stated that before she would initiate the bowel protocol, she assessed the resident and listened for bowel sounds and notified the Medical Director. LPN #2 reviewed Resident #213's BM documentation and stated based on the documentation, the bowel protocol should have been initiated for the resident. LPN #2 acknowledged she had cared for Resident #213 and had no reason or explanation for why she had not started the bowel protocol for him/her. She further stated the Director of Health Services (DHS), who used to run the BM report and post it for staff to review, had stopped posting the BM report about a year ago. During an interview on 03/15/2024 at 9:53 AM, the DHS stated if a resident had not had a BM for three (3) days nurses were expected to follow the facility's bowel protocol. The DHS said that prior to the initiation of the bowel protocol, she expected nurses to assess the resident and document their findings in the nurse's notes of the resident's medical record. She stated the Certified Registered Care Associates (CRCAs) were responsible for documenting BMs and informing the nurses if a resident had no BM for three (3) days. The DHS stated however, the CRCAs were unable to review BM documentation and would be unable to determine how long it had been since a resident had a BM. She stated nurses were also expected to communicate from shift to shift if a resident had not had a BM during their shift. The DHS stated she was responsible for generating residents' BM reports and notifying the nurses if a resident had not had a BM for three (3) days. The DHS reviewed Resident #213's BM record, and stated the bowel protocol should have been implemented when the resident had no BM for five (5) days and longer. During an interview on 03/15/2024 at 1:50 PM. The ED stated he expected nurses to follow the facility's bowel protocol for any resident when the resident had no BM for three (3) days.

Based on observation, interview, and record review, the facility failed to provide necessary foot care for one (1) of seven (7) residents sampled for activities of daily living (ADLs), (Resident #3). Observation revealed Resident #3's toenails extended half an inch to one (1) inch beyond the tips of his/her toes. The findings include: A policy was requested regarding nail care on 03/15/2024 at 4:45 PM; however, the Assistant [NAME] President of Clinical Operations stated the facility did not have a policy that addressed toenail care. Review of Resident #3's Resident Face Sheet revealed the facility admitted the resident on 03/25/2022, and most recently readmitted the resident on 12/24/2022, with diagnoses that included unspecified dementia, chronic respiratory failure with hypoxia (low oxygen level in the blood), chronic kidney disease with heart failure, and chronic obstructive pulmonary disease (COPD). Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/21/2023, revealed a Staff Assessment for Mental Status (SAMS) determined Resident #3 had short- and long-term memory problems and was moderately impaired cognitively. Further review of the MDS revealed Resident #3 had expressed no rejection of care during the assessment period. In addition, MDS review revealed Resident #3 was dependent on staff to put on or take off footwear and to shower/bathe and required substantial/maximal assistance from staff with personal hygiene. Review of Resident #3's Care Plan, revealed the facility identified a Problem area, started on 12/10/2021 and revised on 02/26/2024, that indicated the resident had impairment in his/her ADLs in regard to bed mobility, transfers, toileting, and eating. Further review revealed an intervention dated 12/10/2021, which directed staff to encourage Resident #3 to be as independent as safely possible. Review further revealed there were no documented interventions that addressed toenail care. Review of an untitled document dated 12/06/2021 and signed by Resident #3 revealed the resident declined a variety of outside resources, including dental, vision, and auditory services. However, further review of the document revealed it did not address podiatry services. During an observation on 03/13/2024 at 11:00 AM, Resident #3 was observed lying on his/her bed with Certified Resident Care Assistant (CRCA) #14 and CRCA #16 present in the room to provide care for the resident. Continued observation revealed Resident #3's toenails were observed to extend a half an inch to one (1) inch beyond the tips of his/her toes. During an interview on 03/13/2024 at 11:20 AM, CRCA #12 stated she was assigned to care for Resident #3, and confirmed the resident's toenails needed to be cut. CRCA #12 stated she reported the need for toenail care for Resident #3 a few months ago; however, was unable to recall who she reported the information to. During a concurrent observation and interview on 03/13/2024 at 11:25 AM, Registered Nurse (RN) #10 observed Resident #3's toenails and stated the resident's toenails needed to be trimmed. During a follow-up interview on 03/13/2024 at 12:38 PM, RN #10 stated podiatry services was last in the facility either in January 2024 or February 2024. RN #10 stated Director of Social Services (DSS) #38 was responsible for arranging podiatry services for residents. She further stated she was responsible for Resident #3's care on 03/13/2024; however, additionally stated no one had reported Resident #3's long toenails to her. During a concurrent observation and interview on 03/14/2024 at 10:23 AM, CRCA #13 and CRCA #14 were observed providing Resident #3 a shower. Per observation, Resident #3's toenails had not been trimmed, and his/her right great toenail extended approximately one (1) inch beyond the tip of the toe and curved under the right second toe. Continued observation revealed Resident #3's third toenail on his/her right foot extended approximately a quarter inch to a half inch beyond the tip of the toe, and the left great toenail extended approximately one (1) inch beyond the tip of the toe and curved left, resting under the left second toe. CRCA #13 stated the CRCAs were not allowed to cut residents' toenails, further stated a podiatrist visited the facility every three (3) months. CRCA #13 stated if a resident required podiatry services, the facility placed the resident's name on a list, and the resident was seen when the podiatrist came to the facility. During an interview on 03/15/2024 at 9:24 AM, the Director of Health Services (DHS) stated the podiatrist visited the facility every three (3) months, but added that recently the podiatrist had canceled a few visits. The DHS stated DSS #38 was the person who coordinated all ancillary services, including podiatry services. She stated she had observed Resident #3's toenails and stated the toenails should not have been that long. The DHS further stated no one had reported the condition of Resident #3's toenails. She additionally stated she expected Resident #3's toenails to be cut to the proper length. During an interview on 03/15/2024 at 10:50 AM, DSS #38 stated the podiatrist came to the facility every two (2) to three (3) months and the podiatry service was who sent her the list of residents to be seen. She further stated she was unsure when Resident #3 had last been seen. During a follow-up interview on 03/15/2024 at 11:24 AM, DSS #38 said Resident #3 had not received podiatry services since his/her admission to the facility and agreed podiatry care should have been provided for the resident. DSS #38 also stated she had reviewed Resident #3's admission paperwork, and the resident had declined some outside resources but she confirmed podiatry services had not been discussed with the resident. During an additional interview on 03/15/2024 at 3:46 PM, DSS #38 stated she called the facility's podiatry provider, and they confirmed Resident #3 was not receiving their services and they had never seen the resident. During an interview on 03/14/2024 at 11:53 AM, the Medical Director stated if a resident's toenails extended half an inch to one (1) inch beyond the tips of their toes, he expected the facility to arrange with an outside source to have the resident's nails trimmed.

Based on observation, interview, and record review, the facility failed to identify and implement appropriate safety interventions for one (1) of six (6) sampled residents (Resident #213) reviewed for accidents/hazards out of the total sample of twenty (20) residents. The facility failed to identify loose screws in a round metal ring that covered the grab bar in Resident #213's shower which contributed to the resident's fall on 02/09/2024. The findings include: The State Survey Agency (SSA) was not provided a policy related to the prevention of accidents and incidents. However, during an interview with the Executive Director, on 03/15/2024 at 1:50 PM, he stated it was his expectation that maintenance issues would be reported and repaired for the safety of the residents. Review of Resident #213's Resident Face Sheet revealed the facility admitted him/her on 01/04/2024, with diagnoses that included dementia and osteoarthritis. Review of Resident #213's Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/05/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating he/she had severe cognitive impairment. Further review of the MDS Assessment revealed the facility additionally assessed Resident #213 as dependent on staff for bathing. Review of Resident #213's Care Plan, revealed the facility identified a problem with activities of daily living (ADLs) with a start date of 01/12/2024. Continued review revealed the facility assessed the resident to require staff assistance to complete self-care and mobility functional tasks completely and safely. Review of the facility's Event Report, for Resident #213 revealed on 02/09/2024, the resident sustained a fall in his/her bathroom. Per review of the Event Report, the fall was witnessed by Certified Occupational Therapy Assistant (COTA) #18, who assisted Resident #213 with a transfer from the shower bench to the wheelchair. Continued review revealed during Resident #213's transfer the resident slipped and was lowered to the floor by COTA #18. Review of the Event Report further revealed Resident #213 sustained a skin tear to his/her right and left elbow and a hematoma to the posterior upper arm. During an interview on 03/14/2024 at 2:27 PM, COTA #18 stated she entered Resident #213's room and the resident stated he/she needed to use the bathroom, so she assisted the resident to the bathroom where she lowered the resident's pants. She stated upon lowering the resident's pants she noticed he/she had been incontinent, so she called for assistance to provide incontinence care. COTA #18 stated Certified Resident Care Associate (CRCA) #12 came to assist and stated Resident #213 needed to take a shower. She stated she rolled the resident's wheelchair to the shower area of the bathroom and with her gait belt around the resident, she had Resident #213 stand while holding onto the grab bar. COTA #18 stated while she held onto the gait belt the resident started to pivot to sit in the shower chair and his/her feet slipped, so she and CRCA #12 assisted the resident to slide down the COTA's right leg and right arm. She stated Resident #213 initially placed his/her hand on the grab bar, but due to his/her dementia, she thought the resident's hand moved and ended up on the loose piece of the grab bar. COTA #18 stated she thought when the round piece of the grab bar moved it startled or frightened Resident #213, and he/she then lost momentum and focus which resulted in the fall. She stated the resident's elbow hit on the spinning part of the loose bar and Resident #213 sustained a skin tear that turned into a hematoma. COTA #18 further stated the slippage of the round thing on the grab bar had something to do with Resident #213's fall as the resident had his/her hand on that piece of the bar. During an interview on 03/14/2024 at 2:00 PM, CRCA #12 stated she responded to the call light turned on by the COTA that needed assistance with Resident #213. CRCA #12 stated COTA #18 had taken Resident #213 to the bathroom and was in the process of transferring him/her to the shower chair. She stated COTA #18 had the resident stand up from the wheelchair and hold onto the grab bar in the shower. CRCA #12 stated as Resident #213 pivoted, the resident's feet started to slip, and his/her hand was on the metal circle part of the grab bar which was loose. She stated as Resident #213 slid down and his/her arm hit the loose part of the metal circle which caused a skin tear. CRCA #12 stated she thought the fall resulted because of a combination of the resident's feet slipping and his/her hand on the loose part of the grab bar and he/she sliding down. She stated she had not noticed the round part of the grab bar being loose before, and after the incident the grab bar having a loose part was reported to Registered Nurse (RN) #19, that same day. During an interview on 03/14/2024 at 3:17 PM, RN #19 stated she was made aware of Resident #213's fall by one of the staff members involved; however, was unable to remember if it was CRCA #12 or COTA #18. RN #19 stated however, COTA #18 or CRCA #12 never mentioned the loose metal cover on the grab bar as being the cause of Resident #213's fall and skin tear. She stated when she went into Resident #213's room, the resident was in the bathroom sitting in the wheelchair, and she observed a small amount of blood on the resident's arm. Observation on 03/14/2024 at 2:12 PM, with CRCA #12 of Resident #213's shower area, revealed the round ring covering the screws on the grab bar, on the left wall of the shower, were movable and slid the entire length of the grab bar. During an interview on 03/14/2024 at 4:15 PM, the Director of Plant Operations (DPO) stated he checked for work orders; however, had no work orders to repair any issues for the room where Resident #213 resided while at the facility. He said he also had not been notified of any issues with the grab bar in the shower in Resident #213's room. Observation at the time of interview revealed the DPO looked at the grab bar in the room where Resident #213 resided and found the circular screw cover was loose from the wall and was able to slide up and down the grab bar. The DPO stated the circular screw cover, if properly applied would have been so snug it would not come off or slide up and down the grab bar. He stated since the edges of the screw cover were sharp, it was possible a resident could sustain a skin tear if the circle was away from the wall, and his/her skin encountered the sharp area. During an interview on 03/15/2024 at 9:53 AM, the Director of Health Services (DHS) stated Resident #213's fall had been reported to her by RN #19. The DHS stated RN #19 reported Resident #213 sustained a fall with a skin tear in the shower; however, had not given any details of how the fall occurred. She stated the nurses were expected to place immediate interventions in place that should relate directly to what caused the resident to fall in order to prevent another fall from occurring. The DHS further stated she had not been informed of the loose fitting on the grab bar that caused the resident's injury. During a concurrent observation and interview on 03/15/2024 at 10:08 AM, the DHS observed the grab bar in the shower where Resident #213 resided while at the facility, and stated no one had informed her the screw cover did not fit properly and slid across the entire grab bar. The DHS stated no one informed her that Resident #213's hand settled on the screw cover and when the cover moved, it startled the resident and that had affected his/her balance and resulted in the fall. She acknowledged the grab bar fitting had not been properly applied, and agreed the edge of the fitting was sharp. The DHS stated the cover should not slide. During an interview on 03/15/2024 at 1:50 PM, the Executive Director (ED) stated he expected maintenance issues to be fixed as soon as identified, and expected staff to report those issues especially if the issue could affect a resident's safety.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pharmaceutical services to meet the needs of one (1) of six (6) sampled residents reviewed for pharmacy services (Resident #209). The facility admitted Resident #209 on 09/25/2023; however, failed to ensure the resident's medications were ordered from the pharmacy until the following day, on 09/26/2023. Consequently, Resident #209 missed ten (10) doses of his/her routine medications on 09/26/2023, because the medications were not available. The findings include: Review of a facility policy titled, Provider Pharmacy Requirements, revised in November 2018, revealed Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. Continued review of the policy revealed under the procedures area, section D the provider pharmacy agreed to perform the following pharmaceutical services provision of routine and timely pharmacy service as contracted, and emergency pharmacy services twenty-four (24) hours per day, seven (7) days per week. Per policy review, emergency or stat (needed urgently) medications were to be available for administration no more than four (4) hour(s) after the order was received by the pharmacy and a STAT request was made via a phone call from a facility representative. Further review revealed if an emergency or stat medication could not be provided to the facility within four (4) hours the facility was to be notified with an expected delivery window. Review further revealed all other new medication orders faxed prior to the daily cutoff were received and to be available for administration as soon as possible on the next routine delivery, unless indicated otherwise by facility personnel. In addition, medications were to be delivered by the primary pharmacy or back-up pharmacy, or were to be available from the emergency medication kit. Review of Resident #209's Resident Face Sheet revealed the facility admitted the resident on 09/25/2023 at 5:45 PM, with diagnoses that included pneumonia, acute and chronic respiratory failure with hypoxia, sarcoidosis of the lung (condition which cause small lumps of inflammatory cells in the lungs), acute pulmonary edema, diabetes, hypercholesterolemia, nonrheumatic aortic stenosis, and asthma. Review of Resident #209's Five-Day Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 09/28/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating he/she was intact cognitively. Per review of the MDS, Resident #209 also had active diagnoses that included heart failure, hypertension, and acute pulmonary edema. Review of Resident #209's Order History, revealed physician orders were started on 09/26/2023, the day after the resident's admission to the facility. Continued review of the Order History revealed Resident #209 had orders for the following medications: - atorvastatin (treats high cholesterol) 40 milligram (mg) tablet by mouth (po) once per day; - furosemide (treats fluid retention) 40 mg tablet po twice a day; - hydrocodone-acetaminophen (narcotic pain medication) 7.5-325 mg tablet po twice per day; - ipratropium-albuterol solution for nebulization (treats chronic obstructive pulmonary disease) 0.5 mg-3 mg (2.5 mg base)/3 milliliters (mL), 1 inhalation twice per day; - levothyroxine (treats hypothyroidism) 75 microgram (mcg) tablet po daily; - losartan (treats high blood pressure) 25 mg tablet po daily; - metformin (treats high blood sugar levels) 500 mg tablet, 2 tablets po in the morning and 1 tablet po in evening; and - potassium chloride (potassium supplement)10 milliequivalent (mEq) extended release tablet po daily. Review of Resident #209's Medications Administration History, dated 09/01/2023 to 09/30/2023, revealed no documented evidence the resident had the following medications administered on 09/26/2023, due to lack of availability of the medications: - atorvastatin: one (1) dose; - furosemide: two (2) doses; - hydrocodone-acetaminophen: one (1) dose; - ipratropium-albuterol: one (1) dose; - levothyroxine: one (1) dose; - losartan: one (1) dose; - metformin tablet: two (2) doses; and - potassium chloride: one (1) dose. Review of Resident #209's Progress Notes, dated 09/26/2023 at 3:14 PM, revealed Registered Nurse (RN) #10 contacted the provider pharmacy to send the resident's antibiotic order, and the rest of his/her routine medications stat (immediately/urgently). During an interview on 03/13/2024 at 12:49 PM, RN #10 stated details about Resident #209 were unclear, but could recall the resident's name and the resident being transferred to the hospital. RN #10 stated when a resident was admitted , the physician orders from any hospital paperwork were entered into the facility's computer system and staff then called the pharmacy to obtain the medications. Per RN #10, if the pharmacy expedited the medications (stat), then the medications were to arrive within four (4) hours of the request. The RN stated staff could also pull some medications necessary from the facility's emergency drug kit (e-kit) if the medications were not available from the pharmacy. During an interview on 03/15/2024 at 9:39 AM, a Pharmacy Customer Care Representative stated the pharmacy received Resident #209's medication orders on 09/26/2023, between 1:00 and 1:40. The Pharmacy Customer Care Representative stated however, as the pharmacy no longer had a patient profile for Resident #209, there was no way to tell whether the order time was AM or PM. The Pharmacy Customer Care Representative further stated the pharmacy staff could also see the medications were ordered stat at some point on 09/26/2023. During an interview on 03/13/2023 at 10:08 AM, Licensed Practical Nurse (LPN) #2 stated when a resident was admitted and once the physician orders were verified, facility staff entered the medication orders into the computer system, then called the pharmacy. LPN #2 stated medications generally arrived from the pharmacy in a couple of hours. LPN #2 stated if the hospital sent a prescription for a medication, staff could administer the medications from the facility's e-kit. The LPN stated medications could be late due to pharmacy delivery, but she was not aware that a resident missing multiple doses of his/her medications. Further interview revealed LPN #2 stated staff could pull medications from the facility's medication storage/dispensing machine; however, not all medications a resident might need were in the machine. During an interview on 03/13/2024 at 12:20 PM, LPN #3 stated when a resident was admitted , staff entered their medication orders into a computer and called the pharmacy to have the medications sent stat. She stated if medications did not arrive in a timely manner, staff could retrieve the medications from the medication storage/dispensing machine. During an interview on 03/13/2024 at 1:07 PM, LPN #4 stated if staff sent a new resident's admission medication orders to the pharmacy before 3:00 PM, the pharmacy would send the medication to the facility that same night. Per LPN #4, if a resident was admitted after 3:00 PM, staff had to call the pharmacy to have the medications sent stat, which took four (4) to six (6) hours to receive. LPN #4 stated when residents' medications were not available she pulled the medications from the e-kit. During an interview on 03/13/2024 at 1:53 PM, LPN #5 stated when a resident was admitted to the facility, a nurse was to input the medication orders into the computer and call the pharmacy to have the medications sent stat because not all medications were in the facility's e-kit. She stated if a resident was admitted at or after 6:00 PM, the nurse was to call the pharmacy to expedite the resident's medications. LPN #5 stated the medications should arrive between 10:00 PM to 2:00 AM the same night. In continued interview the LPN stated the facility could not enter medication orders until the resident was physically present at the facility. She stated night shift staff should have called the pharmacy to ensure Resident #209's medications were at the facility before the morning shift. LPN #5 further stated it was not good for a resident to miss that many medication doses. During an interview on 03/13/2024 at 11:21 AM, the Medical Director stated there could be delays in the facility receiving medications because the correct list of medications might not be available until the resident was physically present in the facility. The Medical Director stated not receiving ordered medications could be detrimental to a resident. The Medical Director reviewed Resident #209's medications that were not administered on 09/26/2023, and stated that missing the medication doses had not caused further respiratory problems or caused the resident's condition to worsen. During an interview on 03/13/2024 at 2:21 PM, LPN #11 stated when a resident was admitted to the facility, she entered the medication orders in the computer, and said staff could have the pharmacy send the medications stat, which meant the medications should arrive within four (4) hours. She stated if a resident was admitted after 5:00 PM, and his/her medications were not ordered stat, the pharmacy would not deliver the medications until the next night. She stated there were medications available in limited supplies in the facility's e-kit. LPN #11 stated she did not remember Resident #209 or the situation with the resident's medications; however, LPN #11 further stated if medications were not available for administration, there should have been a note entered on the MAR, and the medications started the next day once they arrived. LPN #11 further stated apparently she did not notify the Director of Health Services (DHS) that some of Resident #209's medications were not available to give. During an interview on 03/14/2024 at 1:52 PM, the DHS stated she was not aware Resident #209's medications had not been available after admission until the next day. She stated she was also not aware the resident missed doses of his/her routine medications after admission. The DHS stated however, she expected residents to receive their ordered medications. She stated when a resident was admitted , nursing staff could request the medications be delivered stat, which could take up to four (4) hours or more to arrive at the facility. The DHS further stated some medications were available for administration in the facility's medication storage/dispensing machine. During an interview on 03/15/2024 at 8:57 AM, the Executive Director (ED) stated when the facility admitted a resident, he expected nursing staff to contact the pharmacy to acquire the medications timely and, if they were ordered stat, the medications should arrive within four (4) hours. The ED stated if a resident arrived in the evening for admission, the nurse ordering the medications needed to order the medications stat so the medications would be at the facility by midnight. The ED further stated he expected nursing staff to communicate with the DHS to determine why a resident's medications were not available for administration and to escalate the order if needed.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure staff implemented the care plan to prevent falls for one (1) of three (3) sampled residents, Resident #204. Record review revealed the facility determined Resident #204 required one (1) staff assistance for transfers and toileting and was care planned for staff to assist with transfers and toileting. However, on [DATE] at 4:00 AM, staff found the resident on the floor close to the bathroom, on his/her right side and back, when the resident attempted to go the bathroom unassisted. On [DATE] at 3:15 AM, staff found the resident on the floor when he/she attempted to go to the bathroom unassisted. The resident was sent to the hospital for treatment of [REDACTED]. Review of the Certificate of Death revealed the cause of death was complications from fall. The facility's failure to have an effective system in place to ensure care plans were followed has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Comprehensive Care Plan Guideline, reviewed [DATE], revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Care plan interventions should be reflective of the risk area(s) or disease processes that impacted the individual resident. The comprehensive care plan would be developed with problem areas that should identify the relative concerns, with goals that should be measurable and attainable, and with interventions reflective of the individual's needs and risk influence as well as the resident's strengths. Review of the facility's policy, Fall Management Program Guideline, reviewed [DATE], revealed care plan interventions should be implemented which addressed the resident's fall risk factors. Review of Resident #204's closed clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted for rehabilitation, physical therapy, and strengthening. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required limited assistance of one (1) person for bed mobility, transfers, and toileting, and had no falls prior to admission. The facility assessed the resident with a Brief Interview for Mental Status score of thirteen (13) of fifteen (15) and determined the resident cognitively intact. Review of Resident #204's Care Plan, dated [DATE], revealed the resident was at risk for falls with an intervention to assist the resident with transfers as needed. In addition, the resident was at risk for incontinence and staff was to offer and provide assistance to toilet as needed and/or requested. The resident required staff assistance to complete Activities of Daily Living (ADL) tasks safely with a goal for the resident to have ADL needs met safely by staff. Resident #204 had impaired cognition with associated short-term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness, and staff was to pay attention to basic needs and provide ADL care as required. Review of Resident #204 Physical Therapy (PT) Progress Notes, dated [DATE], revealed the resident made progress with getting up to walk by means of a walker and was able to transfer but forgot a few of the important safety cues while transferring. According to the Progress Notes, dated [DATE], an admission care plan meeting was held with PT, Social Services, MDS, Resident #204, and the resident's daughter and discussed Resident #204 had done well with PT with the exception of the last two (2) days, the resident had tremors and was tired. Resident #204 fatigued easily with Occupational Therapy but was doing well. In addition, Progress Notes, dated [DATE], revealed Resident #204 had become emotional labile and tried to be more dependent on staff. Review of a Fall Event, dated [DATE], revealed on [DATE] at 4:00 AM, staff found the resident on the floor near his/her bathroom. The resident was trying to go to the bathroom unassisted; however, the care plan stated the resident was to have staff assistance for transfers and toileting. The resident lost his/her balance and fell , landing on his/her right side and back causing skin tears to the middle and right fingers of the right hand and upper back. The physician was notified and ordered an x-ray of the swollen and bruised hand. The resident had no complaints of pain or discomfort at that time, but later complained of low back pain and an x-ray of the back was ordered. The facility determined the root cause of the fall was self-transfer to the restroom. The resident was educated on using the call light for assistance with toileting. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 11:50 AM, revealed she cared for Resident #204 on [DATE] when the resident fell . She stated the resident was independent and could make his/her needs known; however, stated he/she did not use the call light, and did not have any alarms to signal staff when he/she got up. Per interview, the nurse could not remember what interventions were in place for the resident and could not remember the last time she had checked on the resident. Review of an Event Report, dated [DATE], revealed on [DATE] at 3:15 AM, staff found Resident #204 on the bathroom floor, alone, with his/her walker in front of him/her. Resident #204 sustained two (2) skin tears on the bridge of the nose and under the left eye, a hematoma around the right eye, and three (3) skin tears to the bilateral lower extremities. Staff contacted the physician and the resident was sent to the emergency room . Interview with LPN #10, on [DATE] at 8:46 PM, revealed she cared for Resident #204 on [DATE] when the resident fell . She stated she was at the desk and heard a thump and found the resident on the floor. She stated the resident required one (1) staff to assist to the restroom and used a walker. The LPN revealed she rounded on residents every two (2) hours and was able to meet the needs of the residents. She stated she could not remember the last time she rounded on the resident. Review of Hospital Records revealed Resident #204 presented to the emergency department on [DATE] at 4:41 AM complaining of a fall that occurred when walking to the restroom. The resident tried to reach his/her walker, missed, and fell . It was the resident's second fall in 24 hours. On exam, Resident #204 was hyperventilating, and had palpable deformities to the left chest, marked facial swelling, and ecchymosis. Computed [NAME]ography (CT) of the chest revealed the resident had three (3) fractured ribs, blood in the right lung base, and possible hemothorax. Resident #204 expired at the hospital on [DATE] at 12:17 PM. Review of the Certificate of Death, dated [DATE], revealed the cause of death was complications from fall. Interview with LPN #1, on [DATE] at 9:49 AM and [DATE] at 3:59 PM, revealed she vaguely remembered Resident #204 and the care plan interventions. She stated if the care plan specified a resident was to have staff assistance, it meant a staff member would need to be present and if not, the resident was not safe. She stated even if the resident presented as independent, staff must assist the resident until the care plan was changed. Interview with the Director of Health Services (DHS), on [DATE] at 1:58 PM and [DATE] at 4:20 PM, revealed the Rehab unit nurse rounded every two (2) hours. The DHS stated staff followed the care plan since Resident #204 was cognitively intact and had assistance available to him/her. Interview with the Executive Director (ED), on [DATE] at 5:53 PM, revealed her overall responsibilities included overseeing the facility, including the nursing staff. She stated if the residents needed assistance of more than one (1) person, the resident was moved to another hall. According to the ED, the nurses were capable of providing every resident's care needs at night. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #204 was discharged on [DATE]. 2. On [DATE], a Quality Assurance and Assessment (QAA) meeting was held to discuss the details of the Immediate Jeopardy and action items contained in the A[NAME]. The Executive Director (ED), Director of Health Services (DHS), Assessment Support, Clinical Support (CS), Divisional Vice President, and Medical Director were present. 3. On [DATE], the CS ensured nine (9) residents, who had a fall within the last one hundred and twenty (120) days, were included in the Clinically at Risk (CAR) program. During the weekly CAR meeting, the DHS, Director of Social Services, or Registered Dietitian ensured efficacy of interventions related to the root cause that was identified. The ED will audit CAR meetings to monitor interventions to ensure revisions, monthly. Residents with a fall would be monitored during the weekly CAR meeting up to four (4) weeks to ensure implemented interventions remained effective. All findings will be presented to QAA. 4. On [DATE], the DHS, Assistant Director of Health Services (ADHS), and Minimum Data Set (MDS) Assessment Support reassessed all residents for fall risk. MDS Assessment Support reviewed and revised all care plans as needed and the Certified Resident Care Associate (CRCA) sheets were updated to reflect new interventions if applicable. Fall risk safety interventions for three (3) residents were revised. The DHS, ADHS, Evening Supervisor, or MDS Nurse will conduct random care plan audits on five (5) residents identified at risk for falls four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total of one (1) year. Findings will be presented to the QAA committee. 5. On [DATE], the Corporate Clinical Support educated the Interdisciplinary Team (IDT) on determining root cause of an incident and implementing interventions. The Corporate Clinical Support or Assessment Support will audit up to five (5) falls to ensure the root cause had been determined by the IDT with appropriate interventions implemented weekly for eight (8) weeks, then monthly for one (1) month, and then quarterly for three (3) quarters. All findings will be presented to the QAA committee. 6. On [DATE], the ED, DHS, ADHS, and/or CS initiated in-service education to the licensed nurses and CRCAs. The nurses were educated on the Falls Management Policy, which included determining the root cause, initiating interventions when a resident was identified at risk for falls or had a fall to reduce risk of repeat fall, review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions, and supervision to prevent accidents related to transfers and toileting; and Guidelines for Neurological Checks to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that might alert staff for potential for head injury or [MEDICAL CONDITION] activity. The CRCAs were educated on the falls management, identification of changes in residents, observation of environment risk, notifying the nurse if the CRCA sheet needed revision, following the CRCA assignment sheets, and importance of reporting immediately any resident changes. Staff had to pass a posttest with a score of 100% and if less than 100%, staff was re-educated. Any nurse or CRCA not educated on [DATE] would not be permitted to work until the training and test were completed. In addition, the MDS Nurses were in-serviced regarding reviewing and revising care plans with interventions for residents identified at risk for falls; and to revise the care plan to include identified root cause with interventions. 7. The DHS, ADHS, MDS Nurse, and/or ED will review newly admitted residents, identified at risk for falls, in the daily Clinical Care Meeting to ensure appropriate interventions were in place. In the daily meeting, the IDT will review falls, determine root cause, and implement interventions related to the root cause with revisions made to care plans as indicated. The DHS, ADHS, MDS Nurse, and /or ED will conduct random audits on five (5) residents identified at risk for falls to verify interventions were in place, observe nursing staff providing assistance with transfers and toileting on varied shifts, and ensure CRCAs were following care plan interventions, four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total on one (1) year. Findings will be presented to the QAA committee. 8. The QAA committee will review results of all audits weekly to ensure 100% compliance and make modifications when necessary. The committee will monitor for any additional educational needs, the effectiveness of the plan, and revise the plan related to areas identified through the audit process. The DHS or ADHS will be responsible to provide additional education as identified during the audits and suggestions made by the QAA committee. The Medical Director will review the progress with the ED (DHS/ADHS in the ED's absence) on a weekly basis. The SSA validated the facility implemented the following actions: 1. Record review revealed Resident #204 was discharged on [DATE]. 2. Record review revealed a QAPI meeting was held on [DATE], with the Medical Director, DHS, ED, Clinical Support, Assessment Support, and the Divisional Vice President present. 3. Interview with the ADHS, on [DATE] at 2:10 PM, revealed the CAR met weekly to discuss residents with falls to ensure interventions were effective. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they participated in the CAR and Clinical Care Meeting to ensure interventions were in place and effective. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she attended the CAR meeting to ensure the root cause of falls were discussed and interventions in place. Interview with the ED, on [DATE] at 3:58 PM, revealed she would audit the CAR meetings monthly. Record review revealed residents at risk for falls were reviewed in the CAR meetings, including the nine (9) who had a fall in the last one hundred and twenty (120) days. 4. Interview with the DHS, on [DATE] at 3:07 PM, revealed all resident were reassessed for fall risk and three (3) residents were identified needing additional interventions. She stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Record review revealed all residents were assessed for fall risk, care plans were reviewed, and three (3) residents' plans were revised. Record review revealed an audit tool the facility was to use to perform the audits. 5. Interview with the ADHS, on [DATE] at 2:10 PM, the DHS on [DATE] at 3:07 PM, and the ED at 3:58 PM, revealed the Clinical Support educated the IDT on determining root cause and implementing interventions. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she trained the IDT on determining the root cause and implementing interventions. Record review revealed the IDT was educated per the A[NAME]. 6. Interviews with CRCA #9, on [DATE] at 2:33 PM, CRCA #10 at 2:50 PM, Certified Medication Technician #2 at 3:08 PM, Licensed Practical Nurse (LPN) #1 at 3:56 PM, LPN #2 on [DATE] at 1:23 PM, Registered Nurse (RN) #1 at 9:39 AM, and RN #2 at 1:42 PM, revealed they were educated per the A[NAME] and completed a posttest. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they were educated on care plan interventions for falls and the root cause analysis. Interviews with Clinical Support, on [DATE] at 5:24 PM, and the ADHS on [DATE] at 2:10 PM, revealed they educated the nurses and the CRCAs per the A[NAME]. The Clinical Support stated staff not educated on [DATE] were educated prior to the working their next scheduled shift, and all staff passed the test with a 100% score. Record review revealed staff was educated per the A[NAME] with posttest completion. 7. Interview with the ADHS, on [DATE] at 2:10 PM, DHS on at 3:07 PM, MDS Coordinator at 4:51 PM, and Assistant MDS Coordinator at 5:01 PM, revealed the IDT reviewed new admissions to ensure fall interventions were in place during the daily Clinical Care Meeting, and determined the root cause of falls to revise the care plans. The DHS stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she would be assisting in the falls and care plan audits. Record review revealed falls and care plans were reviewed per the A[NAME]. Record review revealed an audit tool the facility was to use to perform the audits. 8. Interview with the ED, on [DATE] at 3:58 PM, revealed the QAA committee would review the audits to track the data. She stated she would meet with the Medical Director weekly to review the progress of the audits.

Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to have an effective system in place to provide adequate supervision to prevent accidents and injuries for one (1) of three (3) sampled residents, Resident #204. Record review revealed on [DATE] at 4:00 AM, Resident #204 acquired skin tears on his/her right middle and ring fingers and a skin tear along his/her upper back related to an unwitnessed fall. The night shift nurse found Resident #204 in her/his room by the bathroom. Per interviews, staff was aware the resident did not always use the call light to request assistance; however, after the fall, the resident's supervision was not increased and on [DATE], the resident fell again. Continued record review revealed Resident #204 had a second unwitnessed fall on [DATE] at 3:15 AM, when he/she attempted to go to the bathroom unassisted. He/she sustained two (2) skin tears, on the bridge of nose and under the left eye, a hematoma around the right eye, and three (3) skin tears to the bilateral lower extremities. Resident #204 was sent to the hospital for treatment and was found to have three (3) fractured ribs, blood in the right lung base, and possible hemothorax. The resident was admitted to the hospital and later expired. Review of the Certificate of Death revealed the cause of death was complications from fall. The facility's failure to ensure residents were supervised to prevent accidents and injuries has caused or likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. An acceptable Allegation of Compliance (A[NAME]) was received on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) verified the IJ was removed on [DATE], prior to exit on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (P[NAME]) and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Fall Management Program Guideline, review date [DATE], revealed the fall risk assessment identified risk factors to evaluate for the contribution they might have to the resident's likelihood of falling. Should the resident experience a fall, the attending nurse would complete the Fall Event. This included an investigation of the circumstance surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce the risk of repeat fall episodes, and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Review of the facility's policy, Guidelines for Neurological Checks, review date [DATE], revealed the purpose was to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that might alert staff for potential for head injury or [MEDICAL CONDITION] activity. Residents having a fall should be evaluated for injury and four (4) neurological checks (recommended every 15 minutes) should be completed. If the resident had a change of condition, (change from baseline) a serial neurological checks would be performed for twenty-four (24) hours. Review of the facility's policy, Assisting Residents to the Bathroom, review date [DATE], revealed the facility would provide residents an opportunity to use the bathroom by providing appropriate assistance to maintain safety and prevent resident falls. Review of Resident #204's closed clinical record revealed the facility admitted the resident on [DATE], for rehabilitation, physical therapy, and strengthening. Resident #204 had [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of a thirteen (13) out of fifteen (15) and determined the resident cognitively intact. The facility assessed the resident required physical assistance of one (1) staff for bed mobility, transfers, dressing, personal hygiene, and toilet use. The facility assessed the resident was not steady and only able to stabilize with staff assistance for surface-to-surface transfers, walking, moving from seated to standing position, and moving on and off the toilet. The resident used a walker for mobility. Review of Resident #204's Care Plan, dated [DATE], revealed the resident was at risk for falls with an intervention to assist the resident with transfers as needed. In addition, the resident was at risk for incontinence and staff was to offer and provide assistance to toilet as needed and/or requested. The resident required staff assistance to complete Activities of Daily Living (ADL) tasks safely with a goal for the resident to have ADL needs met safely by staff. Resident #204 had impaired cognition with associated short-term memory impairment and was at risk for confusion, disorientation, altered mood, and impaired or reduced safety awareness, and staff was to pay attention to basic needs and provide ADL care as required. Review of Daily Physical Therapy (PT) Notes, dated [DATE], revealed Resident #204 safely demonstrated transferring back and forth requiring contact guard assistance due to unsteadiness. Resident #204 made slow progress and Pneumonia had inhibited the progress. On [DATE], the resident received therapy to include seated bilateral lower extremity exercise to increase lower extremity strength needed for improving transfers and gait, standing activities with rolling walker to improve stability, and ambulation with staggering gait. Per the PT note, nursing staff was aware Resident #204 had increased fatigue and nausea and required contact guard assistance for all functional transfers. Review of Daily Occupational Therapy (OT) Notes, dated [DATE], revealed Resident #204 required supervision when performing dressing, toileting, and hygiene, and fatigued with minimal exertion. On [DATE], Resident #204 participated in therapy; however, she/he experienced a feeling of nausea and fatigue. Resident #204 was educated on using the call light for transfers but required supervision for safety. Review of an Event Report, dated [DATE], revealed on [DATE] at 4:00 AM, Resident #204 had an unwitnessed fall. Licensed Practical Nurse (LPN) #9 found Resident #204 on the floor by the bathroom in his/her room. LPN #9 reported Resident #204 was going to the bathroom but did not have on his/her oxygen, his/her oxygen saturation (blood oxygen level) had dropped, he/she lost his/her balance and fell . Resident #204 landed on his/her right side and back causing skin tears to the right middle and ring fingers and a skin tear along the upper back spine. LPN #9 completed two (2) neurological checks (4:00 AM and 4:15 AM) which Resident #204 presented as lethargic/drowsy, had weak upper and lower left and right extremity movements, and speech was unclear. Documentation revealed the resident exhibited a change in mental status with new onset of lethargy and slurred speech. The fall risk re-assessment listed the resident had cognitive or memory impairment that effected safety and judgement, he/she required assistance to ambulate safely, and he/she refused to comply with safety measures such as call light use and appliances. Immediate intervention was for the bed to be in the lowest position. Further review revealed LPN #9 failed to complete the third and fourth follow-up neurological checks, per the facility's policy. The Physician was notified and orders obtained for an x-ray to the resident's swollen and bruised right hand. Later in the shift, LPN #1 notified the physician Resident #204 complained of low back pain related to the fall and obtained an order to add x-ray of the back. X-ray results revealed [MEDICAL CONDITION] changes and scoliosis noted to the lumbar, and the wrist had a scapholunate dissociation, dorsal tilt to the lunate. The physician was notified and no new orders were given. Telephone interview with LPN #9, on [DATE] at 11:46 AM, revealed she requested not to work the Rehab unit (where Resident #204 resided) because there was never a Certified Resident Care Associate (CRCA) on third shift, and sometimes she was not able to meet all of the residents' care needs being the only one on the unit. LPN #9 expressed her concerns to the Director of Health Services (DHS). She recalled Resident #204 completed things independently and had been educated several times on using the call light to ask for assistance and had stop signs posted in his/her room. LPN #9 stated on [DATE], the resident got up with his/her walker and tripped going to the bathroom because he/she did not have on his/her oxygen and became dizzy and confused. She found the resident in front of her/his bathroom with skin tears on the hand, finger, and back, and hurt his/her wrist. LPN #9 believed the fall was unwitnessed and neurological checks were completed on unwitnessed falls for one (1) hour every fifteen (15) minutes. She stated Resident #204 would sometimes take the oxygen off and did not use the call light. She stated the resident was checked on every two (2) hours and after the fall, the intervention put into place was to have the bed in the lowest position, she could not remember if more supervision was added. LPN #9 revealed if a resident needed two (2) person assistance, the resident was transferred to another part of the facility as soon as possible. Review of the Interdisciplinary Team's (IDT) evaluation of the root cause of the [DATE] fall for Resident #204 revealed the IDT agreed the root cause was due to self-transfer to the restroom. The immediate intervention was to put the resident's bed in the lowest position and changed to obtain a bedside commode. Review of an Event Report, dated [DATE], revealed on [DATE] at 3:15 AM, Resident #204 had an unwitnessed fall. LPN #10 rushed into the resident's room when she/he heard a strange thump and found the resident on the bathroom floor with his/her walker in front of him/her. Resident #204 sustained two (2) skin tears on the bridge of the nose and under the left eye, a hematoma around the right eye, and three (3) skin tears to the bilateral lower extremities (BLE). Four (4) neurological checks were completed and found the resident alert, with weak upper and lower right and left extremity movement, and with clear speech. The fall risk re-assessment listed the resident required assistance to transfer, required assistance to ambulate safely, required use of an assistive device and/or often forgot to use, and he/she refused to comply with safety measures such as call light use and appliances. LPN #10 contacted the physician and the resident was sent to the emergency room . Interview with LPN #10, on [DATE] at 8:46 PM, revealed on [DATE], Resident #204 had an unwitnessed fall. The resident seemed a little bit more confused than usual. LPN #10 heard a thump and found the resident on the floor. Resident #204 received a hematoma right above the eyes and the resident's head was a major concern so the emergency medical services were called along with the physician and relative. She remembered Resident #204 needed one (1) person assistance and used a walker. Resident #204 had been educated on using the call light for assistance and had stop signs in his/her room. LPN #10 stated the Rehab unit was full and she completed rounds every two (2) hours and was able to meet the needs of the residents. Review of the IDT's evaluation of the root cause of the [DATE] fall for Resident #204 revealed the IDT agreed the root cause was due to self-transfer to the restroom. The IDT agreed with the immediate intervention to transfer the resident to the emergency room . No acute injuries were noted. Review of Hospital Records revealed an Emergency Department Encounter, dated [DATE], which revealed Resident #204 presented to the emergency department on [DATE] at 4:41 AM complaining of a fall that occurred when walking to the restroom. The resident tried to reach his/her walker, missed, and fell . It was the resident's second fall in 24 hours. The resident complained of rib pain, denied neck, abdominal, and lower back pain. Review of the Emergency Department Provider Notes, dated [DATE], revealed the resident arrived to the emergency department due to an unwitnessed fall. The resident complained of rib pain with multiple facial and bilateral knee skin tears. On exam, Resident #204 was hyperventilating, and had palpable deformities to the left chest, no flail segment. The resident had marked facial swelling and ecchymosis. Resident #204 was admitted on [DATE] for palliative care related to his/her respiratory status. Computed [NAME]ography (CT) of the chest revealed the resident had three (3) fractured ribs, blood in the right lung base, and possible hemothorax. Final [DIAGNOSES REDACTED]. Resident #204 expired at the hospital on [DATE] at 12:17 PM. Review of the Certificate of Death, dated [DATE], revealed the cause of death was complications from fall. Interview with LPN #1, on [DATE] at 9:49 AM and [DATE] at 3:59 PM, revealed she vaguely remembered Resident #204 and his/her fall interventions. She stated if a resident fell with no apparent reason, then a urine culture was sent out for possible urinary tract infection. If the care plan specified a resident was to have assistance of one (1), then a staff member needed to be present and if not, the resident was not safe. LPN #1 reviewed the neurological checks dated [DATE], and stated the nurse should have done the checks every fifteen (15) minutes for one (1) hour, and if baseline changes were noted, then they were done for seventy-two (72) hours to watch the resident intensely. If a resident presented with symptoms of lethargy, dizziness, weakness, and did not have his/her oxygen on, she would call the physician and give a detail description of the resident so the physician could make an informed decision. In addition, she would have increased supervision for more frequent checks than every two (2) hours. LPN #1 stated Resident #204 needed more supervision during night shift. Interview with the MDS Coordinator, on [DATE] at 11:51 AM, revealed Resident #204 had short-term memory impairment and needed assistance of one (1) staff. The MDS stated neurological checks were incomplete for the [DATE] fall, as only two (2) of four (4) were completed which was against policy. The nurse would not know if Resident #204 was swaying from the baseline to implement effective interventions from the unwitnessed fall, which could cause the resident harm. Interview with the DHS, on [DATE] at 4:20 PM, revealed the standard for rounding for nurses was every two (2) hours unless the physician ordered more frequent checks, or the care plan was changed. Even if a resident experienced a fall, after the neurological checks were completed the resident went back to the two (2) hour rounding. The DHS stated resident care needs were met when the call light was answered; however, staff interviews revealed Resident #204 did not use the call light. Per interview, the IDT determined the root cause and made changes and/or approved interventions for Resident #204's [DATE] and [DATE] falls. She stated staff could have checked on Resident #204 every five (5) minutes and he/she still could have fallen. According to the DHS, Resident #204 had a BIMS of thirteen (13) and had a choice to use the call light or not to get assistance. Interview with the Social Worker, on [DATE] at 11:37 AM, revealed a BIMS score of thirteen (13) - fifteen (15) indicated a resident was cognitively intact and typically alert and oriented; however, Dementia could impair a resident's decision-making. Interview with the Nurse Practitioner (NP), on [DATE] at 11:00 AM, revealed Resident #204 would get up without assistance and nursing staff would get upset with her/him and educated the resident on using the call light. The NP stated Resident #204 got tired easy and was weak because of his/her respiratory condition and he/she had Pneumonia. She stated the CRCAs checked on the resident often because the resident was on diuretics (increases urine); however, per interviews, there was only one (1) nurse on the Rehab unit at night. Interview with the Executive Director (ED), on [DATE] at 5:53 PM, revealed if a resident needed assistance for more than one (1) staff, the resident was moved to another hall. Resident #204 had a BIMS of thirteen (13) and she/he was teachable to the call light in order to receive assistance. She further stated the facility consulted with the physician and determined Resident #204's falls were unavoidable. The ED revealed the minimum requirement for rounding was every two (2) hours and staff was not required to document every time they rounded so it was unclear how often Resident #204 was supervised. Interview with Resident #204's Daughter, on [DATE] at 8:15 AM, revealed Resident #204 had been educated on using the call light; however, she stated the resident had been diagnosed with [REDACTED]. She stated Resident #204 had lived with her prior to admission to the facility and required assistance with some of his/her daily needs. She stated when she saw Resident #204 at the hospital after the fall, she did not recognize the resident due to the swelling and bruising on his/her face, and the resident was in a lot of pain. The Daughter stated the hospital was going to transfer the resident to a trauma center; however, she stated the resident's oxygen dropped and he/she passed away. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #204 was discharged on [DATE]. 2. On [DATE], a Quality Assurance and Assessment (QAA) meeting was held to discuss the details of the Immediate Jeopardy and action items contained in the A[NAME]. The Executive Director (ED), Director of Health Services (DHS), Assessment Support, Clinical Support (CS), Divisional Vice President, and Medical Director were present. 3. On [DATE], the CS ensured nine (9) residents, who had a fall within the last one hundred and twenty (120) days, were included in the Clinically at Risk (CAR) program. During the weekly CAR meeting, the DHS, Director of Social Services, or Registered Dietitian ensured efficacy of interventions related to the root cause that was identified. The ED will audit CAR meetings to monitor interventions to ensure revisions, monthly. Residents with a fall would be monitored during the weekly CAR meeting up to four (4) weeks to ensure implemented interventions remained effective. All findings will be presented to QAA. 4. On [DATE], the DHS, Assistant Director of Health Services (ADHS), and Minimum Data Set (MDS) Assessment Support reassessed all residents for fall risk. MDS Assessment Support reviewed and revised all care plans as needed and the Certified Resident Care Associate (CRCA) sheets were updated to reflect new interventions if applicable. Fall risk safety interventions for three (3) residents were revised. The DHS, ADHS, Evening Supervisor, or MDS Nurse will conduct random care plan audits on five (5) residents identified at risk for falls four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total of one (1) year. Findings will be presented to the QAA committee. 5. On [DATE], the Corporate Clinical Support educated the Interdisciplinary Team (IDT) on determining root cause of an incident and implementing interventions. The Corporate Clinical Support or Assessment Support will audit up to five (5) falls to ensure the root cause had been determined by the IDT with appropriate interventions implemented weekly for eight (8) weeks, then monthly for one (1) month, and then quarterly for three (3) quarters. All findings will be presented to the QAA committee. 6. On [DATE], the ED, DHS, ADHS, and/or CS initiated in-service education to the licensed nurses and CRCAs. The nurses were educated on the Falls Management Policy, which included determining the root cause, initiating interventions when a resident was identified at risk for falls or had a fall to reduce risk of repeat fall, review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions, and supervision to prevent accidents related to transfers and toileting; and Guidelines for Neurological Checks to evaluate the level of consciousness, evaluate pupil response, motor function, and vital signs that might alert staff for potential for head injury or [MEDICAL CONDITION] activity. The CRCAs were educated on the falls management, identification of changes in residents, observation of environment risk, notifying the nurse if the CRCA sheet needed revision, following the CRCA assignment sheets, and importance of reporting immediately any resident changes. Staff had to pass a posttest with a score of 100% and if less than 100%, staff was re-educated. Any nurse or CRCA not educated on [DATE] would not be permitted to work until the training and test were completed. In addition, the MDS Nurses were in-serviced regarding reviewing and revising care plans with interventions for residents identified at risk for falls; and to revise the care plan to include identified root cause with interventions. 7. The DHS, ADHS, MDS Nurse, and/or ED will review newly admitted residents, identified at risk for falls, in the daily Clinical Care Meeting to ensure appropriate interventions were in place. In the daily meeting, the IDT will review falls, determine root cause, and implement interventions related to the root cause with revisions made to care plans as indicated. The DHS, ADHS, MDS Nurse, and /or ED will conduct random audits on five (5) residents identified at risk for falls to verify interventions were in place, observe nursing staff providing assistance with transfers and toileting on varied shifts, and ensure CRCAs were following care plan interventions, four (4) times weekly for eight (8) weeks, then three (3) times weekly for eight (8) weeks, then two (2) times weekly for eight (8) weeks, then monthly for a total on one (1) year. Findings will be presented to the QAA committee. 8. The QAA committee will review results of all audits weekly to ensure 100% compliance and make modifications when necessary. The committee will monitor for any additional educational needs, the effectiveness of the plan, and revise the plan related to areas identified through the audit process. The DHS or ADHS will be responsible to provide additional education as identified during the audits and suggestions made by the QAA committee. The Medical Director will review the progress with the ED (DHS/ADHS in the ED's absence) on a weekly basis. The SSA validated the facility implemented the following actions: 1. Record review revealed Resident #204 was discharged on [DATE]. 2. Record review revealed a QAPI meeting was held on [DATE], with the Medical Director, DHS, ED, Clinical Support, Assessment Support, and the Divisional Vice President present. 3. Interview with the ADHS, on [DATE] at 2:10 PM, revealed the CAR met weekly to discuss residents with falls to ensure interventions were effective. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they participated in the CAR and Clinical Care Meeting to ensure interventions were in place and effective. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she attended the CAR meeting to ensure the root cause of falls were discussed and interventions in place. Interview with the ED, on [DATE] at 3:58 PM, revealed she would audit the CAR meetings monthly. Record review revealed residents at risk for falls were reviewed in the CAR meetings, including the nine (9) who had a fall in the last one hundred and twenty (120) days. 4. Interview with the DHS, on [DATE] at 3:07 PM, revealed all resident were reassessed for fall risk and three (3) residents were identified needing additional interventions. She stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Record review revealed all residents were assessed for fall risk, care plans were reviewed, and three (3) residents' plans were revised. Record review revealed an audit tool the facility was to use to perform the audits. 5. Interview with the ADHS, on [DATE] at 2:10 PM, the DHS on [DATE] at 3:07 PM, and the ED at 3:58 PM, revealed the Clinical Support educated the IDT on determining root cause and implementing interventions. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she trained the IDT on determining the root cause and implementing interventions. Record review revealed the IDT was educated per the A[NAME]. 6. Interviews with CRCA #9, on [DATE] at 2:33 PM, CRCA #10 at 2:50 PM, Certified Medication Technician #2 at 3:08 PM, Licensed Practical Nurse (LPN) #1 at 3:56 PM, LPN #2 on [DATE] at 1:23 PM, Registered Nurse (RN) #1 at 9:39 AM, and RN #2 at 1:42 PM, revealed they were educated per the A[NAME] and completed a posttest. Interview with the MDS Coordinator, on [DATE] at 4:51 PM, and the Assistant MDS Coordinator at 5:01 PM, revealed they were educated on care plan interventions for falls and the root cause analysis. Interviews with Clinical Support, on [DATE] at 5:24 PM, and the ADHS on [DATE] at 2:10 PM, revealed they educated the nurses and the CRCAs per the A[NAME]. The Clinical Support stated staff not educated on [DATE] were educated prior to the working their next scheduled shift, and all staff passed the test with a 100% score. Record review revealed staff was educated per the A[NAME] with posttest completion. 7. Interview with the ADHS, on [DATE] at 2:10 PM, DHS on at 3:07 PM, MDS Coordinator at 4:51 PM, and Assistant MDS Coordinator at 5:01 PM, revealed the IDT reviewed new admissions to ensure fall interventions were in place during the daily Clinical Care Meeting, and determined the root cause of falls to revise the care plans. The DHS stated she was starting to conduct random audits to ensure care plan interventions for falls were in place and followed. Interview with Clinical Support, on [DATE] at 5:24 PM, revealed she would be assisting in the falls and care plan audits. Record review revealed falls and care plans were reviewed per the A[NAME]. Record review revealed an audit tool the facility was to use to perform the audits. 8. Interview with the ED, on [DATE] at 3:58 PM, revealed the QAA committee would review the audits to track the data. She stated she would meet with the Medical Director weekly to review the progress of the audits.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure staff accurately coded the Minimum Data Set (MDS) assessment for one (1) of five (5) sampled residents, Resident #41, related to falls. Resident #41 sustained a fall prior to admission and had a fall in the facility; however, the falls were not identified on the MDS. The findings include: Interview with MDS Coordinator #1, on 04/26/19 at 3:37 PM, revealed the facility did not have a policy to ensure MDS assessments were accurately coded but the facility followed the RAI User's Manual to code assessments. Review of the CMS RAI 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR), Chapter 3, pages J-27 through J-35, revealed the facility should code item J1700A, Fall History on Admission/Entry or Reentry, as 1-Yes if the resident or family report, or transfer records or medical records documented a fall in the month preceding the resident's admission (A1600). The facility should code item J1800, Any Falls since Admission/Entry or Reentry or Prior Assessment (OBRA) or Scheduled PPS, whichever was more recent, as 1-Yes if the resident had fallen since the last assessment then continue to item J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever was more recent. Continued review of the RAI Manual revealed for item J1900A, No Injury, the facility should code as 0-No if the resident had no injurious fall since the Admission/Entry or Reentry, or Prior Assessment (OBRA or Scheduled PPS). The facility should code J1900B, Injury (except major), as 1-Yes if the resident had an injurious fall (except major), which included skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that caused the resident to complain of pain since Admission/Entry or Reentry, or Prior Assessment (OBRA or Scheduled PPS). In addition, the facility should code J1900C, Major Injury, as 0-No if the resident had no major injurious fall since Admission/Entry or Reentry, or Prior Assessment (OBRA or Scheduled PPS). Record review revealed the facility admitted Resident #41 on 04/08/19, with multiple diagnoses, which included Other Fracture of Left Ilium and Subsequent Encounter for Fracture with Routine Healing. Review of the Hospital History and Physical, dated 03/30/19, revealed Resident #41 presented to the hospital with pelvic pain due a mechanical fall and found to have pelvic fractures. However, review of the Admission MDS, dated [DATE] revealed item J1700A, did the resident have a fall in the last month prior to admission, was coded as 0-No; and J1700C, fracture related to a fall in the 6 months prior to admission, was coded as 0-No. Review of Nursing Progress Notes and a Fall Event Report, revealed Resident #41 had one (1) witnessed fall on 04/11/19 at 2:45 PM, with three (3) skin tears noted to the right forearm. Review of Resident #41's Physician Orders, dated 04/11/19 and 04/12/19, revealed to cleanse open areas on left elbow and skin tear to right elbow and forearm with normal saline and apply foam dressing every three (3) days. However, continued review of the Admission MDS, dated [DATE] revealed item J1800, Any Falls since Admission/Entry or Prior Assessment (OBRA or Scheduled PPS), whichever was more recent, was coded as 0-No. Item J1900A, No Injury, was blank, J1900B Injury (except major) was blank, and J1900C Major Injury was blank. Interview with the MDS Coordinator, on 04/26/19 at 3:37 PM, revealed she had completed the Admission MDS assessment, dated 04/15/19. She stated she had inaccurately coded items J1700, J1800, and J1900. The MDS Coordinator was aware she should have coded Resident #41's fall sustained one (1) month prior to admission, and the fall with injury sustained on 04/11/19 in the facility. Further interview revealed another MDS Coordinator in the facility and the regional MDS Coordinator monitored the MDS assessments for accuracy. Interview with the Campus Support Resident Assessment MDS Coordinator, on 04/26/19 at 4:21 PM, revealed he was responsible for monitoring to ensure accurate coding of the MDS assessments and had not identified any coding issues since his employment with the facility. Further interview revealed Resident #41's Admission MDS should have coded J1700A as 1-yes, J1800 as 1-yes, and J1900B should have been coded for minor injury, because the resident was admitted after a fall at home, and sustained a fall in the facility with minor injuries. Interview with the Executive Director (ED), on 04/26/19 at 4:36 PM, revealed staff should code MDS assessments accurately; however, they did make mistakes.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the transmission of disease and infection for one (1) of fourteen (14) sampled residents, Resident #16. Observation revealed Licensed Practical Nurse (LPN) #3 and Certified Resident Care Associate (CRCA) #1 exited Resident #16's isolation room without washing their hands. In addition, the Activities Director walked into Resident #16's isolation room without donning Personal Protective Equipment (PPE) and left without washing her hands, and entered another resident's room. The findings include: Review of the facility's policy, Guidelines for Handwashing/Hand Hygiene, reviewed 02/19/17, revealed handwashing was the single most important factor in preventing transmission of infections. Health care workers were to perform hand hygiene before and after having direct physical contact with residents. Review of the facility's policy, Guidelines for Contact Precaution, reviewed 05/22/18, revealed the purpose was to prevent the spread of infectious disease organisms. Direct contact transmission involved skin to skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized resident (turning, bathing, and other resident care activities or resident to resident contact). Indirect contact transmission involved contact of a susceptible host with a contaminated object, usually inanimate, in the resident's environment. Contact precaution was indicated to prevent and control HAI (health-care-associated infections) transmissions. Personal Protective Equipment (PPE), which included gloves and a clean non-sterile gown, was needed when entering the room if it was anticipated clothing would have substantial contact with the resident or environmental surfaces, or when there was the likelihood that organisms from blood, stool, or wound drainage might be on surfaces or items in the resident's room. Record review revealed Resident #16 was under contact isolation for a urinary tract infection [MEDICAL CONDITION] with Extended Spectrum Beta-Lactamase (ESBL-contagious) in the urine. Observation, on 04/23/19 at 8:35 AM, revealed Life Enrichment #1 entered Resident #16's room without donning PPE and exited the room without performing hand hygiene. The Life Enrichment staff member continued to another resident's room, where she touched the foot of the bed and handed the resident a reacher. Observation of LPN #3, on 04/23/19 at 9:29 AM, revealed she came out of Resident #16's room without washing her hands with a biohazard bag in her hand and touched the door handle. Interview with LPN #3, on 04/23/19 at 9:31 AM, revealed she did not wash her hands prior to leaving Resident #16's room with the biohazard bag. She stated she touched the door handle that the resident probably touched. The LPN stated not washing her hands meant she could potentially transport the infection outside the resident's room. Observation of CRCA #1, on 04/23/19 at 2:49 PM, revealed he exited Resident #16's room without washing his hands and with used PPE in a regular garbage bag. Interview with CRCA #1, on 04/23/19 at 2:53 PM, revealed he did not wash his hands prior to leaving Resident #16's room. It was his understanding to take off the gown and the mask at the door, tie up all PPE, take it to the utility room, and wash his hands in there. However, he stated it would be important to wash hands prior to leaving the room to prevent contaminating other items, like the sink. CNA #1 stated residents at the facility had a weaker immune system and using PPE and hand washing decreased the possible spread of infection. Interview with the Assistant Director of Health Services (ADHS), on 04/27/19 at 11:19 AM, revealed staff was to don a gown and gloves prior to entering a contact isolation room. After care, staff was to remove the gloves, then the gown, and dispose both in the trash bag, and the resident's brief in a biohazard bag. Staff was to wash their hands before leaving the room to prevent spreading the organism to other residents and staff. The ADON further stated the facility had an elderly population, their immune systems were not strong, and they got infections easily. Interview with the Director of Health Services (DHS), on 04/23/19 at 11:49 AM, revealed staff should perform hand hygiene prior to leaving Resident #16's room. Interview with the Executive Director, on 04/28/19 at 10:06 AM, revealed staff was to use gowns and gloves prior to entering an isolation room, and sanitize their hands prior to exiting the room to prevent the spread of the germ.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation during the initial tour of the kitchen on 12/13/16, revealed two (2) containers of Simply Thick were not dated, and a third container next to them had no label to identify the product and no date. The findings include: Review of the facility Dietary Department for Refrigerated Storage Policy, effective date 05/31/16, revealed food was to be covered, dated and stored loosely to permit air circulation. Review of the facility Food Labeling and Dating Policy, undated, revealed all food once opened, or had the manufactory's seal broken, or had been prepped in any way, needed to be labeled and dated with the correct shelf life from the Food Dating Guide. Further review revealed there must be a label that contained the following: item name, date & time, use by date, initials of person labeling item, and a label must be made immediately when the food product was going into storage (non-negotiable). Observation during the initial tour of the kitchen on 12/13/16 at 10:00 AM, revealed two (2) containers of liquid labeled Simply Thick were not dated, and a third container of brown liquid next to them had no label or date. Interview with Dietary Aide #1, on 12/13/16 at 10:40 AM, revealed the containers of liquid in the refrigerator should be labeled better and immediately disposed of the contents. Interview with Dietary Aide #3, on 12/13/16 at 10:45 AM, revealed he should have labeled the containers with identification and date when he poured the contents into the containers this morning. When asked why it was important to label everything that was open in the refrigerator, he answered so we know what it is . Interview with the Director of Food Services, on 12/13/16 at 10:42 AM, revealed all foods in containers in the refrigerator should have a label to identify the contents and date prepared. Further interview revealed the date was important to know when the food items should be discarded, and also to prevent residents from consuming foods which needed to be discarded which could make them ill. Interview with Acting Director of Nursing on 12/15/16 at 2:30 PM, revealed it was important to date and label open food items so staff would know when they should be discarded. Interview with the Executive Director, on 12/15/16 at 2:45 PM, revealed it was his expectation that the person who opened or prepared the food item should label the food and ensure the food was dated.

Based on observation, interview, and review of facility policy, it was determined the facility failed to establish an infection prevention and control program to provide a sanitary environment and to help prevent the development of infections. Observation during the survey on 12/14/16, revealed individual resident refrigerators in thirty-five (35) resident rooms on the 400 and 500 units. However, interviews with staff revealed the refrigerators were not monitored daily for temperatures and were not monitored for sanitation. The findings include: Review of the facility Guidelines for Refrigerators Policy, developed 12/14/16, after surveyor questioned the process for sanitation and monitoring of resident room refrigerators, revealed all resident refrigerators would have a functioning thermometer; would be monitored daily; temperatures would be documented on refrigerator monitoring log; and if temperatures were out of range the perishable contents of the refrigerators would be discarded. Observation of the refrigerator in room [ROOM NUMBER] on 12/14/16 at 1:00 PM, revealed a temperature within appropriate range of 39 degrees Fahrenheit and the refrigerator was clean. Observation of the refrigerator in room [ROOM NUMBER] on 12/14/16 at 1:05 PM, revealed an appropriate temperature of 35 degrees Fahrenheit, and the refrigerator was clean. Interview with the Housekeeper on 12/15/16 at 9:50 AM, revealed refrigerators were cleaned when residents were discharged or when residents asked that this be done. Further interview revealed thermometers were not checked until the refrigerator was cleaned and the temperature was not recorded anywhere, but maintenance was notified if the refrigerator was not cold. Interview with the Director of Food Services on 12/15/16 at 2:08 PM, revealed neither he nor his staff had ever been asked to monitor the thermometers in the resident room refrigerators or check the refrigerators for cleanliness. Interview with the Acting Director of Nursing on 12/15/16 at 2:30 PM, revealed the cleaning and monitoring of the temperatures of resident room refrigerators should be the responsibility of environmental services. Interview with the Executive Director on 12/15/16 at 2:45 PM, revealed the resident room refrigerators should have their temperatures checked and recorded daily, should be cleaned after each resident discharge, and should be spot-checked on a regular basis for cleanliness, then cleaned as needed. Additional interview revealed there had been no policy related to this until 12/14/16.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure resident care plan interventions were revised related to fall prevention interventions in order to prevent further falls for six (6) of twenty-five (25) sampled residents. (Resident's #5, #8, #9, #10, #11, and #13) On 09/26/15 Resident #8 sustained an unwitnessed fall that resulted in a right non-displaced lateral 8th rib fracture. The staff heard the resident yelling for help, went to investigate and found the resident on the floor. The resident sustained [REDACTED]. The care plan was not revised to prevent further falls. On 09/09/15 Resident #9 was found on the floor by the resident's son. The resident's right foot was bleeding and the resident continued to be extremely confused. The resident's bed alarm was noted on the floor and non-functioning with a tear in the wiring. The family transported the resident to the hospital for evaluation. The resident received ten (10) sutures to the right foot, underneath and between the fourth and fifth toes and a closed non-displaced [MEDICATION NAME] fifth metatarsal. The facility failed to revise the care plan to prevent further falls or injury. On 09/30/15 Resident #10 was found on the floor by staff complaining of back pain. The resident stated he/she had attempted to get to their walker and it tipped over with the resident going over with it. Emergency Medical Services were called and transferred the resident to the hospital. Hospital x-ray result, revealed a [MEDICATION NAME] compression fracture at T9. The resident continued to have severe pain and muscle spasms and a back brace was ordered. The facility failed to revise the care plan to prevent further falls or injury. In addition, Resident #5, #11 and#13 sustained falls without revisions to the care plans to prevent further falls and/or injuries. The facility's failure to have an effective system in place, to ensure care plans were revised for residents with a history of falls has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on 09/07/15. The facility provided an acceptable Allegation of Compliance (AOC) on 10/22/15 which alleged removal of the Immediate Jeopardy on 10/23/15. The State Survey Agency verified Immediate Jeopardy was removed on 10/23/15 as alleged prior to exit on 10/29/15. The scope and severity was lowered to an E at F280, while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Interdisciplinary Team Care Plan Guidelines, dated June 2015, revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairments, disability, or disease in accordance with state and federal guidelines. The care plan interventions would be reflective of the impact the risk area(s), disease process(es) have on the individual resident. Goals would be measurable and attainable. Interventions would be reflective of the individual's needs and risk influence as well as the resident's strengths. Review of the facility's policy regarding Clinical Documentation Systems, Circumstance, and Reassessment Forms, not dated, revealed the purpose was to provide a tool to document an investigation as to the root cause of an episodic event. Reassessment of the resident's risk factors that may have contributed to the event and evaluate the current care of plan interventions for effectiveness and select additional interventions if required. The care plan would be reviewed for effectiveness of the current interventions in place to minimize or eliminate the risk factors. New interventions would be implemented as appropriate. Review of the facility's policy for Falls Management, dated February 2015, revealed the facility would maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Should the resident experience a fall the attending nurse would complete the Fall Circumstance and Reassessment Form. The form included an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of a repeat and a review by the Interdisciplinary Team to evaluate thoroughness of the investigation and appropriateness of the interventions. The resident care plan/profile would be updated to reflect any new or change in interventions. 1. Review of the clinical record for Resident #8 revealed the facility admitted Resident #8 on 08/04/15 with [DIAGNOSES REDACTED]. The resident had a hospital admission on 09/15/15 and was re-admitted to the facility on [DATE]. Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment, completed on 09/29/15, revealed the facility assessed the resident using the Brief Interview for Mental Status with a score of fourteen (14) of fifteen (15) meaning the resident was interviewable. The facility also assessed the resident as needing the extensive assistance of one with transfers, walking, and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. Review of the Comprehensive Care Plan for Resident #8 revealed the facility developed a plan of care related to skin integrity and falls on 09/15/15 with updated goals and target dates for 12/15/15. The goals stated the resident would have no falls with major injury and would maintain intact skin. The approaches directed staff to check placement and function of the bed/chair alarm, assist the resident with transfers, and keep the call light within reach. Resident #8 had an unwitnessed fall on 09/26/15 and sustained a skin tear, bruise to the right elbow, and a right rib fracture. However, review of Resident #8's plan of care for falls revealed the facility did not revise the plan until eleven (11) days later on 10/07/15. Interview with Minimum Data Set (MDS) Nurse #1 on, 10/27/15 at 11:05 AM, revealed she had revised Resident #8's plan of care on 10/07/15. She stated the date at the bottom of the plan of care was the date the care plan had been revised. She stated normally she revised care plans the next business day after the event. She stated nursing staff would have to verbally tell each other if they developed additional care plan interventions for a resident until she was able to make revisions to the computerized plan of care. Interview with Licensed Practical Nurse (LPN) #8, on 10/14/15 at 8:10 PM, revealed Resident #8 did have a bed alarm on prior to the last admission to the hospital; however, it was not reinstated after the resident was readmitted to the facility. She stated a bed alarm should have been put in place after readmission to alert staff of the resident's attempts to transfer without assistance. She revealed she did not make revisions to care plans and that MDS nursing staff made them. She stated her part of care plan revision was completed when she filled out a facility Event Form. She stated the forms had areas for her to click for possible interventions to be added to the care plan; however, the care plan itself was not updated until sometime later when the management team met to review the event information. She stated if she implemented an intervention she would verbally tell staff, but if they did not tell others, the information would not be known by all. She stated revising care plans and communicating the information timely would ensure resident care needs were met. Interview with the Director of Health Services (DHS), on 10/16/15 at 3:00 PM, revealed Resident #8's plan of care should have been revised to address the fall to ensure the resident needs were met. 2. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 09/23/15 with a history of falls with [MEDICAL CONDITION] and kidney transplant. The resident had [DIAGNOSES REDACTED]. Review of Resident #10's five-day Minimum Data Set (MDS) assessment, completed on 09/30/15, revealed the facility assessed the resident using the BIMS with a score of fourteen (14) of fifteen (15) meaning the resident was interviewable. The facility also assessed the resident as needing the extensive assistance of one with transfers, bed mobility and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when: moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. Review of the Comprehensive Care Plan for Resident #10 revealed the facility developed a plan of care related to activities of daily living and falls on 08/28/15 with updated goals and target dates for 08/28/15. The approaches directed staff to provide assistance with mobility. The care plan stated the resident needed the assistance of one when transferring, used a rolling walker with staff assistance and needed a wheelchair for long distances. The care plan also stated the resident required assistance with; oral care, grooming, bathing and dressing. In addition, the fall care plan approaches directed staff not to leave the resident alone up in the wheelchair for extended periods of time, keep the call light within reach and remind the resident to use it. Further review revealed nursing staff did not revise the care plans after the resident sustained [REDACTED]. Review of Resident #10's Nursing Notes, dated 09/30/15 at 1:52 PM, revealed staff found the resident on the floor complaining of back pain. Nursing noted the resident stated he/she had attempted to use their rolling walker and it tipped over causing the resident to go over with it. Emergency Medical Services was called and transferred the resident to the hospital for evaluation and treatment. The resident was diagnosed with [REDACTED]. The resident continued to have severe pain and muscle spasms and a back brace was ordered and the resident returned to the facility on [DATE]. Interview with LPN #4, on 10/09/15 at 12:55 PM, revealed Resident #10 experienced an unwitnessed fall with injury on 09/30/15. She stated she did not revise the plan of care because the resident was sent to the hospital. Interview with the DHS, on 10/16/15 at 3:00 PM, revealed the care plan was not revised due to the resident not immediately returning to the facility. However, review of the plan of care for activities of daily living and falls revealed no revisions for fall interventions had been made since the resident's return. Per interview, an intervention that could have been put in place would be for staff to continually check on the resident to anticipate their needs. She stated the plan of care directed staff on how to meet the needs of the resident. 3. Review of the closed clinical record for Resident #9 revealed the facility admitted the resident on 09/09/15 with [DIAGNOSES REDACTED]. Review of Resident #9's Admission Minimum Data Set (MDS) assessment, completed on 09/16/15, revealed the facility assessed the resident using the BIMS and scored the resident as a twelve (12) of fifteen (15) meaning the resident was interviewable. The facility also assessed the resident as needing the extensive assistance of two with transfers, bed mobility and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when: moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. Review of the Comprehensive Care Plan for Resident #9 revealed the facility developed a plan of care for fall prevention on 09/14/15 with updated goals and target dates for 11/14/15. On 09/09/15, the plan of care noted the resident was found on the floor (family at bedside) and sustained a cut to the foot requiring the resident to be sent to the emergency room for evaluation. The plan of care was edited on 10/01/15 and stated the bed/chair alarm was discontinued; however, no revisions were made after this edit. In addition, Resident #9 had a care plan related to short term memory loss and recall impairments. The goal stated the resident's cognitive impairment would not interfere with care routine or quality of life. Review of the approaches revealed no revisions were made after the development of the plan of care. Review of the Nursing Notes, dated 09/09/15, revealed the facility admitted the resident on 09/09/15 at 1:51 PM and nursing noted seven (7) hours later, at 8:45 PM, that Resident #9 was found on the floor by the resident's son. The resident's right foot was bleeding and the resident continued to be extremely confused. The resident's bed alarm was on the floor and non-functioning with a tear in the wiring. The family transported the resident to the hospital for evaluation and the resident received ten (10) sutures to the right foot, underneath and between the fourth and fifth toes. The X-ray results at the hospital revealed a closed non-displaced [MEDICATION NAME] fifth metatarsal. Review of Resident #9's Fall Circumstance Event Form (FCEF), dated 09/09/15, revealed nursing did not implement any new interventions that would prevent/decrease the opportunity for another fall. The interventions listed were to apply direct pressure to the wound and elevate the extremity. Review of the Fall Circumstance Event Form, dated 10/02/15, revealed Resident #9 had an unwitnessed fall from the wheelchair, without injury. Continued review of the FCEF, revealed nursing did not revise the care plan or implement any additional interventions to prevent another fall. Interview with LPN #9, on 10/15/15 at 11:40 AM, revealed she believed the resident was still under the effects of anesthesia when he/she was admitted on [DATE]. She stated the son found the resident on the floor and notified staff and staff could not determine exactly what the resident was trying to do at the time of the fall. She stated the second incident occurred when the resident was reaching for a hat and fell out of the wheelchair. She stated the resident told her he/she had forgotten to lock the wheelchair and slid out onto the floor. She stated she did not revise the resident's plan of care as it was not her responsibility. She stated she also forgot to completely fill out the Fall Circumstance Event Form. She stated updating the resident's plan of care ensured the resident's changing care needs were met. 4. Review of the closed clinical record for Resident #11 revealed the facility admitted the resident on 06/01/15 with [DIAGNOSES REDACTED]. Review of Resident #11's Admission Minimum Data Set (MDS) assessment, completed on 07/31/15, revealed the facility assessed the resident using the BIMS and scored the resident as an eleven (11) of fifteen (15) meaning the resident was interviewable. The facility also assessed the resident as needing the extensive assistance of two with transfers, bed mobility and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. Review of the Comprehensive Care Plan for Resident #11 revealed the facility developed a plan of care for falls on 07/06/15 with updated goals and target dates for 10/06/15. The goal stated the resident would have no falls with major injury while a resident at the facility. Review of the clinical record revealed Resident #11 sustained a fall on 06/18/15, 07/06/15 and 08/14/15. Continued review of the care plan revealed the facility did not revise the plan of care after each fall event with interventions to prevent another fall. The information listed on the care plan after the fall on 06/18/15 stated the resident had a fall with no injuries and the intervention listed stated, place the bed in the low position; even though the fall occurred when the resident transferred themselves from the toilet. The care plan documentation for the 07/06/15 fall, stated the resident had a fall with a hematoma and the intervention to prevent another fall was to send the resident to the emergency department for evaluation. The 08/15/15 fall intervention information listed on the plan of care, stated education was provided to staff to transfer the resident the way the daughter transferred the resident. Even though the facility assessed the resident as needing the assistance of two with transfers; and determined the daughter had transferred the resident alone. Interview with LPN #4, on 10/08/15 at 2:25 PM, revealed Resident #11 had an unwitnessed fall on 07/06/15 but she must have forgotten to fill out the Fall Circumstance Event Form in the computer. She stated the form had areas for her to click on to add possible interventions to prevent another fall. She stated the MDS Nurses actually revised resident's plans of care after an event. She stated if a resident's care plan did not get revised with interventions to prevent another fall the resident could experience another fall. Interview with LPN #7, on 10/16/15 at 12:00 PM, revealed she did not revise care plans because she was not the person to do so. She stated revising care plans ensured staff would meet the changing needs of the resident. She stated if a care plan did not get revised a bad outcome could occur to the resident. Interview with LPN #13, on 10/26/15 at 5:30 PM, revealed if an event occurred an electronic form was filled out that required staff to click on interventions which could be implemented to prevent another incident. However, she did not revise the residents' actual plans of care, and as far as she knew the interventions she clicked on did not automatically populate over to the resident's actual plan of care. She stated she had to verbally tell other staff if she implemented a new intervention, but if they did not continue to tell others the information might not be known to everyone. Interview with Minimum Data Set Nurse #1, on 10/08/15 at 10:40 AM and 10/27/15 at 11:05 AM, revealed resident care plans were usually revised the next business day after an event occurred. She stated the revision that stated, send Resident #11 to the emergency room after the fall, would not prevent another fall. She stated the plan of care should have been revised to include interventions that would actually prevent another fall. She stated without the revisions the resident could experience another fall. Interview with the Director of Health Services, on 10/16/15 at 3:00 PM, revealed Resident 11's care plan should have been revised with interventions that would prevent another fall. She stated sending the resident to the emergency room would not prevent another fall. She stated she had not identified the information added to Resident #11's plan of care would not prevent another fall event until discussion with the surveyor. She stated revising the care plan with an intervention to provide increased supervision or a scheduled toileting program would have been interventions to prevent additional falls. 5. Review of the clinical record for Resident #13 revealed the facility admitted the resident on 07/03/15 from an acute hospital with the following Diagnoses: [REDACTED]. Review of the admission MDS assessment, dated 07/10/15, revealed the facility assessed the resident to have severe cognition impairment with a BIMS score of five (5) out of a possible fifteen (15). The facility assessed the resident to need extensive assistance from staff for bed mobility, transfers, locomotion, toilet use, and ambulation. The facility assessed the resident to have a balance deficit with unsteady gait and impaired with range of motion on one side. The resident was assessed to be high risk of falling. Review of the comprehensive care plan, created 07/15/15 revealed the facility had identified the resident at risk for falling due to weakness, incontinence, history of falls, medications, and needing assistance from staff with all ADLs. The goal was for the resident to remain free from major injuries during the resident's stay at the facility. The care plan approaches included to keep call light within reach, provide clutter free walkway, adequate footwear, appropriate lighting, and remind the resident to call for assistance prior to getting up. In addition, the resident was to remember to lock the wheelchair brakes before getting up. Review of the clinical record revealed Resident #13 had sustained falls on 08/12/15, on 09/06/15, and on 10/01/15. Review of the resident's care plan revealed no documented evidence the care plan was revised after the fall on 09/06/15 and on 10/01/15 the resident fell and sustained a skin tear to the left elbow, and the resident's right knee, left forehead, and left side of face was red with complaints of left shoulder/arm pain (6 out of 10 on the pain scale). Interview with MDS Coordinator #1, on 10/16/15 at 8:20 AM, revealed after the 09/06/15 fall (where the resident was found alone in the bathroom), the team did not revise the care plan but continued to implement the intervention to check the PSA for placement and function. She revealed the interventions for the resident to use the call light and request assistance prior to transfer was not effective. She stated the resident did not use the call light and request staff assistance prior to the three (3) previous falls and stated the resident didn't know to use the call light. Interview with the Director of Health Services (DHS), on 10/16/15 at 9:50 AM, revealed she reviewed Resident #13's care plan and stated the care plan was not appropriate for the resident because due to the resident's impaired cognition, the resident was not able to utilize the call light and recall safety instructions. 6. Review of the clinical record for Resident #5, revealed the facility admitted the resident on 03/05/14 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/05/15, revealed the facility assessed Resident #5 with a score of five (5) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, which meant the resident could not be interviewed. The facility also assessed the resident as needing the extensive assistance of one with transfers, bed mobility and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when: moving from a seated to standing position, moving on and off the toilet and from surface to surface. Review of the updated Comprehensive Care Plan, dated 08/19/15, revealed the resident was at risk for falls related to the need for extensive assistance with most Activities of Daily Living (ADL's), a history of falls, and the use of [MEDICAL CONDITION] medications. In addition, the resident had a care plan developed for safety and the need for assistance with transferring. The goal related to fall prevention, stated the resident would be free from falls during their stay at the facility. The goal related to activities of daily living stated the resident would be as independent as possible with ADL's. The goal related to safety stated the use of the chair/bed alarm would alert staff of the resident's need for assistance. The approaches directed staff to provide assistance with transfers, and check the bed/chair alarm for placement and functionality every shift. Review of the Fall Circumstance Event Form, dated 07/11/15, revealed Resident #5 sustained an unwitnessed fall and was found on his/her back on the bathroom floor next to the wheel chair on 07/11/15. Resident #5's personal safety chair alarm had not sounded and the resident was unable to explain what he/she was doing due to cognition. Review of Resident #5's care plan revealed no new intervention was placed for the 07/11/15 fall event. Interview with the RN #2, on 10/15/15 at 3:15 PM, revealed she completed Resident #5's Fall Circumstance Event Form, on 07/11/15 and was not aware she had not implemented an immediate intervention. Per interview, she had not viewed Resident #5's care plan because she was not responsible for making changes to the care plan. Review of the Fall Circumstance Event Form, dated 08/11/15, revealed Resident #5 sustained an unwitnessed fall on 08/11/15 when he/she transferred unassisted to the bathroom. There were no contributing factors noted on the Fall Circumstance Event Form and no evidence the interventions were revised on the care plan to prevent further falls. Interview with LPN #14, on 10/15/15 at 2:35 PM, revealed she was not aware Resident #5 had prior falls in the bathroom. LPN #14 stated when documenting in the Fall Event Report, she could not review the care plan to determine what interventions were already in place because it was in the computer and she did not know how to retrieve it. Interview with the DHS, on 10/09/15 at 12:20 PM, revealed the MDS Coordinators were responsible for reviewing the Fall Care Plan interventions during the IDT meeting and she was unaware this was not consistently occurring. The DHS stated Resident #5's repeated falls might not have occurred if the IDT and MDS Coordinators had identified the discrepancies in the Fall Event Reports and lack of appropriate immediate interventions. Continued interview with MDS Coordinator #1, on 10/16/15 at 8:20 AM, revealed all falls are discussed in the morning Clinical Care Meeting and the interdisciplinary team determine appropriate care plan interventions. She stated the team always reviews the Fall Circumstance Event Report during the meetings. Continued interview with the DHS, on 10/16/15 at 9:50 AM, revealed the staff nurses are supposed to complete the Fall Circumstance Event Report and find out what caused the fall. She reviewed all Fall Circumstance Event Reports during the meeting and the team would review the care plan to determine if the care plan inventions were appropriate and would prevent additional falls. She continued to state the team looked at existing care plan interventions to see if they are working and remove if not. The facility provided an acceptable credible Allegation of Compliance (AOC) on 10/22/15 and took the following actions to remove the Immediate Jeopardy on 10/23/15: 1. The facility conducted a review of the sixty-three (63) current residents' care plans from October 12-20, 2015 by the Minimum Data Set (MDS) nurses to ensure care plan interventions were current. Eight (8) care plans required revision. Change in condition (including falls) will be reviewed with care plan revision as needed during the Clinical Care Meeting. The Director of Health Services will be responsible for overseeing the meetings with follow up on events that have occurred within the last twenty-four (24) hours. Education was provided for the Interdisciplinary Team (Administrative Nurses, Social Services, Activities, Therapy Director, and MDS Nurses on 10/19/15 by the Assessment Support Nurse and the External Audit Nurse. 2. A Care Plan Audit tool was developed and will be used to ensure care plans are reviewed and revised during the Clinical Care Meeting (Monday-Friday) and weekend days by the Director of Health Services, Assistant Director of Health Services, or MDS Nurse. 3. A Profile binder with current safety interventions (based on the care plan) for each resident was placed on each unit, on 10/21/15, for the nursing aides. The binders will be updated daily after the Clinical Care Meeting by the MDS or Medical Records. Audits will be completed daily. 4. Charge Nurses will round daily during the Medication Pass to observe for compliance with safety interventions according to the plan of care. Audits will be conducted on the first and second shift and Night Shift Nurses will conduct routine rounds that included observing for safety interventions for five (5) random residents. 5. Falls will be reviewed during the weekly Clinical at Risk meetings to ensure effective interventions are in place. Residents who sustained a fall will be followed in these meetings for four (4) weeks. 6. Safety Device audits (five residents per day) will be conducted daily by department leaders, on random shifts, to ensure devices are in place and functioning. 7. An audit was conducted on 10/18/15 of each resident's medical record to ensure proper information related to Advance Directives were in the Soft File at each unit. Advance Directives information will be obtained at admission with appropriate papers signed and placed into the Soft File at each unit. This would include each resident's code status. 8. Education for the Executive Director, Medical Record Staff, Director of Health Services and her assistant, and Social Services were completed on 10/19/15, by the Clinical Director, of the importance of maintaining the integrity of medical record and Advance Directives information being available for Charge Nurses in the event of a resident was transferred to the hospital. 9. Scanning guidelines will be followed based on protocols for the Electronic Health Record. Daily audits will be conducted by the DHS, ADHS, MDS, and Medical Records to ensure completion of all admission records and Advance Directive information placed into the Soft Files. These audits will be reviewed during the daily Clinical Care Meeting. 10. A Quality Assurance (QA) Meeting was conducted on 09/18/15 to review Falls Trending. Another QA meeting was held on 10/19/15 with the Medical Director in attendance to review the Guidelines and protocol for conducting Quality Assurance Meetings. 11. Education was provided by the Clinical Director to the Executive Director, Director of Health Services and her assistant, and other department leaders that included issues of fall management, Advance Directives, and monitoring of care plans. Corrective plans were developed based on trends prevalent in a system not in compliance. Action plans developed with focus on goals and protocols for Clinical Care Meeting and its direct relationship to Quality Assurance activities. 12. Audits implemented will be reviewed during the monthly QA meeting and during the Clinical Support Nurse's routine visits that occur once a week. Audits included Safety Device, Advance Directive, and Soft files, Clinical Care Meetings, Clinical at Risk Meetings, Care Plans, and QA. The State Survey Agency (SSA) validated the implementation of the facility's AOC as follows: 1. Record review revealed Residents #5, #8, #10, #13, and #19 care plans were revised. Resident #20 was sampled during the extended survey due to being the only resident with a fall since the alleged Immediate Jeopardy abatement date of 10/23/15. The resident's care plan was reviewed during the Clinical Care Meeting and revised as needed. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, revealed the Interdisciplinary team received training on care plan revision and implementation. She stated she was responsible for overseeing the Clinical Care Meetings and ensured the care plan was revised and all events received follow-up monitoring to ensure the event reports were comp

Based on observation, interview, record review and review of the facility's policy and manufacturer's guidelines, it was determined the facility failed to have an effective system in place to ensure residents' care plan interventions were implemented related to supervision, placement and the functionality of bed and chair alarms, and the availability of fluids to ensure hydration. The facility's failure affected five (5) of twenty-five (25) residents (Resident #1, #2, #5, #6, and #12). The staff failed to transfer Resident #1 with assistance of one, failed to keep the call light within reach, and ensure the bed alarm was functioning which resulted in a fall on [DATE] when the resident sustained [REDACTED]. Review of the Death Summary, dated [DATE], revealed the resident passed, thirteen (13) hours after the fall, on [DATE], due to the injuries sustained from the fall which led to [MEDICAL CONDITION]. In addition, on [DATE] Resident #12 sustained an unwitnessed fall with injury. Nursing documented that the resident stated he/she tried to get up from the potty chair and fell . Nursing assessment revealed the resident had swelling and an abrasion with bleeding to the nose. The Event Report documentation revealed there were no possible contributing factors present at the time of the fall. However, the care plan directed staff to assist with transfers to the bathroom. Review of Nursing Notation, dated [DATE] at 3:30 AM, revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. The staff failed to monitor for placement and functionality of bed and chair alarms as care planned for Residents #2, #5, and #6. Further staff failed to keep fluids within reach to ensure hydration as care planned for dehydration/urinary tract infection for Resident #2. The facility's failure to have an effective system in place, to ensure care plans were implemented has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AOC) on [DATE] which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency verified Immediate Jeopardy was removed on [DATE] as alleged prior to exit on [DATE]. The scope and severity was lowered to an E at F282 while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy regarding Interdisciplinary Team Care Plan Guidelines, dated [DATE], revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairments, disability, or disease in accordance with state and federal guidelines. The care plan interventions should be reflective of the impact the risk area(s) and disease process(es) have on the individual resident. Goals should be measurable and attainable. Interventions should be reflective of the individual's needs and risk influence as well as the resident's strengths. Review of the facility's policy regarding Clinical Documentation Systems, Circumstance, and Reassessment Forms, not dated, revealed the purpose was to provide a tool to document an investigation as to the root cause of an episodic event; to reassess the resident's risk factors that may have contributed to the event; evaluate the current care plan interventions for effectiveness; and, select additional interventions if required. The care plan should be reviewed for effectiveness of the current interventions in place to minimize or eliminate the risk factors. New interventions should be implemented as appropriate. Review of the facility's policy for Falls Management, dated February 2015, revealed the facility would maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The fall risk assessment was included as part of the Admission and Monthly Nursing Assessment and Review and Circumstance forms. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. In addition, care plan interventions developed from the fall risk assessment which addressed the resident's risk factors, should be implemented. Further review revealed the facility did not provide a policy related to the bed/chair alarms that would direct staff in how to follow the care plan intervention to check the alarms for functionality. However, review of the manufacturer's guidelines for the three (3) types of bed/chair alarm systems, revealed the facility used Medline, Posey and Universal Medical Products. Review of the Medline bed/chair alarm brand revealed it was the responsibility of the facility to implement structured training procedures for all employees using the system. Failure to adequately train employees may cause system failure due to user error. In addition, incorrect use of the equipment may also result in system failure. The company recommended all expired, soiled or contaminated pads be disposed of in accordance with the law and facility policy. The sensor pads had a limited expected useful life. The facility must record the warranty date in the area provided on the label. The facility must not use the sensor pad after the in-service warranty expiration date. To set up the system first visually inspect the pad and wires for damage. Power the unit by inserting a 9-volt battery, use adhesive strips on the bottom of the pad before putting in place to prevent shifting. When securing the system, take up extra slack in the cord that could become tangled with the resident, bed or chair. Failure to do so may result in resident injury. Insert the pad plug into the sensor pad, and the control unit should flash a green light and beep. In addition, the unit could be silenced for 30 seconds, by pressing the silence button. If the resident does not return to the pad within thirty seconds the unit turns itself off requiring the staff to reset it again. Review of the POS [REDACTED]. Check to make sure sensor cable was out of the way and did not pose a tripping hazard. The manufacturer's information stated a nine (9) volt battery provided up to 280 hours of continuous alarm. Alarm may fail to sound if the sensor pad was bent or folded under the resident or not directly under the resident's buttocks. Further review revealed the Posey brand had a warning statement that informed the user to never connect the Posey brand sensor pads to other manufacturers' alarm units or connect other manufacturers' sensor pads to the Posey brand alarm units. Review of the Universal Medical Products (UMP) revealed the UMP pressure pads were designed for use with UMP monitors only. Do not substitute any other fall monitoring devices. In addition, the company directed user's to write on the pad the date the pad was put into use. The UMP stated the user should test the system before each use and inspect pads and monitor regularly to make sure they were not damaged. Users should test the system by pressing firmly on the pad for three (3) seconds. When pressure was removed from the pad, the alarm should sound. Reset the alarm. Place the UMP pad directly under the resident so that the bulk of the resident's weight (buttock area) would rest on the pad. Plug the end of the pad cable into the jack on the bottom of the monitor. For added safety from accidental pulls on the cord, route the cable through the strain relief slot on the bottom of the monitor. When the resident's weight was placed on the pad, the user would hear a brief confirmation tone letting them know the pad was operational. UMP standard bed pads were designed to withstand normal wear and tear for a period of 45-day, 90-day, 180-day or 1-year depending on the model. Beyond this time, the pad may fail and fail without warning due to prolonged use and other factors, e.g. bending, exposure to moisture, punctures, repeated cord pulls and connector damage. Be sure that facility protocols directed staff to log the 45-day, 90-day, 180-day and 1-year Date Put in Use date in the blank provided on the pad itself and in the resident's chart. If the pad was used on more than one resident, the original Date put in use date must be transferred from chart to chart. Interview with the Director of Health Services (DHS), on [DATE] at 2:00 PM, revealed she had not read the manufacturer's recommendations for the three (3) types of bed/chair alarm in use at the facility. She stated she did not know each had a different process to check the functionality of the alarms. In addition, she stated the facility had not provided training to staff using the manufacturer's guidelines. She stated staff would need to know this information in order to follow the care plan intervention related to checking functionality. 1. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed Resident #1 with a score of eleven (11) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment meaning the resident was not interviewable. The facility also assessed the resident as needing the extensive assistance of one with transfers, personal hygiene, and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when moving from a seated to a standing position, walking, moving on and off the toilet and surface to surface, such as between the bed and chair or chair to wheelchair. Review of the Comprehensive Care Plan for Resident #1 revealed the facility developed a plan of care for falls and assistance with activities of daily living on [DATE], with updated goals and target dates for [DATE]. Problems on the care plans stated the resident was at a risk for falls related to weakness, history of falls and the need for extensive assistance with activities of daily living, transfers and mobility. The goals stated the resident would stay free of falls, in order to be as independent as possible, while keeping the resident safe and comfortable. The approaches stated staff would provide assistance with activities of daily living and the assistance of one with transferring and mobility. Staff would keep the call light within the residents' reach and check on the resident frequently. The resident used a bed and chair alarm for safety and staff would check it for functionality every shift and if they heard it alarm they were to check on the resident to ensure their safety. Review of the Fall Event Form, dated [DATE], revealed Resident #1 had a fall on [DATE] with no injuries. The plan of care was revised to include the use of a bed/chair alarm and to check it for placement and functionality every shift. Review of the Fall Event Form, dated [DATE] at 4:04 AM, revealed the resident experienced an unwitnessed fall with injuries. The form noted the resident's mental status was at baseline; which was confused and forgetful, but able to recall their name. The form noted there were no possible contributing factors to the fall and the immediate measures taken to prevent another fall was to use a bed alarm; even though one was already in place at the time of the fall. The form also noted the outcome of interventions as No Interventions Used. On [DATE] at 8:44 AM, interview with Certified Nursing Assistant (CNA) #1, revealed Resident #1 required the assistance of one to transfer and ambulate. She stated the resident had a bed and chair alarm and staff had to check it for placement and functionality every shift. She stated she had checked on Resident #1, around 12:00 AM on [DATE] but she did not check the bed alarm or look to see if the call light was within reach. She stated around 3:45 AM she heard Resident #1 yelling for help and went to investigate. She stated it was determined the resident's call light was not within reach and the bed alarm was turned off. She stated following the resident's plan of care related to ensuring the resident's call light was within reach and the bed alarm was functioning was part of meeting the resident's care needs. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 9:30 AM, revealed she was off the unit using the bathroom when the resident fell while attempting to transfer without assistance. She stated she did not check the bed alarm for functionality prior to the fall because she had all shift to check it. She stated she did not check it after the fall because she was tending to the resident's needs. She stated the resident sustained [REDACTED]. On [DATE] at 2:00 PM, interview with the Director of Health Services (DHS), revealed the facility determined the cause of Resident #1's fall with injury was due to the resident not using the call light to ask staff for assistance. She stated Resident #1's care plan directed staff to make sure the call light was in reach, nursing staff would check the bed/chair alarm every shift for functionality and placement, and staff would frequently check on the resident. The DHS stated although interviews conducted after the fall determined Resident #1's call light was not within reach, the bed alarm had not sounded, and staff was not available to provide frequent supervision; the facility did not identify, staff had not followed the resident's care plan interventions. She stated care plan interventions should be followed to ensure resident safety. On [DATE] at 2:40 PM, interview with the Interim Executive Director, revealed the interviews and statements obtained from staff were not taken into account. She stated the facility determined the root cause of the fall was the resident frequently did not use the call light to ask for assistance prior to transferring. She stated the facility did not determine the staff failed to follow the care plan interventions related to ensuring bed alarm functionality, call light kept in reach or checking on the resident frequently; even though interviews and written statements obtained stated the bed alarm did not sound. In addition, interviews and statements indicated the bed rail was in the down position with the call light attached and not within reach of the resident. On [DATE] at 3:20 PM, interview with the Executive Director, revealed he had briefly reviewed Resident #1's incident/event file after he began his employment on [DATE]. He stated after reviewing the event he did not provide any further direction to staff to determine if there was a system issue with not following care plan interventions. He stated if he had conducted the investigation and determined the bed alarm did not sound he would have directed staff to conduct an audit of the alarms to determine if staff were ensuring they were functional at all times. He stated if he had determined the call light had not been in reach of the resident he would have conducted audits of call light accessibility. He stated if he had determined staff was not available to meet the needs of the resident he would have looked into that also. He stated following the resident's plan of care was the responsibility of all staff to ensure resident safety. 2. Review of Resident #12's clinical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's Annual Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed Resident #12 with a score of six (6) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment meaning the resident was not interviewable. The facility assessed the resident as needing the limited assistance of one to transfer and to ambulate. In addition, the resident required the extensive assistance of one with dressing and toileting. The facility assessed the resident's balance as not steady and only able to stabilize with staff assistance when walking, turning around or moving on and off the toilet and from bed to chair or wheelchair. Review of the Comprehensive Care Plan for Resident #12 revealed the facility developed an admission safety plan of care on [DATE] with interventions to ensure the call light remained accessible, staff would provide assistance for transfers and ambulation, and would observe the resident for compliance with safety interventions. Review of Resident #12's Fall Circumstance Event Form, dated [DATE] at 11:37 PM, revealed the resident sustained [REDACTED]. Nursing documented the resident stated he/she tried to get up from the potty chair and fell . The nursing assessment revealed the resident had swelling and an abrasion with bleeding to the nose. The Event Report documentation revealed there were no possible contributing factors present at the time of the fall. Interviews on [DATE] with CNA #9 at 2:05 PM, CNA #11 at 2:15 PM, and CNA #5 at 2:30 PM revealed they did not recall Resident #12's fall incident; however, stated following residents care plan interventions would be important to maintain their safety. Interview with the Registered Nurse (RN) #4, on [DATE] at 2:45 AM, revealed the facility had just started the new Electronic Medical Record (EMR) and she was still learning how to navigate through the computerized medical record. She stated she had not looked at Resident #12's care plan and did not know where to locate it in the new EMR. She stated she depended on shift to shift report for resident care information and review of the Medication and Treatment Administration Records to tell her the care needs of the resident. She stated following care plan interventions was important to meet the needs of the resident. Interview with the Assistant Director of Health Services, on [DATE] at 11:30 AM, revealed Resident #12 always tried to get up without assistance. He stated according to the plan of care the resident required assistance with transferring and used a bedside commode when toileted. He stated the resident preferred to have the bedside commode placed across the room from the bed close to the bathroom door. He stated the plan of care directed staff in the care needs of the resident and staff should have provided assistance with transferring. 3. Review of the clinical record for Resident #5, revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #5 with a score of five (5) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, which meant the resident could not be interviewed. The facility also assessed the resident as needing the extensive assistance of one with transfers, bed mobility and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when: moving from a seated to standing position, moving on and off the toilet and from surface to surface. Review of the updated Comprehensive Care Plan, dated [DATE], revealed the resident was at risk for falls related to the need for extensive assistance with most Activities of Daily Living (ADL's), a history of falls, and the use of [MEDICAL CONDITION] medications. In addition, the resident had a care plan developed for safety and the need for assistance with transferring. The goal related to fall prevention, stated the resident would be free from falls during their stay at the facility. The goal related to activities of daily living stated the resident would be as independent as possible with ADL's. The goal related to safety stated the use of the chair/bed alarm would alert staff of the resident's need for assistance. The approaches directed staff to provide assistance with transfers, and check the bed/chair alarm for placement and functionality every shift. Review of the Fall Event Report, dated [DATE] at 4:12 PM, revealed Resident #5 sustained an unwitnessed fall and was lying on his/her back on the bathroom floor next to the wheelchair. The chair alarm had not sounded and the resident was unable to explain what he/she was doing due to cognition. Interview with the Registered Nurse (RN) #2, on [DATE] at 3:15 PM, revealed she completed Resident #5's Fall Circumstance Event Form after the fall on [DATE]. RN #2 stated after Resident #5 sustained the unwitnessed fall in the bathroom she had determined the chair alarm was broken. She stated typically nursing staff checked the alarms at the beginning of their shift for placement and functionality. However, she could not remember if she had checked the alarm for functionality or placement on [DATE], per the plan of care. RN #2 stated she was not responsible for determining if staff followed care plan interventions. Observation of Resident #5's UMP bed alarm pad, on [DATE] at 2:20 PM, revealed the pad did not have a date written on the label that informed staff when it expired or was put in service. Interview and observation with CNA #4, on [DATE] at 2:20 PM, revealed Resident #5 was care planned for being at risk for falls and used a bed/chair alarm to alert staff if they attempted to transfer without assistance. She stated staff were responsible for checking it for placement and functionality every shift as part of the plan of care. She stated the resident had a pad on the bed; however, did not know the pad was undated. Observation revealed CNA #4 removed a black marker from her pocket and wrote [DATE] on the pad. She stated following resident care plan interventions ensured resident needs were met. Interview with LPN #4, on [DATE] at 2:30 PM, revealed Resident #5 was at risk for falls and had a care plan intervention that directed staff to check the alarm for placement and functionality every shift. She stated dating the pad was part of the process. She did not know Resident #5's pad had not been dated and believed all pads in the facility were good for 90 days. She stated following the care plan interventions related to the alarms ensured staff would meet the needs of the resident. Interview with the DHS, on [DATE] at 2:00 PM, revealed Resident #5 was at risk for falls and had care plan intervention that required staff to check on the resident frequently, provide assistance with transferring, and to check the bed/chair alarm for placement and functionality. She stated staff should date the alarm pads with an expiration date to ensure functionality. She stated it was her expectation that staff follow the resident's care plan interventions to ensure resident needs were met. 4. Review of the clinical record for Resident #2 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed Resident #2 with a score of four (4) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment meaning the resident was not interviewable. The facility also assessed the resident as needing the extensive assistance of one with transfers, personal hygiene, and toileting. The facility assessed the resident's balance, as not steady on their feet, and only able to stabilize with staff assistance when: moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. Review of the care plan, dated [DATE], revealed the facility developed care plans related to fall risk, dehydration and resident's history of Urinary Tract Infections [MEDICAL CONDITION] with updated goals and target dates for [DATE]. The care plan stated the resident was at a risk for falls and needed extensive assistance with activities of daily living, transfers and mobility due to weakness. The goal related to falls stated the resident would stay free of falls, in order to be as independent as possible, while keeping the resident safe and comfortable. The approaches stated staff would check the placement and functionality of the bed and chair alarm every shift, in addition to keeping the call light and frequently used items within easy reach of the resident. The care plan related to UTI's stated the resident was at risk for dehydration related to history of UTI's. The goal related to dehydration, activities of daily living and UTI's stated the resident would improve the current level of self-care, and have no UTI's. Interventions for the history of UTI's and potential for dehydration directed staff to keep fresh ice water within reach of the resident and to encourage the resident to drink fluids as tolerated. Observations, on [DATE] at 10:40 AM, on [DATE] at 8:00 AM, on [DATE] at 10:00 AM, revealed Resident #2 was in bed and the water pitcher or fluids and cup was not within reach of the resident. Interview with CNA #3, on [DATE] at 11:30 AM, revealed Resident #2 had a current Urinary Tract Infection [MEDICAL CONDITION] and was in isolation precautions because of the infection. She stated she did not know the resident's water pitcher had not been within reach and thought maybe someone had moved the bed side table and just did not put it back within reach of the resident. She stated again she did not have time to read all of her resident's plans of care in the computer. But it was important to follow the plan of care to have fluids within reach of Resident #2 due to his/her current UTI. Interview with LPN #7, on [DATE] at 12:00 PM, revealed Resident #2 had a Urinary Tract Infection and staff were to ensure fluids were within reach of the resident according to the care plan. She stated following care plan interventions would meet the resident's care needs related to the infection and if not followed the resident's condition could get worse. Observation of Resident #2, on [DATE] at 12:45 PM and 1:18 PM, revealed the resident was sitting on the bed and the resident's call light cord was wrapped around the bottom of the bed rail and not within reach of the resident during each observation. In addition, observations of the Posey bed alarm unit revealed the light was not blinking to tell you the unit was turned on. Observation, on [DATE] at 3:00 PM, revealed Resident #2 was sitting in a recliner next to the bed and both call lights were located on the bed and not within reach of the resident. Interview with CNA #3, on [DATE] at 1:22 PM and [DATE] at 2:35 PM, revealed she did not know how Resident #2's bed rail had gotten in the down position; preventing the resident from having access to the call light. She stated the call light should always be accessible to the resident, per the plan of care, for the resident to make staff were aware of their needs. Continued observation of Resident #2 being assisted to the bathroom from the bed, on [DATE] at 1:18 PM by CNA #3, revealed a small blue rectangular pad was underneath the resident and no alarm sounded from the unit attached to it when the resident was assisted up from the bed. Interview with CNA #3, on [DATE] at 1:22 PM, revealed Resident #2 was at risk for falls and had bed/chair alarms in place as part of their plan of care. She stated the alarm system alerted staff when a resident attempted to transfer without assistance. She stated the pad should cause the alarm to go off when the resident got up from the bed and said it probably was malfunctioning. She stated the pad should also have a date of expiration written on it, but it did not. She stated staff had the responsibility of dating the pad, with the date it expired, after removing it from its packaging. She stated this process was part of the resident's plan of care and should be followed to ensure their safety. Interview with LPN #7, on [DATE] at 1:25 PM, revealed she had not checked Resident #2's bed/chair alarm for functionality only for placement. She stated the certified nursing assistants checked for functionality when they got the resident up or transferred them. She stated checking for placement and functionality was a part of the resident's plan of care and interventions should be followed to ensure resident safety. Interview with the DHS, on [DATE] at 11:45 AM, revealed she expected staff to ensure resident call lights were accessible at all times, fluids were within reach and the bed/chair alarms were checked for placement and functionality every shift to maintain resident safety. She stated following care plan interventions ensured resident needs were met. 5. Review of the clinical record for Resident #6 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's Admission Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed Resident #6 with a score of eight (8) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment meaning the resident was interviewable. The facility also assessed the resident as needing the extensive assistance of one with transfers, walking, and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when: moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. Review of the Comprehensive Care Plan for Resident #6 revealed the facility developed a plan of care for falls on [DATE] with updated goals and target dates for [DATE]. The goal stated the resident would have no falls with major injury. The approaches directed staff to check for bed/chair alarm placement and functionality every shift, check on the resident frequently and to keep the call light within reach. Review of the Physician order [REDACTED]. Observation, on [DATE] at 2:20 PM, revealed Resident #6's bed alarm did not have a date of expiration written on it to make staff aware when the pad needed to be discarded. Interview, on [DATE] at 2:20 PM, with CNA #6 revealed part of the plan of care for Resident #6 was to mark the alarm pad with an expiration date. She stated a new pad was put in place; however she had forgot to mark the alarm pad with the date of expiration after taking it out of the package and placing it on Resident #6's bed. She stated it was important to follow the resident's plan of care and marking the pad was a part of the plan. Interview with LPN #4, on [DATE] at 2:30 PM, revealed Resident #6 had been ordered a bed/chair alarm and the nursing aides usually were the ones to put them in place. She stated when an order for [REDACTED].

Based on observation, interview, record review and review of the manufacturer's guidelines and the facility's policy, it was determined the facility failed to have an effective system in place to ensure staff provided adequate supervision to prevent accidents. In addition, the facility failed to ensure the facility's bed/chair alarms were used in accordance with the manufacturer's recommendations, and failed to complete the Fall Circumstance forms and/or determine the root cause for the falls. The facility's failure affected ten (10) of twenty-five (25) sampled residents. (Residents #1, #2, #5, #6, #8,#9, #10, #11, #12 and #13). On [DATE], Resident #1 sustained an unwitnessed fall that resulted in injury and transfer to the hospital. Review of the emergency room record, dated [DATE], revealed the resident sustained [REDACTED]. Review of the Death Summary, dated [DATE], revealed the resident passed, thirteen (13) hours after the fall on [DATE], due to the injuries sustained from the fall which led to respiratory failure. Staff stated they were busy off the unit or tending to other residents on another hall when Resident #1 fell . Additional interview with staff revealed the bed alarm unit was not turned on and the resident's call light was not within reach at the time of Resident #1's fall. On [DATE] Resident #10 sustained an unwitnessed fall. The staff found the resident on the floor complaining of back pain. The resident told the staff he/she had attempted to get to their walker; however, the walker tipped over and the resident fell . Emergency Medical Services was called and transferred the resident to the hospital. Hospital x-ray results revealed a thoracic compression fracture at T9. The resident continued to have severe pain and muscle spasms and a back brace was ordered. On [DATE] Resident #9 sustained an unwitnessed fall. The resident was found on the floor by the resident's son. The resident's right foot was bleeding and the resident continued to be extremely confused. The resident's bed alarm was noted on the floor and non-functioning with a tear in the wiring. The family transported the resident to the hospital for evaluation and the resident required ten (10) sutures to the right foot, underneath and between the fourth and fifth toes. The hospital X-ray results revealed a closed non-displaced transverse fracture of the right fifth metatarsal. On [DATE] Resident #12 sustained an unwitnessed fall with injury. The resident reported he/she tried to get up from the potty chair and fell . The resident had swelling and an abrasion with bleeding to the nose. The Event Report revealed there were no possible contributing factors present at the time of the fall. The resident returned from the hospital with a [DIAGNOSES REDACTED]. In addition, the facility failed to ensure staff provided assistance to residents for toileting to prevent falls for Residents #11 and #13 and failed to monitor and follow the manufacture's recommendations for use of sensor pads for Residents #2, #5, and #6. The facility's failure to have an effective system in place to ensure adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AOC) on [DATE] which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency verified Immediate Jeopardy was removed on [DATE] as alleged prior to exit on [DATE]. The scope and severity was lowered to an E at F323, while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy for Falls Management, dated February 2015, revealed the facility would maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. The fall risk assessment was included as part of the Admission and Monthly Nursing Assessment and Review and Circumstance forms. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. In addition, care plan interventions developed from the fall risk assessment which address the resident's risk factors, should be implemented. Should the resident experience a fall the attending nurse shall complete the Fall Circumstance and Reassessment Form. The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat and a review by the Interdisciplinary Team to evaluate thoroughness of the investigation and appropriateness of the interventions. The resident I care plan/profile should be updated to reflect any new or change in interventions. Nursing staff will monitor and document continued resident response and effectiveness of interventions for seventy-two (72) hours; discuss risks and interventions with resident and/or responsible party; and, communicate interventions during shift report and update the twenty-four hour report and the nursing assistant assignment worksheet. Review of the facility's policy regarding Clinical Documentation Systems, Circumstance, and Reassessment Forms, not dated, revealed the purpose was to provide a tool to document an investigation as to the root cause of an episodic event. Reassessment of the resident's risk factors that may have contributed to the event and evaluate the current care of plan interventions for effectiveness and select additional interventions if required. The facility did not provide a policy related to the bed/chair alarms that would direct staff in how to check the alarms for functionality. However, observation on [DATE] at 2:10 PM, and review of the manufacturer's guidelines revealed the facility had three (3) different bed/chair alarm systems the facility used Medline, Posey and Universal Medical Products (UMP). Interview with the Director of Health Services (DHS), on [DATE] at 2:00 PM; and, on [DATE] at 12:20 PM, revealed the facility had not provided training to the staff for quite sometime. She stated she began her role in February of 2015 and she had not provided training and had not instructed anyone else to train staff on the bed/chair alarms. She stated she had not read the manufacturer's recommendations and was not aware there were three (3) different brands in use. She stated malfunctions could occur if staff did not know how to test the alarms appropriately and resident harm could occur. Review of the Medline bed/chair alarm brand revealed it was the responsibility of the facility to implement structured training procedures for all employees using the system. Only users who have received adequate training on the use of the system should use the system. Failure to adequately train employees may cause system failure due to user error. In addition, incorrect use of the equipment may also result in system failure. The company recommended all expired, soiled or contaminated pads be disposed of in accordance with the law and facility policy. The sensor pads had a limited expected useful life. The facility must record the warranty date in the area provided on the label. The facility must not use the sensor pad after the in-service warranty expiration date. To set-up the system first visually inspect the pad and wires for damage. Power the unit by inserting a 9-volt battery, use adhesive strips on the bottom of the pad before putting in place to prevent shifting. When securing the system, take up extra slack in the cord that could become tangled with the resident, bed or chair. Failure to do so may result in resident injury. Insert the pad plug into the sensor pad, and the control unit should flash a green light and beep. In addition, the unit could be silenced for 30 seconds, by pressing the silence button. If the resident does not return to the pad within 30 seconds the unit turns itself off requiring the staff to reset it again. Interview on [DATE] at 2:30 PM, with LPN #4, revealed she did not know if the facility had a policy regarding the bed/chair alarms. She stated she had not received training on the alarms from the facility or the manufacturer. Review of the Posey manufacturer recommendations, revealed before leaving a resident unattended staff should always follow these steps each time: check to make sure that the sensor cable and unit were intact and undamaged; place weight on sensor pad; turn alarm unit on and verify the green light blinks; verify the unit had fresh batteries in place; listen for intermittent chirp that will alert staff of a low battery; and, check to make sure the audible alarm functioned properly by applying and lifting weight off the sensor pad in several spots to activate alarm. Check to make sure sensor cable was out of the way and did not pose a tripping hazard. The manufacturer's information stated a nine (9) volt battery provided up to 280 hours of continuous alarm. The alarm may fail to sound if the sensor pad was bent or folded under the resident or not directly under the resident's buttocks. Review of the Posey brand revealed a warning statement that informed the user to never connect the Posey brand sensor pads to other manufacturers' alarm units or connect other manufacturers' sensor pads to the Posey brand alarm units. Review of the Universal Medical Products (UMP) also stated UMP pressure pads were designed for use with UMP monitors only and not substitute any other fall monitoring devices. In addition, the company directed user's to write on the pad the date the pad was put into use. The UMP stated the user should test the system before each use and inspect pads and monitor regularly to make sure they were not damaged. Users should test the system by pressing firmly on the pad for three (3) seconds. When pressure was removed from the pad, the alarm should sound and then reset the alarm. Place the UMP pad directly under the resident so that the bulk of the resident's weight (buttock area) would rest on the pad. Plug the end of the pad cable into the jack on the bottom of the monitor. For added safety from accidental pulls on the cord, route the cable through the strain relief slot on the bottom of the monitor. When the resident's weight was placed on the pad, the user would hear a brief confirmation tone letting them know the pad was operational. The UMP standard bed pads were designed to to withstand normal wear and tear for a period of 45-day, 90-day, 180-day or 1-year depending on the model. Beyond this time, the pad may fail and fail without warning due to prolonged use and other factors, e.g. bending, exposure to moisture, punctures, repeated cord pulls and connector damage. The information stated that facility protocols should direct staff to log the 45-day, 90-day, 180-day and 1-year Date Put in Use date in the blank provided on the pad itself and in the resident's chart. If the pad was used on more than one resident, the original Date put in use date must be transferred from chart to chart. Interview on [DATE] at 2:20 PM, with CNA #4 revealed she had not received training on the alarms from the facility or the manufacturer. She stated the facility reminded her to ensure the alarms were in place but did not train her on the specific characteristics of each system. 1. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Record review revealed the resident had fallen at the facility on [DATE]. Review of the Fall Circumstance Event Form, dated [DATE], revealed Resident #1 had an unwitnessed fall on [DATE] with no injuries. Review of the Fall Circumstance Form, dated [DATE], revealed the resident transferred without assistance from the couch. It was determined the resident's alarm pad was on the wheelchair seat instead of under the resident on the couch. The root cause determined by the interdisciplinary team was the resident fell due to a wet floor. Review of the resident's plan of care stated to continue the use of the bed/chair alarm and to check it for placement and functionality every shift. Review of Resident #1's Significant Change in Status Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident as needing the extensive assistance of one with transfers, personal hygiene, and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance with moving from a seated to standing position, walking, moving on and off the toilet and surface to surface, such as between the bed and chair or chair to wheelchair. The facility assessed Resident #1 with a score of eleven (11) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was interviewable. Review of the Comprehensive Care Plan for Resident #1 revealed the facility developed a plan of care for falls and assistance with activities of daily living on [DATE], with updated goals and target dates for [DATE]. Problems on the care plans stated the resident was at a risk for falls related to weakness, history of falls and the need for extensive assistance with activities of daily living, transfers and mobility. The goals stated the resident would stay free of falls, in order to be as independent as possible, while keeping the resident safe and comfortable. The approaches stated staff would provide assistance with activities of daily living and the assistance of one with transferring and mobility. Staff would keep the call light within the residents' reach and check on the resident frequently. The resident used a bed and chair alarm for safety and staff would check it for functionality every shift and if they heard it alarm they were to check on the resident to ensure their safety. Review of Resident #1's emergency room documents and the Death Summary, both dated [DATE], revealed the resident sustained [REDACTED]. The resident also sustained rib fractures to the second and third ribs on the left side with a Flailed Chest. The resident experienced respiratory failure requiring a breathing tube to be placed. The patient's sons arrived and discussion of the resident's prognosis, including the likelihood of death, if the resident was extubated. The resident's sons agreed that extubation was what the resident would have wanted and the resident was extubated and passed away at 4:50 PM on [DATE]. Review of the Fall Circumstance Event Form (FCEF), dated [DATE] at 4:04 AM, revealed the resident experienced an unwitnessed fall with injuries. The documentation noted the resident's mental status was at baseline; which was confused and forgetful, but able to recall their name. The FCEF stated the resident sustained [REDACTED]. Assessment findings stated the resident's oxygen saturation level was at 76% (normal 95%-100%) after the fall. Assessment of lung fields revealed gurgles and crackles from the left side of the chest. The form noted there were no possible contributing factors to the fall and the immediate measure taken to prevent another fall was to use a bed alarm; even though one was already in place at the time of the fall. The form also noted the outcome of interventions was No Interventions Used. Interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 8:44 AM, revealed she went down the 100 Hall around midnight because she heard a resident's alarm going off. She stated she peeked in on Resident #1, but it was not Resident #1's alarm that was sounding; however, she noted the resident's oxygen tubing was not in place. She stated she placed the tubing back in the resident's nose and left the room and no other care or services were provided. She stated after leaving she went down the 200 Hall and found the resident with the bed alarm sounding and assisted them. After this she began performing rounds on other residents with CNA #2. She stated they returned to the nurses' station area around 3:45 AM, and heard someone calling for help. They went to investigate and found Resident #1 on the floor next to the bed with a very deep cut to the eye that went down to the cheek. She stated when they entered the room, the resident's call light was not on or within reach of the resident and the bed alarm was not sounding and was not turned on. CNA #1 stated CNA #2 went to find the nurse while she stayed with the resident. Per interview, the aides worked as a team when making rounds because it would take two people to turn and change incontinent residents. She stated if they were in a room providing care they could not always hear the call lights or alarms sounding. Interview with CNA #2, on [DATE] at 2:05 PM and on [DATE] at 9:15 AM, revealed she had checked on the resident around 10:30 PM. The resident had a Posey brand alarm. CNA #2 stated she observed the alarm box but she did not see a blinking light on it. CNA #2 stated she had not received any recent training regarding the alarms and she did not know that a green blinking light on the Posey brand alarms meant the alarm was turned on. CNA #2 stated she and CNA #1 worked as a team on night shift, and around 3:00 AM, they were providing care to another resident and then returned to the nurses' station sometime after 3:00 AM. Per interview, they heard a resident yelling for help. They went to investigate and found Resident #1 on the floor beside the bed. She stated CNA #1 stayed with the resident and she went to find the nurse. She stated she approached the nurse as she was returning to the unit and informed her, Resident #1 had sustained a fall with injury. She stated Licensed Practical Nurse (LPN) #1 assessed the resident and called emergency medical personnel to transfer the resident to the hospital. CNA #2 stated she did not know how to locate a resident's plan of care in the new electronic medical record. She stated prior to the new computerized system the aides had a paper document telling them the care each resident required. She stated now the new system required her to answer questions about the resident's level of assistance needed during care provided. Interview with LPN #1, on [DATE] at 9:30 AM, revealed she was off the unit using the bathroom when the resident fell . She stated when she returned to the nurses' station CNA #2 notified her Resident #1 had sustained a fall with injury. She stated the resident had a cut to the eye and cheek area and began to have breathing trouble. She stated Emergency Medical Services was called to transport the resident to the hospital. LPN #1 stated she did not review resident care plans normally, but depended on the medication and treatment records to direct her care of residents. She stated she received shift to shift reports from the off going nursing staff and that was how she knew of Resident #1's care needs. She stated all residents were checked on every two hours and if a care plan intervention stated check on resident frequently, then residents would be checked on every two hours. She stated if residents needed increased supervision, an order would be written for hourly checks; however, Resident #1 did not have hourly checks ordered. She stated she did not check the bed alarm for functionality prior to the fall because she had all shift to check it. She stated she did not check the alarm after the fall because she was tending to the resident's needs. LPN #1 stated she had not been trained on the manufacturers recommendations for each type of bed/chair alarms in the facility. She stated ensuring the residents' fall interventions were implemented would maintain resident safety. LPN #1 stated she did not conduct the investigation into the fall or determine the root cause. She stated those activities were completed by Management. Interview with the Director of Health Services (DHS), on [DATE] at 2:00 PM and on [DATE] at 12:20 PM, revealed the facility determined the cause of Resident #1's fall with injury was due to the resident not using the call light to ask staff for assistance. She stated to keep the resident safe and meet their needs, staff should ensure the resident's call light was always in reach, the bed/chair alarm was checked every shift for functionality and placement, and staff should frequently check on the resident. The DHS stated although interviews conducted after the fall determined Resident #1's call light was not within reach, the bed alarm had not sounded, and staff was not available to provide frequent supervision; the facility did not identify staff had not provided the necessary care and services to meet the resident's needs for safety and fall prevention. She stated the resident should have called for assistance prior to transferring self. Interview with the Interim Executive Director, on [DATE] at 2:40 PM, revealed interviews and statements obtained from staff were not taken into account. She stated the facility determined the root cause of the fall was the resident frequently did not use the call light to ask for assistance prior to transferring. She stated the facility did not determine the staff failed to follow care plan interventions related to ensuring bed alarm functionality, call light was kept in reach or checking on the resident frequently; even though interviews and written statements obtained stated the bed alarm did not sound, the bed rail was in the down position with the call light attached and not within reach of the resident. Interviews and written statements also indicated the nurse was off the unit and the two (2) CNAs were busy providing care to another resident at the time of the fall. Interview with the Executive Director, on [DATE] at 3:20 PM, revealed he briefly reviewed Resident #1's incident/event file after he began his employment on [DATE]. He stated after reviewing the event he did not provide any further direction to staff to determine if there were system issues in relation to meeting the care needs of the resident. He stated if he had conducted the investigation and determined the bed alarm had not sounded; he would have directed staff to conduct an audit of the alarms to determine if they were functional at all times. He stated if he had determined the call light had not been in reach of the resident he would have conducted audits of call light accessibility. He stated if he had determined staff was not available to meet the needs of the resident he would have looked into that also. He stated it was the facility's responsibility to ensure resident safety. 2. Review of the clinical record for Resident #8 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. The resident had a hospital admission on [DATE] and was re-admitted to the facility on [DATE]. Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment, completed on [DATE], revealed the facility assessed the resident as needing the extensive assistance of one with transfers, walking, and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. The facility assessed Resident #8 with a score of fourteen (14) of fifteen (15) on the BIMS assessment, indicating the resident was interviewable. Review of the Comprehensive Care Plan for Resident #8 revealed the facility developed a plan of care related to skin integrity and falls on [DATE] with updated goals and target dates for [DATE]. The goals stated the resident would have no falls with major injury and would maintain intact skin. Review of Resident #8's Fall Circumstance Event Form, dated [DATE], revealed Resident #8 sustained an unwitnessed fall with injury. The report stated staff heard the resident yelling for help and found the resident on the floor next to the bed. The resident sustained [REDACTED]. The possible contributing factors noted on the form were cardiac/respiratory disease, discomfort/pain, and antihypertensive/antipsychotic medications. The interventions immediately taken to prevent another fall were noted as a bed alarm, first aid, and rest. However, there was no documented evidence a review of the fall was conducted by the Interdisciplinary Team or of the seventy-two hours of nursing assessment documentation regarding the resident's response to treatments or the effectiveness of the interventions as per the facility's policy. Review of Radiology Report, dated [DATE], revealed Resident #8 had a right non-displaced lateral 8th rib fracture. Interview with Resident #8, on [DATE] at 8:16 AM, revealed on [DATE] he/she had used the call light to ask staff for assistance with toileting. However, staff did not arrive timely so he/she attempted to toilet without assistance and fell . The resident stated he/she hit their back and side on the chair next to the bed; and, sustained a rib fracture and the laceration to the right arm, along with other bruises. Interview with CNA #13, on [DATE] at 9:30 PM, revealed the resident could not walk without assistance and at night would get very confused. She stated the electronic medical record had information regarding the resident's activities of daily living for her review; however, she did not routinely have time to review that information during her shift. She stated she had been told in report, at the beginning of her shift, that Resident #8 was confused and had been frequently getting up to use the bed pan in the chair without assistance. She stated the resident did not have a bedside commode. She stated she was not provided direction or additional safety interventions during report or at any time prior to Resident #8's fall. CNA #13 stated at the time of resident #8's unwitnessed fall she was providing care to another resident. She stated the resident was found on the floor with stool all over their bottom. She stated a bed alarm and/or closer supervision could have been put in place prior to the event to prevent Resident #8's fall with injuries. Interview with LPN #8, on [DATE] at 8:10 PM, revealed Resident #8's short term memory was not good and the resident had periods of confusion. She stated the resident would get up frequently between 2:00 AM and 3:00 AM to try and toilet self. She stated staff made rounds on all residents every two hours and the resident was not on a toileting program due to this type of rounding. She stated the resident did have a bed alarm prior the last admission to the hospital; however, it was not put back into use after the resident was readmitted to the facility. She stated a bed alarm should have been put in place after readmission to alert staff of the resident's attempts to transfer without assistance. She stated an intervention to toilet the resident consistently at 2:00 AM, could have prevented the resident's fall also. She stated after a fall she completed a Fall Circumstance Event Form and that form had areas for her to denote contributing factors of the fall and possible additional care plan interventions. However, she did not make revisions to care plans because that was the responsibility of the MDS nursing staff. In addition, LPN #8 stated she did not determine the root cause of resident falls. She stated nursing would ask the resident what happened or what they were trying to do at the time of the fall only. She stated if she implemented an intervention she would verbally tell staff, but if the information did not get transferred by telling others, it would not be known by all. Interview with the DHS, on [DATE] at 3:00 PM, revealed staff should have assisted Resident #8 with toileting on the night of the fall. In addition, staff should have developed a scheduled toileting program for the resident, knowing the resident frequently wanted to toilet around 2:00 AM. 3. Review of the clinical record for Resident #10 revealed the facility admitted the resident on [DATE], with the [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of Resident #10's five day MDS assessment, completed on [DATE], revealed the facility assessed the resident as needing the extensive assistance of one with transfers, bed mobility and toileting. The facility assessed the resident as not steady on their feet and only able to stabilize with staff assistance when moving from a seated to standing position, walking, moving on and off the toilet and from surface to surface. The facility assessed Resident #10 with a score of fourteen (14) of fifteen (15) on the BIMS assessment indicating the resident was interviewable. Review of the Comprehensive Care Plan for Resident #10 revealed the facility developed a plan of care related to activities of daily living and falls on [DATE] with updated goals and target dates for [DATE]. The approaches directed staff to provide assistance with mobility. The care plan stated the resident needed the assistance of one when transferring, the resident used a rolling walker with staff assistance and needed a wheelchair for long distances. The care plan also stated the resident required assistance with oral care, grooming, bathing, and dressing. In addition, the fall care plan approaches directed staff not to leave the resident alone up in the wheelchair for extended periods of time, keep the call light within reach and remind the resident to use it. Review of the Nursing Notes, dated [DATE] at 1:52 PM, revealed Resident #10 sustained an unwitnessed fall with injury. The resident complained of back pain, requiring Emergency Medical Services to transfer the resident to the hospital for treatment. Nursing noted the resident stated he/she had attempted to get to their walker and it tipped over with the resident going over with it. Review of the hospital History and Physical, dated [DATE], revealed the resident fell trying to get to his/her walker. The x-ray results revealed a thoracic compression fracture at T9. The resident continued to have severe pain and muscle spasms and a back brace was ordered. The resident was admitted back to the facility on [DATE]. Interview with Resident #10, on [DATE] at 3:20 PM, revealed he/she fell on [DATE], after attempting to rise from the wheelchair to use their roller walker. Resident #10 stated the rolling walker flipped over and he/she flipped over with it. The resident stated they fractured their spine at T9 and now must wear a brace when out of bed. Resident #10 stated they were in a lot of pain and still required pain medication for the fracture. Interview, on [DATE] at 2:30 PM, with CNA #3 revealed she had assisted Resident #10 to the bathroom on [DATE], put tooth paste on the resident's tooth brush and left the room to go complete charting. She stated twenty to thirty minutes later a housekeeper notified her that the resident had fallen. She stated she went to Resident #10's room and found the resident on the floor behind the entry door to the room. She stated the resident said he/she was trying to use their rolling walker and it flipped over with them. She stated she had only taken care of Resident #10 two or three times prior to the fall and had not reviewed the plan of care. She stated she thought she could leave the resident a

Based on interview, record review, and facility policy review, it was determined the Administration failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility's Interim Administration failed to have oversight in the overall safe environment in order to evaluate the facility's Falls Policy to ensure the policy was effective for prevention of avoidable accidents, as well as the Interdisciplinary Team Care Plan Guidelines; the Clinical Documentation System and Forms; the Electronic Medical Records; and Quality Assurance. On 09/07/15, Resident #1 sustained an unwitnessed fall that resulted in injury and transfer to the hospital. Review of the emergency room record, dated 09/07/15, revealed the resident sustained [REDACTED]. Review of the Death Summary, dated 09/07/15, revealed the resident passed, thirteen (13) hours after the fall, on 09/07/15, due to the injuries sustained from the fall which led to [MEDICAL CONDITION]. On 09/30/15, Resident #10 sustained an unwitnessed fall. The staff found the resident on the floor complaining of back pain. The resident told the staff he/she had attempted to get to his/her walker; however, the walker tipped over and the resident fell . Emergency Medical Services was called and transferred the resident to the hospital. Hospital x-ray results revealed a [MEDICATION NAME] compression fracture at T9. The resident continued to have severe pain and muscle spasms and a back brace was ordered. On 09/09/15, Resident #9 sustained an unwitnessed fall. The resident was found on the floor by the resident's son. The resident's right foot was bleeding and the resident continued to be extremely confused. The resident's bed alarm was noted on the floor and non-functioning with a tear in the wiring. The family transported the resident to the hospital for evaluation and the resident required ten (10) sutures to the right foot, underneath and between the fourth and fifth toes. The hospital x-ray results revealed a closed non-displaced [MEDICATION NAME] fifth metatarsal. In addition, the facility failed to ensure staff provided assistance to residents for toileting to prevent falls for Residents #11 and #13; and, failed to monitor and follow the manufacture's recommendations for use of sensor pads for Residents #2, #5, and #6. Refer to F323. The facility's failure to have an effective Administration, with oversight to ensure an overall safe environment, in order to evaluate the facility's Falls Policy to ensure the policy was effective in the prevention of avoidable accidents placed Resident #1 and other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 10/16/15 and determined to exist on 09/07/15 at 42 CFR 483.20 Resident Assessment (F280 and F282) at a Scope and Severity of a K; 42 CFR 483.25 Quality of Care (F323) at a Scope and Severity of a K; and, 42 CFR 483.75 Administration (514 and 520) at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. The facility was notified of the Immediate Jeopardy on 10/16/15. An acceptable Allegation of Compliance (AOC) was received on 10/22/15 which alleged removal of the Immediate Jeopardy on 10/23/15. The State Survey Agency verified Immediate Jeopardy was removed on 10/23/15 as alleged prior to exit on 10/29/15. The Scope and Severity was lowered to an E at F280, F282, F323, F514, and F520, while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. After supervisory and CMS review, F490 was cited at a Scope and Severity of a K. The facility provided an acceptable AOC on 12/03/15 alleging removal of Immediate Jeopardy on 10/23/15. Refer to F280, F282, F323, F514, and F520. The findings include: Review of the facility's policy regarding Interdisciplinary Team Care Plan Guidelines, dated June 2015, revealed the purpose was to ensure appropriateness of services and communication that would meet the residents' needs, severity/stability of conditions, impairments, disability, or disease in accordance with state and federal guidelines. The care plan interventions would be reflective of the impact the risk area(s), disease process(es) have on the individual resident. Goals would be measurable and attainable. Interventions would be reflective of the individuals' needs and risk influence as well as the resident's strengths. Review of the facility's policy regarding Clinical Documentation Systems, Circumstance, and Reassessment Forms, not dated, revealed the purpose was to provide a tool to document an investigation as to the root cause of an episodic event. Reassessment of the resident's risk factors that may have contributed to the event and evaluate the current care of plan interventions for effectiveness and select additional interventions if required. The care plan would be reviewed for the effectiveness of the current interventions in place to minimize or eliminate the risk factors. New interventions would be implemented as appropriate. Review of the facility's policy for Falls Management, dated February 2015, revealed the facility would maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Should the resident experience a fall the attending nurse would complete the Fall Circumstance and Reassessment Form. The form included an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of a repeat and a review by the Interdisciplinary Team to evaluate thoroughness of the investigation and appropriateness of the interventions. The resident care plan/profile would be updated to reflect any new or change in interventions. Review of the facility's policy for Scanning of Paper Medical Records into the Matrix Care system, not dated, revealed the purpose was to provide a successful transition from paper-based charts to Electronic Medical Records (EMR). The policy stated the medical records and/or other designated staff would assemble the documents to be scanned into the EMR. After scanning, the document would be reviewed to ensure the document was legible and all pages were present. Once the review had been completed and the document verified to be present the document would be returned to the paper chart. Documents originated after the date of electronic conversion may be disposed of in the confidential bin. All paper documents shall be maintained per the State and/or Federal regulations. Review of the facility's policy related to Guidelines for the Quality Assessment and Assurance Process, not dated, revealed the purpose was to provide continuous evaluation of campus systems to distinguish between isolated, pattern or system concerns, ensure systems were functioning appropriately, to prevent problems from rising to the extent possible, recognize incremental change that may be early signs of potential/future problems, and correct identified issues. The primary purposes of the Quality Assessment and Assurance Plan would be to establish and provide a system whereby a specific process, and the documentation relative to it, would be maintained to support evidence of an ongoing Quality Assessment and Assurance Program, encompassing all aspects of resident care including safety, infection control, and quality of life applicable to campus residents. To develop a plan of correction and evaluate corrective actions taken to obtain the desired results. To provide a centralized, coordinated approach to quality assessment and assurance activities so as to bring about a comprehensive program of quality assessment and assurance to meet the needs of the facility. Interview with the Director of Health Services (DHS), on 10/05/15 at 2:00 PM and on 10/09/15 at 12:20 PM, revealed the facility had not provided training to the staff for quite sometime. She stated she began her role in February of 2015 and she had not provided training and had not instructed anyone else to train staff on the bed/chair alarms. She stated she had not read the manufacturer's recommendations and was not aware there were three (3) different brands in use. She stated malfunctions could occur if staff did not know how to test the alarms appropriately and resident harm could occur. Interview with the Interim Executive Director, on 10/05/15 at 2:40 PM, revealed interviews and statements obtained from staff were not taken into account. She stated the facility determined the root cause of the fall was Resident #1 frequently did not use the call light to ask for assistance prior to transferring. She stated the facility did not determine the staff failed to follow care plan interventions related to ensuring bed alarms were functional, call light was kept in reach or checking on the resident frequently; even though interviews and written statements obtained stated the bed alarm did not sound, the bed rail was in the down position with the call light attached and not within reach of the resident. Interviews and written statements also indicated the nurse was off the unit and the two (2) CNAs were busy providing care to another resident at the time of the fall. Interview with the Executive Director, on 10/05/15 at 3:20 PM, revealed he briefly reviewed Resident #1's incident/event file after he began his employment on 09/21/15. He stated after reviewing the event he did not provide any further direction to staff to determine if there were system issues in relation to meeting the care needs of the resident. He stated if he had conducted the investigation and determined the bed alarm had not sounded; he would have directed staff to conduct an audit of the alarms to determine if they were functional at all times. He stated if he had determined the call light had not been in reach of the resident he would have conducted audits of call light accessibility. Continued interview revealed if he had determined staff was not available to meet the needs of the resident he would have looked into that also, as it was the facility's responsibility to ensure resident safety. Interview with the Interim Executive Director, on 10/07/15 at 11:00 AM, revealed her position was to provide ongoing monitoring, as well as clinical direction. In addition, her position was to review system changes and concerns and communicate them as appropriate. However, she had not received any concerns from the facility. She stated she was not in the building prior to the State's investigation and came to the facility as support for the facility only. The Interim Executive Director further stated the computer system should be fully implemented at this campus. However, interview with the Director of Health Services (DHS), on 10/15/15 at 11:30 AM, revealed the computer system was confusing and since they went to computers, things were getting missed with documentation. The DHS further stated she was not aware what closing out an event form meant and learned she should have been reviewing them. She stated she had not received training on this process as it related to the DHS' responsibility and was still learning where to go first online. Interview with the Executive Director (ED), on 10/16/15 at 3:35 PM, revealed he was aware of open staffing positions that were posted; however, most of them were for part time. The ED was unable to voice the number of staff hired. He further stated he felt the units were adequately staffed for the care provided. The staff can call each other and he stated they did random checks on staff to ensure they were providing care to the residents. During his last check nothing stood out. Interview with the Director of Clinical Support and the Executive Director, on 10/16/15 at 10:45 AM, revealed the QA Committee met monthly to discuss QA issues. They stated no action plan was developed related to falls; however, a plan should have been developed to ensure resident safety. They stated the Interdisciplinary Team (IDT) should have been monitoring the electronic medical record documentation to determine if staff had not completed Event Reports and resident reassessments, in addition to determining the root cause of the events. They stated it was also the role of the DHS to monitor and address any identified concerns. They stated prior to the survey process beginning they had not identified any issues with the QA system process conducted by the IDT or the DHS. They stated prior to the survey process neither had provided direction or guidance to the facility staff in regards to improving the quality processes, related to falls, care planning, or documentation. The facility took the following steps to remove the Immediate Jeopardy: 1. On 10/16/15, immediate education was provided to the Executive Director and other Department Leaders related to causation, systems noncompliance and plan for removal. This was also discussed on 10/17/15. 2. On 10/12/15 through 10/17/15, the External Audit Nurse and the Assessment Support Nurse provided education to the Executive Director and staff related to timely and accurate revisions of care plans based on resident condition and following care plan interventions. In addition, these nurses conducted audits of care plans to ensure accuracy starting on 10/19/15. 3. On 10/18/15-10/22/15, the Divisional Vice President (DVP) educated the Executive Director and reviewed the day to day review of the AOC binder to ensure all audits were being completed; the development of a new binder for the SOD/POC and the DHS' responsibility to maintain; assignment of all Department Leaders to a specific part of the facility for daily monitoring; effectiveness of staff training and communication with new hires; and, reviewed specific tags and how to monitor, and the QA process. 4. On 10/19/15, each campus leader was reeducated by the DVP on the tags related to immediate jeopardy, causation, steps for removal, and steps needed to monitor. Campus leaders included the ED, DHS, MDS, Director of Plant Operations, Therapy Director, Activities, Medical Director, ADHS, Director of Social Services, DFS, Environmental Director, Pharmacy Consultant, and the Director of Clinical Support. 5. QA meetings were held on 09/19/15, 10/09/15, 10/19/15, and 11/24/15. The meetings included education on the Falls Management Program and systems implementation, fall trends, investigation and follow up. In addition, guidelines and protocols for conducting QA meetings, and the development of measurable corrective action plans were discussed. 6. On 10/19/15, the Clinical Director provided education to Campus Leaders and the ED regarding ongoing audits of assigned residents, safety devices, water accessible, and call lights in reach. 7. On 11/24/15, the QA meeting focused on the deficiencies cited regarding care plans, notification of Medical Director and families, supervision to prevent accidents, infection control related to Personal Protective Equipment and handwashing, dietary tags, and medical record audits. The State Survey Agency validated the removal of Immediate Jeopardy on 12/04/15 as follows: 1. Review of Attachment Forms #1-a and #1-b, dated 10/16/15, revealed on 10/16/15 and 10/17/15, immediate education was provided by the Division Vice President to the ED and other Department Leaders related to causation, systems noncompliance and plan for removal. Interview with the Division Vice President on 12/14/15 at 2:30 PM, revealed she provided training to the ED and other department leaders related to causation, systems noncompliance and plan for removal on 10/16/15 and 10/17/15. She stated she mentored the ED regarding the QA process. She stated she specifically went over the audit tools with the ED and mentored him on the process for developing action plans related to issues found and how to monitor for effectiveness and reevaluating to determine if processes were being maintained. 2. Review of Attachment Form #2, undated, revealed on 10/12/15 through 10/17/15, the External Audit Nurse and the Assessment Support Nurse provided education to the ED and staff related to timely and accurate revisions of care plans based on resident condition and following care plan interventions. In addition, these nurses conducted audits of care plans to ensure accuracy starting on 10/19/15. Interview with the Division Vice President (DVP) on 12/14/15 at 2:30 PM, stated she conducted some of the care plan audits herself. She stated she reviewed the audit results and mentored the ED in the QA process. She stated she provided education to the ED related to the care planning process and how to evaluate it for effectiveness. Interview with Director of Clinical Support on 12/04/15 at 2:09 PM, revealed she mentored the ED and reviewed the facility's audits with him. She stated a Safety Device Monitoring Tool was used daily by leaders in the facility to document their audits of safety interventions and devices in use by their residents. She stated she reviewed the results with the ED and did not determine any trends just isolated issues and they were immediately corrected. 3. Review of Attachment Form #3, undated, revealed on 10/18/15-10/22/15 the DVP educated the ED and reviewed the day to day review of the AOC binder to ensure all audits were being completed; the development of a new binder for the SOD/POC and the DHS's responsibility to maintain; assignment of all Department Leaders to a specific part of the facility for daily monitoring; effectiveness of staff training and communication with new hires; and, reviewed specific tags and how to monitor, and the QA process. Interview with DVP on 12/14/15 at 2:30 PM, revealed she trained the ED on the organization's process for on-boarding new employees from 10/18/15-10/22/15. She stated leaders were assigned different areas of the facility to audit for AOC compliance, using the Safety Device Audit Tool. She stated she reviewed the day to day review of the AOC binder to ensure all audits were being completed with the ED. She stated she did not identify any issues during her reviews. She stated she also reviewed the specific tags cited during the survey process; and provided education on how to monitor for continued compliance, along with the how to conduct the QA process with the ED and other QA committee members. 4. Review of Attachment Form #4, undated, revealed on 10/19/15 each campus leader was reeducated by the DVP on the tags related to immediate jeopardy, causation, steps for removal, and steps needed to monitor. Campus leaders were ED, DHS, MDS, Director of Plant Operations, Therapy Director, Activities, Medical Director, ADHS, Director of Social Services, DFS, Environmental Director, Pharmacy Consultant, and the Director of Clinical Support. Interview with Director of Clinical Support on 12/04/15 at 2:09 PM, revealed she attended the training provided by the DVP on 10/19/15, and received education on the tags cited related to immediate jeopardy, causation, steps for removal, and steps needed to monitor. Interview with DVP on, 12/14/15 at 2:30 PM, revealed she held a training on 10/19/15, with campus leaders and discussed tags related to immediate jeopardy, causation, steps for removal, and steps needed to monitor. 5. Review of QA meeting sign in sheets, dated 09/19/15, 10/09/15, 10/19/15, and 11/24/15, revealed QA meetings were held and included education on the Falls Management Program and systems implementation, fall trends, investigation and follow up. In addition, guidelines and protocols for conducting QA meetings, and the development of measurable corrective action plans were discussed. Interview with Director of Clinical Support on 12/04/15 at 2:09 PM, revealed she attended the QA committee meetings and assisted with providing education related to falls, medication errors, infection control, care planning processes and the QA process. Interview with the Division Vice President on 12/14/15 at 2:30 PM, revealed she attended the facility's QA committee meetings and she provided education regarding the Falls Management Program and systems implementation, fall trends, investigation and follow up expectations. In addition, she educated the members on the guidelines and protocols for conducting QA meetings, and the development of measurable corrective action plans. 6. Review of Attachment Form #4, dated 10/19/15, revealed a meeting with Campus Leaders and the ED was held. Interview on 12/04/15 at 2:09 PM with the Director of Clinical Support revealed she provided education, on 10/19/15, to Campus leaders and the ED regarding ongoing audits of assigned residents, safety devices, water accessible, and call lights in reach. 7. Review of QA Committee meeting sign in sheet, dated 11/24/15, revealed a QA Committee meeting was held with the ED, DVP, Director of Clinical Support, DHS, Pharmacy, Dietary and Social Services among others. Interview on 12/04/15 at 2:09 PM with the Director of Clinical Support and the Division Vice President on 12/14/15 at 2:30 PM, revealed the QA meeting held on 11/24/15 focused on the deficiencies cited regarding care plans, notification of MDs and families, supervision to prevent accidents, infection control related to Personal Protective Equipment and handwashing, dietary tags, and medical record audits.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure resident medical records were completed and accurate related to the availability of Do Not Resuscitate documents and completed Circumstance Event Form documentation, along with the required reassessments in order for the residents medical records to reflect the residents actual condition and the services provided. This failure affected five (5) of twenty-five (25) sampled residents (Resident's #1, #8, #9, #10 and #12). Review of Resident #1's emergency room documents and the Death Summary, both dated 09/07/15, revealed the resident sustained [REDACTED]. The resident was transferred to the hospital and diagnosed with [REDACTED]. Upon transfer, the resident's Advance Directive was not sent with the resident to the hospital. The resident experienced [MEDICAL CONDITION] requiring the placement of a breathing tube. However, the resident was a Do Not Resuscitate (DNR). Per the hospital record, the resident's prognosis was discussed with the resident's sons and the resident was extubated and passed away at 4:50 PM on 10/07/15. Review of Resident #8's Fall Circumstance Event Form (FCEF), dated 09/26/15, revealed Resident #8 sustained an unwitnessed fall with injury. The resident sustained [REDACTED]. However, there was no documented evidence a review of the fall was conducted by the Interdisciplinary Team or of the seventy-two hours of nursing assessment documentation regarding the resident's response to treatments or the effectiveness of the interventions as per the facility's policy. Review of Resident #9's FCEF, dated 09/09/15, revealed Resident #9 sustained an unwitnessed fall and sustained a laceration to the right foot. The form did not have seventy-two hours of reassessment documentation of the resident's response to treatments or the effectiveness of the interventions per the facility's policy. Continued review of the form revealed the Interdisciplinary Team did not document a review regarding the evaluation, thoroughness or effectiveness of the actions taken. The resident sustained [REDACTED]. Continued review of the FCEF, revealed the form did not have reassessment documentation of the resident's response to treatments or the effectiveness of the interventions and the Interdisciplinary Team did not document a review regarding the evaluation, thoroughness or effectiveness of the actions taken. Review of the Nursing Notes, dated 09/30/15 at 1:52 PM, revealed Resident #10 sustained an unwitnessed fall and sustained a [MEDICATION NAME] compression fracture at T9 (9th vertebra). Review of Resident #10's medical record revealed no evidence a FCEF was completed for the fall event on 09/30/15. Review of Resident #12's FCEF, dated 08/04/15 at 11:37 PM, revealed the resident sustained [REDACTED]. The form did not have seventy-two hours of reassessment documentation of the resident's response to treatments or the effectiveness of the interventions per the facility's policy and the Interdisciplinary Team did not document a review regarding the established root cause, evaluation, thoroughness or effectiveness of the actions taken. The facility's failure to have an effective system in place, to ensure the facility maintained a complete and accurate clinical record, has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on 09/07/15. The facility provided an acceptable Allegation of Compliance (AOC) on 10/22/15, which alleged removal of the Immediate Jeopardy on 10/23/15. The State Survey Agency verified Immediate Jeopardy was removed on 10/23/15 as alleged prior to exit on 10/29/15. The scope and severity was lowered to a E at F514, while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy for Scanning of Paper Medical Records into the Matrix Care system, not dated, revealed the purpose was to provide a successful transition from paper-based charts to Electronic Medical Records (EMR). The policy stated the medical records and/or other designated staff would assemble the documents to be scanned into the EMR. After scanning, the document would be reviewed to ensure the document was legible and all pages were present. Once the review had been completed and the document verified to be present the document would be returned to the paper chart. Documents originated after the date of electronic conversion may be disposed of in the confidential bin. All paper documents shall be maintained per the State and/or Federal regulations. Review of the facility's policy regarding Clinical Documentation Systems, Circumstance, and Reassessment Forms, not dated, revealed the purpose was to provide a tool to document an investigation as to the root cause of an episodic event. Reassessment of the resident's risk factors that may have contributed to the event and evaluate the current care plan interventions for effectiveness and select additional interventions if required. The care plan would be reviewed for effectiveness of the current interventions in place to minimize or eliminate the risk factors. New interventions would be implemented as appropriate. Review of the facilities policy regarding Clinical Documentation Systems, not dated, revealed the facility would document assessment and provision of services through a variety of forms and systems. The expectations of clinical documentation was to meet the individual needs of the residents and promote independence and prevent decline in physical and mental functioning. The staff would be expected to document their service delivery and assessment of mental and physical functioning. 1. Review of the closed clinical record revealed the facility admitted Resident #1 on 06/08/13, with the [DIAGNOSES REDACTED]. Continued review of the medical record revealed a physician's orders [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on, 10/02/15 at 9:30 AM, revealed she was off the unit when the resident fell on [DATE]. She stated Emergency Medical Services was called to transport the resident to the hospital. She stated Resident #1's medical record stated the resident had made a health care decision not to be resuscitated. However, she was unable to locate the Kentucky Emergency Medical Services Do Not Resuscitate document in the resident's medical record. She stated as required by law, this document had to be provided to the Emergency Medical personnel prior to transferring the resident to the hospital for the resident's wishes to be honored during transport and at another medical facility. However, this was not done. Review of Resident #1's emergency room documents and the Death Summary, both dated 09/07/15, revealed the resident the resident experienced [MEDICAL CONDITION] requiring a breathing tube to be placed. In addition, the Death Summary noted At the time, it was not known about the patient's code status. The family was called and they informed them the patient was indeed a DNR and would not have wanted to be supported on a breathing machine for an extended amount of time. The patient's sons arrived and discussion of the patient's prognosis including likelihood of death if the patient was extubated. The patient's sons agreed that extubation was what the patient would have wanted and the patient was extubated and passed away at 4:50 PM on 10/07/15. Interview with the Medical Records staff member on, 10/05/15 at 3:00 PM, revealed it was determined Resident #1's Do Not Resuscitate (DNR) form did not get scanned into the electronic medical record and was found locked up in the Minimum Data Set (MDS) nurses' office. She stated the facility could not determine how the form came to be located there. Interview with the Director of Health Services (DHS), on 10/05/15 at 2:00 PM, revealed staff informed her the next morning that Resident #1's DNR paperwork could not be located prior to sending the resident to the hospital. She stated the facility recently implemented an all electronic medical record and if residents had paper documents, such as DNR papers, the medical records staff would scan them into the electronic medical record. She stated they also kept a few paper documents in a box at the nurses station. She stated the staff searched for Resident #1's documents in the box and reviewed the electronic medical record again; however, they still were unable to locate the DNR papers. She stated the medical records staff conducted a search of the building and eventually located the documents. She stated if the DNR papers were not in a residents' chart, then the chart was considered incomplete, and care givers would not know or be able to carry out the resident's wishes. 2. Review of the clinical record for Resident #8 revealed the facility admitted Resident #8 on 08/04/15 with [DIAGNOSES REDACTED]. The resident had a hospital admission on 09/15/15 and was re-admitted to the facility on [DATE]. Review of Resident #8's FCEF, dated 09/26/15, revealed Resident #8 sustained an unwitnessed fall and sustained bruising and a skin tear to the right elbow, abrasion to mid-lower spinal bony prominence, and complained of right lower rib pain. The resident was diagnosed with [REDACTED]. Review of Resident #8's EMR revealed sections for X-ray, Laboratory and Other reports; however, review of these sections revealed no evidence of the x-ray report for the resident's recent right rib fracture. Interview, on 10/07/15 at 9:45 AM, with LPN #14, revealed she was unable to locate Resident #8's x-ray report in the EMR or in the black box at the nurses station. She stated medical records staff may have the document and had not scanned it into the system yet. Interview with the Medical Records employee, on 10/07/15 at 10:00 AM, revealed she did not know the location of Resident #8's x-ray report. She stated she would have to look for it. She stated she looked in the EMR and in the black box on the unit and did not find it there. She stated after some searching she located the report in her mail box and did not know how long it had been there. She stated the staff was not filing reports correctly and due to this the medical records were not organized and scanning into the EMR was not always timely. Further review of the FCEF, dated 09/26/15, revealed no documented evidence a review of the fall was conducted by the Interdisciplinary Team or the seventy-two hours of nursing assessment per the facility's policy. 3. Review of the closed clinical record revealed the facility admitted Resident #9 on 09/09/15 with the [DIAGNOSES REDACTED]. Review of Resident #9's FCEF, dated 09/09/15, revealed Resident #9 sustained an unwitnessed fall with injury requiring ten (10) sutures to the right foot, underneath and between the fourth and fifth toes and a closed non-displaced [MEDICATION NAME] fifth metatarsal. The form did not have seventy-two hours of reassessment documentation of the resident's response to treatments or the effectiveness of the interventions per the facility's policy or the documentation by the Interdisciplinary Team regarding the evaluation, thoroughness or effectiveness of the actions taken. Review of the FCEF, dated 10/02/15, revealed Resident #9 had an unwitnessed fall from the wheelchair, without injury. The FCEF, revealed nursing did not document additional interventions to prevent another fall. In addition, the form did not have reassessment documentation of the resident's response to treatments or the effectiveness of the interventions. Continued review of the form revealed the Interdisciplinary Team did not document a review regarding the evaluation, thoroughness or effectiveness of the actions taken. Interview with LPN #9, on 10/15/15 at 11:40 AM, revealed it was a facility policy to perform neurological checks on all residents that sustained an unwitnessed fall. She stated she forgot to do this for Resident #9. She stated she also forgot to completely fill out the FCEF. She stated if nursing did not complete their documentation then management would inform them by giving them a note. However, she had not received a note from management that stated she had incomplete documentation in Resident #9's medical record. She stated a complete medical record ensured staff had the necessary information to meet the needs of the resident. Interview, on 10/16/15 at 3:00 PM, with the DHS revealed she had not identified that all the areas on FCEF were not completed. She stated if the team determined a form had not been completed or had areas left blank they would inform the nurse that she needed to complete the form. However, she had no memory of informing LPN #9 of the need to complete the form, and the team did not keep a record of such notification. She stated if the forms were not complete it would be difficult for the team to analyze the information or for staff to provide the necessary care and services. 4. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 09/23/15 with a history of falls with [MEDICAL CONDITION] and kidney transplant. The resident had [DIAGNOSES REDACTED]. Review of the Nursing Notes, dated 09/30/15 at 1:52 PM, revealed Resident #10 had an unwitnessed fall and sustained a [MEDICATION NAME] compression fracture at T9. The resident continued to have severe pain and muscle spasms and a back brace was ordered. However, record review revealed a FCEF was not completed regarding the fall. Interview with LPN #4, on 10/09/15 at 12:55 PM, revealed did not complete a FCEF. She stated she did not receive any notification from nursing management that she failed to complete a fall event form or other documentation related to Resident #10's fall. Interview with the DHS, on 10/16/15 at 3:00 PM, revealed the nursing staff involved in the incident would complete an event form in the computer. She stated she had no memory or documented evidence that she or the IDT informed the nurse of the need to complete a fall event form. 5. Review of Resident #12's clinical record revealed the facility admitted the resident on 06/12/15 with [DIAGNOSES REDACTED]. Review of Resident #12's FCEF, dated 08/04/15 at 11:37 PM, revealed the resident sustained [REDACTED]. The form did not have seventy-two hours of reassessment documentation of the resident's response to treatments or the effectiveness of the interventions and the Interdisciplinary Team did not document a review regarding the established root cause, evaluation, thoroughness or effectiveness of the actions taken. On 10/15/15 at 2:45 AM, interview with Registered Nurse (RN) #4, revealed she was a new employee and felt uncomfortable with only having received five days of orientation and then was on her own. She stated the facility had just started the new Electronic Medical Record (EMR) and she was still learning how to navigate through the computerized medical record. She stated she had not looked at Resident #12's care plan and did not know where to locate it in the new EMR. She stated if the EMR was not complete she would not have the necessary information to meet the needs of the resident. On 10/27/15 at 11:30 AM, interview with the Assistant Director of Health Services (ADHS), revealed the Interdisciplinary Team reviewed events and determined what caused residents fall. He stated the team had not determined any other issues with the documentation or event investigation process in their review of Resident #12. He stated if the resident's medical record was not complete it would be difficult for staff that were unfamiliar with the resident to meet their needs. Interview with LPN #8, on 10/14/15 at 8:10 PM, revealed the new EMR system was difficult to navigate and she did not know where to locate certain resident information in the computer. She stated the new EMR system had been updated several times since going live in June of 2015; which made it more difficult to remember to document follow-up assessments after a resident event. She stated after an event occurred nursing must document on the resident for 72 hours. She stated the system used to prompt nursing to make follow up assessments and now it did not. She stated if you were unaware of an event then you would not know to perform a resident assessments. She stated a complete and up to date medical record was important for resident care. Interview with LPN #4 on, 10/08/15 at 2:25 PM, revealed the event forms had areas for her to click on, to add additional interventions for resident care; however, she did not know if the EMR automatically developed a plan of care or revised the resident's plan of care, when she clicked on additional interventions. She stated the Minimum Data Set nursing staff normally revised care plans sometime after the event. She stated if she instituted interventions for resident care she verbally told staff, but if they did not continue to tell other staff about the new interventions the information would not get forwarded to ensure resident care needs were met. She stated if the medical record did not contain assessments or pertinent resident information resident needs could not be met. Interview with the DHS, on 10/16/15 at 3:00 PM, revealed she did not know staff were not completing reassessment documentation or assessing for further injuries after an event according to facility policy. In addition, she stated the facility event forms had changed over time and used to have a section for documenting the root cause; however, that section was deleted. She stated if forms were not completed the medical record was not complete and the facility could not analyze data to determine if additional actions needed to be taken for the resident. She stated the Interdisciplinary Team (IDT) met every day, except on weekends and holidays, to discuss events that happened the previous day. She stated the IDT did not keep notes or documentation related to the discussion or decisions made during the review of the event. She stated it would be difficult to provide the necessary care and services to residents if the medical record did not contain all nursing assessments and pertinent documentation. The facility provided an acceptable Allegation of Compliance (AOC) on 10/22/15 and took the following actions to remove the Immediate Jeopardy on 10/23/15: 1. The facility conducted a review of the sixty-three (63) current residents' care plans from October 12-20, 2015 by the Minimum Data Set (MDS) nurses to ensure care plan interventions were current. Eight (8) care plans required revision. Change in condition (including falls) will be reviewed with care plan revision as needed during the Clinical Care Meeting. The Director of Health Services will be responsible for overseeing the meetings with follow up on events that have occurred within the last twenty-four (24) hours. Education was provided for the Interdisciplinary Team (Administrative Nurses, Social Services, Activities, Therapy Director, and MDS Nurses on 10/19/15 by the Assessment Support Nurse and the External Audit Nurse. 2. A Care Plan Audit tool was developed and will be used to ensure care plans are reviewed and revised during the Clinical Care Meeting (Monday-Friday) and weekend days by the Director of Health Services, Assistant Director of Health Services, or MDS Nurse. 3. A Profile Binder with current safety interventions (based on the care plan) for each resident was placed on each unit, on 10/21/15, for the nursing aides. The binders will be updated daily after the Clinical Care Meeting by the MDS or Medical Records. Audits will be completed daily. 4. Charge Nurses will round daily during the Medication Pass to observe for compliance with safety interventions according to the plan of care. Audits will be conducted on the first and second shift and Night Shift Nurses will conduct routine rounds that included observing for safety interventions for five (5) random residents. 5. Falls will be reviewed during the weekly Clinical at Risk meetings to ensure effective interventions are in place. Residents who sustained a fall will be followed in these meetings for four (4) weeks. 6. Safety Device Audits (five residents per day) will be conducted daily by department leaders, on random shifts, to ensure devices are in place and functioning. 7. An audit was conduct on 10/18/15 of each resident's medical record to ensure proper information related to Advance Directives were in the Soft file at each unit. Advance Directives information will be obtained at admission with appropriate papers signed and placed into the Soft File at each unit. This would include each resident's code status. 8. Education for the Executive Director, Medical Record Staff, Director of Health Services and her assistant, and Social Services were completed on 10/19/15, by the Clinical Director, of the importance of maintaining the integrity of medical record and Advance Directives information being available for Charge Nurses in the event of a resident was transferred to the hospital. 9. Scanning guidelines will be followed based on protocols for the Electronic Health Record. Daily audits will be conducted by the DHS, ADHS, MDS, and Medical Records to ensure completion of all admission records and Advance Directive information placed into the Soft Files. These audits will be reviewed during the daily Clinical Care Meeting. 10. A Quality Assurance (QA) Meeting was conducted on 09/18/15 to review Falls Trending. Another QA meeting was held on 10/19/15 with the Medical Director in attendance to review the Guidelines and protocol for conducting Quality Assurance Meetings. 11. Education was provided by the Clinical Director to the Executive Director, Director of Health Services and her assistant, and other department leaders that included issues of fall management, Advance Directives, and monitoring of care plans. Corrective plans were developed based on trends prevalent in a system not in compliance. Action plans developed with focus on goals and protocols for Clinical Care Meeting and its direct relationship to Quality Assurance activities. 12. Audits implemented will be reviewed during the monthly QA meeting and during the Clinical Support Nurse's routine visits that occur once a week. Audits included Safety Device, Advance Directive, and Soft files, Clinical Care Meetings, Clinical at Risk Meetings, Care Plans, and QA. The State Survey Agency (SSA) validated the implementation of the facility's AOC as follows: 1. Record review revealed Residents #5, #8, #10, #13, and #19 care plans were revised. Resident #20 was sampled during the extended survey due to being the only resident with a fall since the alleged Immediate Jeopardy abatement date of 10/23/15. The resident's care plan was reviewed during the Clinical Care Meeting and revised as needed. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, revealed the Interdisciplinary team received training on care plan revision and implementation. She stated she was responsible for overseeing the Clinical Care Meetings and ensured the care plan was revised and all events received follow-up monitoring to ensure the event reports were completed. In addition, she randomly reviewed one-two care plans daily to ensure completion. 2. Sampled Resident #20's fall (10/25/15) was discussed in the Clinical Care Meeting and revision of the care plan was completed. Review of the care plan audits revealed revision of the care plans were occurring after an event or change in the resident. Review of the sampled residents for the extended survey revealed the care plan had been revised after a change in the resident's status to include falls. 3. Observation of the 400, 500, and Health Care Units, on 10/27/15 at 11:30 AM and again at 4:00 PM, revealed Profile Binders at each unit that included specific information about each resident including code status. Observation on 10/27/15 at 4:35 PM, revealed staff updating the Profile Binder on the Healthcare Unit. Interview with the Medical Record Director, on 10/28/15 at 2:40 PM, validated the binders are updated after the Clinical Care Meetings with any new care plan interventions. The MDS Nurses were at a training offsite and unavailable for interview during the extended survey. 4. Observation, on 10/28/15 at 10:00 AM, (on the 500 Unit) revealed the nurse was conducting rounds in the residents rooms during the medication pass for safety devices and call light placement. Interviews with LPN #5, on 10/26/15 at 4:00 PM, LPN #12 on 10/27/15 at 11:15 AM, and LPN #6 on 10/28/15 at 9:00 AM, revealed the nurses conducted walking rounds to check for safety devices and call lights at the beginning of the work shift and again when they administered medications. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, revealed she had randomly observed walking rounds between the nursing aides and nurses giving report. Review of the safety devices/call light audits revealed at least five (5) residents were observed daily for safety device and call light placement and proper functioning of the devices. 5. Review of the Fall Circumstance Event Report for Resident #20, revealed the fall was discussed in the Clinical Care Meeting. Audits revealed Resident #20 was included. Interview with LPN #5, on 10/26/15 at 4:00 PM, revealed the resident slid from the bed and experienced no injury. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, Executive Director, on 10/28/15 at 3:00 PM, and Clinical Director, on 10/29/15 at 12:00 PM, revealed all falls and any change in condition were discussed during the Clinical Care Meetings. Review of the audits revealed the meetings were held on October 21, 22, 23, 26, and 27. A meeting was held on 10/28/15 at 10:00 AM and validated by observation of the SSA. Review of the Changes in condition, including fall investigation and root cause analysis will be discussed during the Clinical Care Meetings. The Fall Circumstance Event Reports are reviewed for completion and ensure appropriate safety interventions had been implemented to reduce the risk of future falls. 6. The facility reviewed all safety devices and conducted assessments with some safety devices discontinued. There were seven (7) residents with safety devices during the extended survey. Review of the audits revealed five (5) or more residents were audits to ensure safety devices were in place and functioning. 7. Review of the Soft Files for the 500, 400, and Health Care Units revealed each resident had been offered Advance Directives and each resident had a code status. These forms were scanned into the electronic record and the original signed form was kept in the Soft File at each unit. Interview with the Medical Record Director, on 10/28/15 at 2:40 PM, revealed she had received training on the Soft Files, scanning forms into the electronic record, and maintaining the medical record. She stated she was responsible for conducting audits of new admission paperwork to ensure the code status and Advance Directive forms are signed and placed into the Soft file on each unit. Observation of the new admission process revealed Advance Directive forms were signed and placed into the soft file. Resident #21, #22, and #23 were sampled during the extended survey to validate the admission paperwork was completed and Advance Directive forms signed and placed into the Soft file. 8. Review of the training record revealed education was provided on 10/19/15 as stated in the AOC. Interview with the Medical Records, on 10/28/15 at 2:40 PM, Director of Health Services, on 10/28/15 at 1:50 PM, and Social Services on 10/28/15 at 2:48 PM, revealed they had received the training. 9. Interview with the Medical Record Director, on 10/28/15 at 2:40 PM, revealed she received training on the scanning guidelines. She stated she now had additional staff to help with the scanning of the medical record into the electronic record. She stated audits were conducted daily to ensure scanning guidelines are followed. Review of the Daily Careplan audit forms, Falls Interventions audit forms, Call Light audit forms, Fall Investigation audit forms, the Safety/Assistive Device audit forms, and the Admission audit forms revealed they were all completed. 10. Review of the QA signature sheets revealed QA meetings were held on 10/19/15 and 10/29/15. Interview with the Executive Director, on 10/28/15 at 3:00 PM, and the Clinical Director on 10/29/15 at 12:00 PM validated the QA meetings were held on those dates. Interview with the Clinical Director and the Clinical Support Nurse, on 10/29/15 at 12:00 PM, revealed the QA meeting on 10/19/15 was to develop the Plan of Action to correct the Immediate Jeopardy, develop audits, and capture any trends of non-compliance. The Clinical Director stated staffing was reviewed to determine if it contributed to the non-compliance and she was looking at staffing as part of the solution. She stated the facility had been given extra hours for staffing and was in the process of determining where the hours would be best spent. The Clinical Director stated the QA meeting of 10/29/15 was to review audits, and evaluate the plans of actions. She stated the audits revealed no problems and the AOC was implemented and monitored as stated. She stated the facility would continue to meet monthly and she would be at the facility almost daily to assist the new Executive Director and ensure compliance. The Clinical Support Nurse stated she would visit the facility at least twice a week and as needed to ensure the Clinical Care and Clinical at Risk meetings were conducted according to the AOC. The Clinical Director stated she would attend the monthly QA meetings for at least six (6) consecutive months. 11. Interview with the Clinical Director, on 10/29/15 at 12:00 PM, revealed she provided the education to the Executive Director and Director of Health Services on 10/19/15. Review of the training records validated the training. Interview with the Executive Director and Director of Health Services on 10/29/15 at 12:15 PM, revealed they received training on Advanced Directives, revision of care plans, documentation, audits, monitoring, scanning guidelines, systems related to falls, and the protocols for Quality Assurance. 12. Review of the audits revealed the facility conducted the audits as stated in the AOC. Interview with the Executive Director, on 10/28/15 at 3:00 PM, and the Clinical Director, on 10/29/15 at 12:00 PM, revealed the audits were conducted and forwarded to them for review of compliance. The audits were brought to the 10/29/15 QA meeting to review and discuss trending.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the Quality Assurance (QA) Committee investigated and developed plans of action in response to identified problems. The facility failed to provide the assessed needs of its residents and failed to maintain a safe environment. Interviews with the Management staff and QA members revealed they were aware of the facility's numerous falls with significant injures. However, they failed to develop a plan of action to meet residents fall risk needs to ensure their safety. This failure affected five (5) of twenty-five (25) sampled residents and had the potential to affect more residents of the facility relative to the system for ensuring that residents received the required supervision of care and services to maintain their safety and well-being. (Refer to F280, F282, F323 and F514) On 09/07/15, Resident #1 sustained an unwitnessed fall that resulted in injury and transfer to the hospital. Review of the emergency room record, dated 09/07/15, revealed the resident sustained [REDACTED]. Review of the Death Summary, dated 09/07/15, revealed the resident passed, thirteen (13) hours after the fall on 09/07/15, due to the injuries sustained from the fall which led to [MEDICAL CONDITION]. Staff stated they were busy off the unit or tending to other residents on another hall when Resident #1 fell . Additional interview with staff revealed the bed alarm unit was not turned on and the resident's call light was not within reach at the time of Resident #1's fall. On 09/26/15 Resident #8 sustained an unwitnessed fall with injury. The staff heard the resident yelling for help, went to investigate and found the resident on the floor. The resident sustained [REDACTED]. Review of the Radiology Report, dated 09/26/15, revealed Resident #8 had a right non-displaced lateral 8th rib fracture. On 09/30/15 Resident #10 sustained an unwitnessed fall. The staff found the resident on the floor complaining of back pain. The resident told the staff he/she had attempted to get to their walker; however, the walker tipped over and the resident fell . Emergency Medical Services was called and transferred the resident to the hospital. Hospital x-ray results revealed a [MEDICATION NAME] compression fracture at T9 (9th vertebra). The resident continued to have severe pain and muscle spasms and a back brace was ordered. On 09/09/15 Resident #9 sustained an unwitnessed fall. The resident was found on the floor by the resident's son. The resident's right foot was bleeding and the resident continued to be extremely confused. The resident's bed alarm was noted on the floor and non-functioning with a tear in the wiring. The family transported the resident to the hospital for evaluation and the resident required ten (10) sutures to the right foot, underneath and between the fourth and fifth toes. The hospital X-ray results revealed a closed non-displaced [MEDICATION NAME] fifth metatarsal. On 08/04/15 Resident #12 sustained an unwitnessed fall with injury. The resident reported he/she tried to get up from the potty chair and fell . The resident had swelling and an abrasion with bleeding to the nose. The Event Report revealed there were no possible contributing factors present at the time of the fall. The resident returned from the hospital with a [DIAGNOSES REDACTED]. The facility's failure to have an effective system in place, to ensure the facility implemented quality assurance activities that ensured resident needs were met, has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was determined to exist on 09/07/15. The facility provided an acceptable Allegation of Compliance (AOC) on 10/22/15 which alleged removal of the Immediate Jeopardy on 10/23/15. The State Survey Agency verified Immediate Jeopardy was removed on 10/23/15 as alleged prior to exit on 10/29/15. The scope and severity was lowered to an E at F520, while the facility implements and monitors the Plan of Correction for the effectiveness of systemic changes and quality assurance. The findings include: Review of the facility's policy related to Guidelines for the Quality Assessment and Assurance Process, not dated, revealed the purpose was to provide continuous evaluation of campus systems to distinguish between isolated, pattern or system concerns, ensure systems were functioning appropriately, to prevent problems from arising to the extent possible, recognize incremental change that may be early signs of potential/future problems, and correct identified issues. The primary purposes of the Quality Assessment and Assurance Plan would be to establish and provide a system whereby a specific process, and the documentation relative to it, would be maintained to support evidence of an ongoing Quality Assessment and Assurance Program, encompassing all aspects of resident care including safety, infection control, and quality of life applicable to campus residents. To develop a plan of correction and evaluate corrective actions taken to obtain the desired results. To provide a centralized, coordinated approach to quality assessment and assurance activities so as to bring about comprehensive program of quality assessment and assurance to meet the needs of the facility. Review, on 10/5/15 at 11:00 AM, of the QA signature sheets revealed the facility conducted QA meetings at least monthly with the required members. Interview with the Medical Director, on 10/16/15 at 12:40 PM, revealed the QA Committee had identified there were fifty-six resident falls from 07/01/15 to 10/01/15. The Medical Director stated the facility had resident's with higher than normal healthcare needs because of their need for rehabilitation after recent hospitalization s. He stated the facility needed to be more vigilant in providing resident care and safety, in order to meet these types of resident needs. He stated the QA Committee determined several residents had sustained significant injuries from their falls and the QA Committee determined the facility also had a staffing issue. He stated the only action plan put in place by the committee, to his knowledge, was to address the staffing issue; however, he did not know if the facility had increased staffing or not. He stated the new Electronic Medical Record also played a huge role in the problems the facility experienced. He stated the role of the QA committee was to improve identified quality issues. Interview with the Director of Health Services (DHS), on 10/16/15 at 11:30 AM, revealed she was aware some residents were missing fall event reports. The DHS stated the nursing management team was responsible for monitoring event reports for completion. The DHS stated when a nurse failed to complete an order the nurse was given a reminder paper to review the area of concern; the process was called the Continuous Quality Improvement (CQI) process. However, the facility did not keep a record of this process and she could not remember the staff that might have received these reminders. She stated she did not know of an action plan put in place by the QA Committee that addressed quality deficiencies related to falls or documentation issues. She stated the QA process was an important role in the facility to ensure resident's needs were met. Interview with the Director of Clinical Support and the Executive Director, on 10/16/15 at 10:45 AM, revealed the QA Committee met monthly to discuss QA issues. They stated no action plan was developed related to falls; however, a plan should have been developed to ensure resident safety. They stated the Interdisciplinary Team (IDT) should have been monitoring the electronic medical record documentation to determine if staff had not completed Event Reports and resident reassessments, in addition to determining the root cause of the events. They stated it was also the role of the DHS to monitor and address any identified concerns. They stated prior to the survey process beginning they had not identified any issues with the QA system process conducted by the IDT or the DHS. They stated prior to the survey process neither had provided direction or guidance to the facility staff in regards to improving the quality processes, related to falls, care planning, or documentation. The facility provided an acceptable Allegation of Compliance (AOC) on 10/22/15 and took the following actions to remove the Immediate Jeopardy on 10/23/15: 1. The facility conducted a review of the sixty-three (63) current residents' care plans from October 12-20, 2015 by the Minimum Data Set (MDS) nurses to ensure care plan interventions were current. Eight (8) care plans required revision. Change in condition (including falls) will be reviewed with care plan revision as needed during the Clinical Care Meeting. The Director of Health Services will be responsible for overseeing the meetings with follow up on events that have occurred within the last twenty-four (24) hours. Education was provided for the Interdisciplinary Team (Administrative Nurses, Social Services, Activities, Therapy Director, and MDS Nurses on 10/19/15 by the Assessment Support Nurse and the External Audit Nurse. 2. A Care Plan Audit tool was developed and will be used to ensure care plans are reviewed and revised during the Clinical Care Meeting (Monday-Friday) and weekend days by the Director of Health Services, Assistant Director of Health Services, or MDS Nurse. 3. A Profile binder with current safety interventions (based on the care plan) for each resident was placed on each unit, on 10/21/15, for the nursing aides. The binders will be updated daily after the Clinical Care Meeting by the MDS or Medical Records. Audits will be completed daily. 4. Charge Nurses will round daily during the Medication Pass to observe for compliance with safety interventions according to the plan of care. Audits will be conducted on the first and second shift and Night Shift Nurses will conduct routine rounds that included observing for safety interventions for five (5) random residents. 5. Falls will be reviewed during the weekly Clinical at Risk meetings to ensure effective interventions are in place. Residents who sustained a fall will be followed in these meetings for four (4) weeks. 6. Safety Device Audits (five residents per day) will be conducted daily by department leaders, on random shifts, to ensure devices are in place and functioning. 7. An audit was conduct on 10/18/15 of each resident's medical record to ensure proper information related to Advance Directives were in the Soft file at each unit. Advance Directives information will be obtained at admission with appropriate papers signed and placed into the Soft File at each unit. This would include each resident's code status. 8. Education for the Executive Director, Medical Record Staff, Director of Health Services and her assistant, and Social Services were completed on 10/19/15, by the Clinical Director, of the importance of maintaining the integrity of medical record and Advance Directives information being available for Charge Nurses in the event of a resident was transferred to the hospital. 9. Scanning guidelines will be followed based on protocols for the Electronic Health Record. Daily audits will be conducted by the DHS, ADHS, MDS, and Medical Records to ensure completion of all admission records and Advance Directive information placed into the Soft Files. These audits will be reviewed during the daily Clinical Care Meeting. 10. A QA Meeting was conducted on 09/18/15 to review Falls Trending. Another QA meeting was held on 10/19/15 with the Medical Director in attendance to review the Guidelines and protocol for conducting Quality Assurance Meetings. 11. Education was provided by the Clinical Director to the Executive Director, Director of Health Services and her assistant, and other department leaders that included issues of fall management, Advance Directives, and monitoring of care plans. Corrective plans were developed based on trends prevalent in a system not in compliance. Action plans developed with focus on goals and protocols for Clinical Care Meeting and its direct relationship to Quality Assurance activities. 12. Audits implemented will be reviewed during the monthly QA meeting and during the Clinical Support Nurse's routine visits that occur once a week. Audits included Safety Device, Advance Directive, and Soft files, Clinical Care Meetings, Clinical at Risk Meetings, Care Plans, and QA. The State Survey Agency (SSA) validated the implementation of the facility's AOC as follows: 1. Record review revealed Residents #5, #8, #10, #13, and #19 care plans were revised. Resident #20 was sampled during the extended survey due to being the only resident with a fall since the alleged Immediate Jeopardy abatement date of 10/23/15. The resident's care plan was reviewed during the Clinical Care Meeting and revised as needed. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, revealed the Interdisciplinary team received training on care plan revision and implementation. She stated she was responsible for overseeing the Clinical Care Meetings and ensured the care plan was revised and all events received follow-up monitoring to ensure the event reports were completed. In addition, she randomly reviewed one-two care plans daily to ensure completion. 2. Sampled Resident #20's fall (10/25/15) was discussed in the Clinical Care Meeting and revision of the care plan was completed. Review of the care plan audits revealed revision of the care plans were occurring after an event or change in the resident. Review of the sampled residents for the extended survey revealed the care plan had been revised after a change in the resident's status to include falls. 3. Observation of the 400, 500, and Health Care Units, on 10/27/15 at 11:30 AM and again at 4:00 PM, revealed Profile Binders at each unit that included specific information about each resident including code status. Observation on 10/27/15 at 4:35 PM, revealed staff updating the Profile Binder on the Healthcare Unit. Interview with the Medical Record Director, on 10/28/15 at 2:40 PM, validated the binders are updated after the Clinical Care Meetings with any new care plan interventions. The MDS Nurses were at a training offsite and unavailable for interview during the extended survey. 4. Observation, on 10/28/15 at 10:00 AM, (on the 500 Unit) revealed the nurse was conducting rounds in the residents rooms during the medication pass for safety devices and call light placement. Interviews with LPN #5, on 10/26/15 at 4:00 PM, LPN #12 on 10/27/15 at 11:15 AM, and LPN #6 on 10/28/15 at 9:00 AM, revealed the nurses conducted walking rounds to check for safety devices and call lights at the beginning of the work shift and again when they administered medications. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, revealed she had randomly observed walking rounds between the nursing aides and nurses giving report. Review of the safety devices/call light audits revealed at least five (5) residents were observed daily for safety device and call light placement and proper functioning of the devices. 5. Review of the Fall Circumstance Event Report for Resident #20, revealed the fall was discussed in the Clinical Care Meeting. Audits revealed Resident #20 was included. Interview with LPN #5, on 10/26/15 at 4:00 PM, revealed the resident slid from the bed and experienced no injury. Interview with the Director of Health Services, on 10/28/15 at 1:50 PM, Executive Director, on 10/28/15 at 3:00 PM, and Clinical Director, on 10/29/15 at 12:00 PM, revealed all falls and any change in condition were discussed during the Clinical Care Meetings. Review of the audits revealed the meetings were held on October 21, 22, 23, 26, and 27. A meeting was held on 10/28/15 at 10:00 AM and validated by observation of the SSA. Review of the changes in condition, including fall investigation and root cause analysis will be discussed during the Clinical Care Meetings. The Fall Circumstance Event Reports are reviewed for completion and ensure appropriate safety interventions had been implemented to reduce the risk of future falls. 6. The facility reviewed all safety devices and conducted assessments with some safety devices discontinued. There were seven (7) residents with safety devices during the extended survey. Review of the audits revealed five (5) or more residents were audits to ensure safety devices were in place and functioning. 7. Review of the Soft files for the 500, 400, and Health Care Units revealed each resident had been offered Advance Directives and each resident had a code status. These forms were scanned into the electronic record and the original signed form was kept in the Soft File at each unit. Interview with the Medical Record Director, on 10/28/15 at 2:40 PM, revealed she had received training on the Soft Files, scanning forms into the electronic record, and maintaining the medical record. She stated she was responsible for conducting audits of new admission paperwork to ensure the code status and Advance Directive forms are signed and placed into the Soft file on each unit. Observation of the new admission process revealed Advance Directive forms were signed and placed into the soft file. Resident #21, #22, and #23 were sampled during the extended survey to validate the admission paperwork was completed and Advance Directive forms signed and placed into the Soft file. 8. Review of the training record revealed education was provided on 10/19/15 as stated in the AOC. Interview with the Medical Records, on 10/28/15 at 2:40 PM, Director of Health Services, on 10/28/15 at 1:50 PM, and Social Services on 10/28/15 at 2:48 PM, revealed they had received the training. 9. Interview with the Medical Record Director, on 10/28/15 at 2:40 PM, revealed she received training on the scanning guidelines. She stated she now had additional staff to help with the scanning of the medical record into the electronic record. She stated audits were conducted daily to ensure scanning guidelines are followed. Review of the Daily Care Plan Audit forms, Falls Interventions audit forms, Call Light audit forms, Fall Investigation audit forms, the Safety/Assistive Device Audit forms, and the Admission audit forms revealed they were all completed. 10. Review of the QA signature sheets revealed QA meetings were held on 10/19/15 and 10/29/15. Interview with the Executive Director, on 10/28/15 at 3:00 PM, and the Clinical Director on 10/29/15 at 12:00 PM validated the QA meetings were held on those dates. Interview with the Clinical Director and the Clinical Support Nurse, on 10/29/15 at 12:00 PM, revealed the QA meeting on 10/19/15 was to develop the Plan of Action to correct the Immediate Jeopardy, develop audits, and capture any trends of non-compliance. The Clinical Director stated staffing was reviewed to determine if it contributed to the non-compliance and she was looking at staffing as part of the solution. She stated the facility had been given extra hours for staffing and was in the process of determining where the hours would be best spent. The Clinical Director stated the QA meeting of 10/29/15 was to review audits, and evaluate the plans of actions. She stated the audits revealed no problems and the AOC was implemented and monitored as stated. She stated the facility would continue to meet monthly and she would be at the facility almost daily to assist the new Executive Director and ensure compliance. The Clinical Support Nurse stated she would visit the facility at least twice a week and as needed to ensure the Clinical Care and Clinical at Risk meetings were conducted according to the AOC. The Clinical Director stated she would attend the monthly QA meetings for at least six (6) consecutive months. 11. Interview with the Clinical Director, on 10/29/15 at 12:00 PM, revealed she provided the education to the Executive Director and Director of Health Services on 10/19/15. Review of the training records validated the training. Interview with the Executive Director and Director of Health Services on 10/29/15 at 12:15 PM, revealed they received training on Advanced Directives, revision of care plans, documentation, audits, monitoring, scanning guidelines, systems related to falls, and the protocols for Quality Assurance. 12. Review of the audits revealed the facility conducted the audits as stated in the AOC. Interview with the Executive Director, on 10/28/15 at 3:00 PM, and the Clinical Director, on 10/29/15 at 12:00 PM, revealed the audits were conducted and forwarded to them for review of compliance. The audits were brought to the 10/29/15 QA meeting to review and discuss trending.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to have an effective system to ensure the comprehensive care plans were reviewed and revised to address the placement and function of a WanderGuard device for two (2) of nine (9) sampled residents (Resident #1 and #2). The facility failed to revise the care plans for Resident #1 and Resident #2 to ensure the resident's safety needs were met. On 02/17/13, the facility readmitted Resident #1, with multiple [DIAGNOSES REDACTED]. The facility obtained a physician's orders [REDACTED]. On 08/29/13, between 6:00 PM and 6:40 PM, Resident #1 exited the facility without staff knowledge. Interview revealed a visitor found Resident #1 alone in a wheelchair, self-propelling down the facility's driveway path, and notified a staff member that the resident was outside in the hot sun. Review of the National Weather Service archive temperature log revealed the afternoon high temperature on 08/29/13 was 94 degrees Fahrenheit. Interview with the staff revealed the resident's WanderGuard did not function when the resident was returned to the facility. Interview and record review revealed the WanderGuard battery life was 90-days and the resident's WanderGuard should have been changed on 07/25/13. The facility was unable to provide evidence that they had a system to monitor and replace the resident's WanderGuard after the ninety (90) days prior to Resident #1's elopement. Review of Resident #1's care plan revealed a replacement date of 05/01/13 for the WanderGuard and the care plan had not been revised to replace the WanderGuard in July per the 90-day battery life. Record review revealed Resident #2's comprehensive care plan was not revised for wandering, for monitoring the function of the WanderGuard, or the life of the WanderGuard's battery after WanderGuard placement. The facility's failure to ensure the care plan was reviewed and revised, placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment or death to a resident. The facility was notified of the Immediate Jeopardy on 09/05/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 09/10/13 alleging Immediate Jeopardy was removed on 09/07/13. Immediate Jeopardy was verified to be removed on 09/07/13 as alleged, prior to exit on 09/11/13 with remaining non-compliance at 42 CFR 483.20 Resident Assessment F280 with the scope and severity lowered to a "D", while the facility develops and implements the quality assurance measures to establish and maintain an effective system to ensure residents receive care according to the plan of care. The findings include: Review of the facility's policy, Clinical Documentation System, undated, revealed the interdisciplinary team (IDT) would plan the resident's care and treatment to ensure appropriateness of service to meet the resident's needs. Review of the Assessment, Review, and Consideration policy, undated, revealed the purpose was to recognize risk factors identified upon admission during the nursing assessment and to provide interventions that impact the resident's condition. The team would care plan the risk factors with specific individualized interventions. Review of the facility's policy, Elopement Risk Reduction, undated, revealed the purpose was to implement preventive interventions in the comprehensive care plan to address the potential for elopement. Review of the manufacture's WanderGuard Departure Alert System, User Instruction/Manual for 90 day and one (1) year Signaling Device, revealed the date imprinted on the back of the WanderGuard device was the last date the device could be activated to permit approximately 90-days of use. Review of the WanderGuard Departure Alert System Manual pages 30 and 32 (section 4) revealed the signaling device should be tested and results recorded in the resident's records. 1. Review of the facility's investigation dated 08/30/13, revealed on 08/29/13 Resident #1 exited the front door at the Health Center entrance. The resident was returned to the facility and was assessed with [REDACTED]. The root cause was determined to be the WanderGuard device was not functioning. Review of the clinical record for Resident #1 revealed the facility readmitted the resident on 02/17/13, with multiple [DIAGNOSES REDACTED].#1 as an elopement risk. On admission the facility assessed Resident #1 as cognitively impaired and at risk for elopement. A comprehensive care plan was developed on 03/01/13 addressing wandering. The interventions included: personal pressure alarm and a WanderGuard; to monitor the resident's whereabouts. On 03/24/13 an intervention was added for a WanderGuard in place and functional, and to replace the resident's WanderGuard on 05/01/13. The goal for the resident's wandering care plan stated the resident would have no unplanned exits or elopements. Review of the Treatment Record dated for 05/01/13 through 05/31/13 revealed a handwritten notation to replace the WanderGuard on 07/25/13 as an "FYI". However, there was no evidence the resident's plan of care was revised to include the 07/25/13 date. Phone interview, with Registered Nurse (RN) # 3, on 09/05/13 at 11:25 AM, revealed the care plan was used to detail the resident's needs. She stated the care plan should reflect the resident's current status. RN #3 continued to state the care plan and the TAR should reflect the same information regarding the date a WanderGuard would be changed. The TAR was where the nurses initialed/dated that the WanderGuard had been checked for placement and function. However, prior to the elopement she was unsure if changing the resident's WanderGuard was completed and was not aware if a change date was on the care plan. She further offered if the clinical record didn't show the WanderGuard was replaced as ordered, then the resident's safety could be compromised. Interview, on 09/05/13 at 1:30 PM, with RN #4 revealed the care plan directed staff on how to provide care. She stated she provided care to Resident #1 often and she did not recall ever changing the resident's WanderGuard and was not aware of any date on the care plan to change the WanderGuard. She stated if the care plan interventions for the WanderGuard were not followed the resident's safety would be in danger. Phone interview, on 09/05/13 at 2:00 PM, with License Practical Nurse (LPN) #2 revealed the care plan was used to inform staff of a resident's care needs. However, she stated the TAR and MAR indicated [REDACTED]. She further stated if the care plan was not revised or the TAR was not accurate to reflect the current care the resident's needs then the care could be altered. Interview, on 09/05/13 at 2:40 PM, with RN #2 the Minimum Data Set (MDS) Coordinator revealed being notified of Resident #1's elopement. She stated the resident's WanderGuard did not function at the time of the elopement. The MDS Coordinator reviewed the resident's care plan and verified the care plan had not been revised to replace the WanderGuard and there was no evidence the WanderGuard was changed on 07/25/13. The MDS Coordinator stated the nurse placed telephone orders on the TAR and 24-hour report sheet, then the DON or ADON transcribes the information to the care plan. The MDS department along with the IDT were responsible to ensure the care plan remained accurate and the nurses were responsible for following the care plan. However, she was not aware of a WanderGuard change date on the care plan. 2. Observation, on 09/04/13 during initial tour of the facility at 11:35 AM, revealed Resident #2 sitting in his/her room in the wheelchair with a WanderGuard device fastened to the right ankle. Review of the clinical record for Resident #2, revealed the facility admitted the resident on 03/24/07, with multiple [DIAGNOSES REDACTED]. The resident had a WanderGuard applied. However, review of the comprehensive care plan revealed no interventions to monitor placement or function of the WanderGuard. Continued review of the record revealed the Treatment Administration Record (TAR) from 03/01/13 through 08/29/13 revealed no monitoring system to verify placement or function of the WanderGuard. Interview, with Certified Resident Care Assistant (CRCA) #1, on 09/04/13 at 2:00 PM, revealed she cared for Resident #2 often. She stated the resident had a WanderGuard for a long time; over a year. She continued to state the nurses were responsible to ensure the WanderGuard was working. Interview, on 09/05/13 at 3:05 PM with Registered Nurse #2 the Minimum Data Set (MDS) Coordinator, revealed Resident #2's care plan did not indicate the WanderGuard would be checked for placement/functioning. The MDS Coordinator stated the lack of revision was from consistent oversight because the resident had always had the WanderGuard and staff assumed they knew what the care needs were. Further interview revealed neither the clinical record or the care plan provided any evidence the care plan was revised to reflect the safety monitoring of the WanderGaurd. She further stated the record did not reflect when the WanderGuard was implemented or when the WanderGuard needed to be changed. She stated the purpose of the care plan was to guide staff on the needed care of the resident, and without an accurate care plan, the resident's care needs may not be met. Interview, on 09/05/13 at 1:30 PM, with RN #4 revealed she provided care to Resident #2 often. She further stated the resident's WanderGuard was probably checked out of habit. However, if the care plan interventions for the WanderGuard were not revised the resident's safety would be in danger. Phone interview with RN #3, on 09/05/13 at 11:25 AM, revealed on 08/29/13 when the resident's WanderGuard was assessed for functioning the device did not function. She further offered the care plan didn't show the WanderGuard was to be check and that the resident's safety could be compromised. Interview, on 09/11/13 at 4:10 PM, with the Executive Director (ED) and the Director Health Services, revealed the care plan was the tool used to inform staff of the resident's needed care and services. The MDS staff was responsible to update, revise, and develop the care plan as needed. Review of the acceptable Allegation of Compliance (AOC), dated 09/10/13, revealed the facility took the following actions: 1. Resident #1 was returned to the 200 Unit and was assessed on 08/29/13 and found no injury was sustained. Resident #1 was placed on every 15 minute checks to increase supervision. The Care Plan of Resident #1 was updated by the Clinical Support nurse on 08/29/13 identifying elopement risk and application of a new WanderGuard. 2. All exit doors in the facility were checked for function on 08/29/13 and found to be in working order by the Director of Plant Operations. 3. Resident #2, and #3 had WanderGuard devices changed on 08/29/13 based on risk assessments. Systematically the facility will use one year WanderGuards instead of 90-day devices. Staff Development education on the differences of the devices was completed on 09/06/13. 4. The facility initiated an investigation on 08/29/13 of the elopement and concluded on 08/30/13 with notification to the Office of Inspector General on 08/30/13 and a five day report on 09/04/13. 5. All residents were reassessed for elopement potential on 09/05/13. All applicable care plans were updated to include wandering behavior. One resident (Resident #5 who was a new admit) was identified as at risk for elopement with the care plan revised to reflect this. 6. The Elopement binders were reviewed by the Assistant Director Health Services on 08/30/13 and were placed at all the Nurses Station and Business Office and Reception Desk (Resident #1, #2, #3, and #5). The facility verified the Treatment Administration Record (TAR) to reflect the current status of the resident and current orders with change dates for the devices. 7. Staff education initiated by Staff Development Nurse on 08/29/13 and completed on 09/06/13. Staff Education included elopement, WanderGuard including the one (1) year device, alarm and missing residents policies. 8. An Elopement Drill was conducted, on 09/05/13 at 6:15 PM, by the Director of Plant Operations. 9. A QA monitoring tool was implemented on 09/05/13 which included review of alarms and Care Plan development. These audit would be completed by the MDS nurse and Nurse Managers. Then the Director of Health Services and Assistant Director of Health Services would complete this audit weekly times 60 days and then monthly times 90 days. All audits would be reviewed during the Quality Assurance Meeting monthly. 10. A QA meeting was held on 09/06/13 that included the Medical Director with discussion of the Immediate Jeopardy, elopement and behavioral changes. The State Survey Agency (SSA) validated the AOC on 09/11/13 as follows: 1. Review of the care plan and the every 15 minute checks for Resident #1 revealed they were completed and updated. 2. Observation, on 09/11/13 at 1:40 PM -1:50 PM of the main entrance door revealed Residents #1, #2, #3 and #5 all had WanderGuards. The facility's main door activated the alarm and locked the door with each resident. Observation, on 09/11/13 at 1:20 PM, of RN #6 revealed she placed the tester 2'' above Resident #3's WanderGuard and the tester flashed green. 3. The SSA validated through observation that all residents who utilized a WanderGuard had the new WanderGuard with a one year battery life. Observation during the extended survey, on 09/11/13 at 9:20 AM - 9:30 AM, revealed the residents currently assessed to be an elopement risk ( Resident #1, #2, #3 and #5) had a WanderGuard applied. Each device was imprinted with Do Not Use past 09/29/14. Interview, on 09/11/13 at 1:25 PM, with RN #6 revealed the writing indicated the day the facility applied the one year WanderGuard plus one year to indicate the date it was to be changed. The RN continued to state the TAR would also have the date the device was applied. She further stated they do not use past date indicated when the manufacturer designated the battery was no longer functional. Interview, on 09/11/13 at 2:40 PM with LPN #1 (Medical Records) revealed all 90-day WanderGuards were removed from stock on 09/06/13 when the one year devices were stocked. 4. Review of the facility's investigation revealed the completion of the investigation on 08/30/13. 5. Review of the audit for reassessment of all residents revealed the audit identified one new resident (Resident #5) as a new resident with a potential for elopement and the care plan was updated to reflect that risk. Observation revealed one resident who was found to be at risk for elopement, had a WanderGuard bracelet applied and was working properly. This was validated through observation of the tester and door alarm. Through record review of four recent admissions since 09/07/13 - 09/11/13 found elopement risk assessments were performed and found not to be at risk. In addition, the SSA validated re-assessments of all residents were completed on 09/05/13. 6. Review of the elopement binders revealed they were located in the Business Office, the Skilled Unit, the 400 Unit and the 500 Unit. The binders contained resident information and pictures of the four residents identified as at risk for elopement. 7. The State Agency validated through record review and evidence of education provided to staff which included policies for: elopement, alarm checks, missing residents, WanderGuards and care plan development completed on 09/06/13. Interview with CRCA #6, on 09/10/13 at 5:05 PM, CRCA #7, on 09/10/13 at 5:10 PM, CRCA #8, on 09/11/13 at 1:40 PM, RN #7, on 09/10/13 at 4:40 PM, RN #6, on 09/11/13 at 9:30 AM, LPN #4, on 09/10/13 at 5:00 PM, LPN #3, on 09/11/13 at 9:10 AM, LPN #5, on 09/11/13 at 12:20 PM, Housekeeper #8, on 09/11/13 at 8:59 AM, and Dietary Director, on 09/11/13 at 8:50 AM revealed all staff members were trained and knowledgeable on the elopement policy. The RNs and LPNs revealed knowledge of the WanderGuard 1 year procedure. 8. Review of the elopement drill and sign sheets, dated 09/05/13 at 6:15 PM by the Director of Plant Operations. 9. Review of the QA monitoring tool revealed the tool was initiated and completed on 09/05/13 by the MDS nurse. 10. Interview with the Medical Director, on 09/11/13 at 2:20 PM, and record review of the sign sheet revealed the facility conducted a Quality Assurance meeting with the Medical Director on 09/06/13. The facility notified him on 08/29/13 between 6 PM - 7 PM of the elopement. He stated he was present at the facility during the Quality Assurance Meeting on 09/05/13. He further stated no concerns with the facility's elopement policy, but staff needed to follow the policy.

Based on observation, interview, record review, and review of facility policy and manufacturer guidelines it was determined the facility failed to have an effective system to provide adequate supervision to prevent accidents for one (1) of nine (9) sampled residents. (Resident #1) The facility failed to follow their Elopement Risk Reduction Policy/Alarm Check Policy. On [DATE], the facility readmitted Resident #1, with multiple [DIAGNOSES REDACTED]. The facility obtained a physician's orders [REDACTED]. On [DATE], between 6:00 PM and 6:40 PM, Resident #1 exited the facility without staff knowledge. Interview revealed a visitor found Resident #1 alone in a wheelchair, self-propelling down the facility's driveway path, and notified a staff member that the resident was outside in the hot sun. Review of the National Weather Service archive temperature log revealed the afternoon high temperature on [DATE] was 94 degrees Fahrenheit. Interview with the staff revealed the resident's WanderGuard did not function when the resident was returned to the facility. Interview and record review revealed the WanderGuard battery life was 90-days and the resident's WanderGuard should have been changed on [DATE]. The facility was unable to provide evidence that they had a system to monitor and replace the resident's WanderGuard after the ninety (90) days prior to Resident #1's elopement. The facility was notified on the Immediate Jeopardy on [DATE]. The facility provided an acceptable credible Allegation of Compliance (AOC) on [DATE] alleging Immediate Jeopardy was removed on [DATE]. Immediate Jeopardy was verified to be removed on [DATE] as alleged, prior to exit on [DATE] with remaining non-compliance at 42 CFR 483.25 Quality of Care F323 with the scope and severity lowered to a "D", while the facility develops and implements quality assurance measures to establish and maintain an effective system to ensure residents receive adequate supervision to prevent accidents. The findings include: Review of the facility's Elopement Risk Reduction/Alarm Check policies (revised [DATE]) revealed the purpose was to prevent elopements by appropriately observing resident patterns, and to implement preventive interventions. The facility's procedure to prevent elopement was to place a WanderGuard bracelet on the resident and the alarms would be activated at all times. The alarm checks would ensure the resident's WanderGuard and door alarms were properly functioning. The batteries should be scheduled for replacement on a routine basis, and alarms should be replaced per the manufacturer's recommendations. Review of the manufacturer's WanderGuard Departure Alert System, User Instruction/Manual for 90-day and one (1) year Signaling Device, revealed the date imprinted on the back of the WanderGuard device was the last date the device could be activated to permit approximately 90-days of use. The date would include the month, day, and year. Review of the WanderGuard Departure Alert System Manual, pages 30 and 32, revealed the reasons a device would fail were the signaling device would be inoperable if beyond the 90-days and poorly trained staff. The manufacturer's instructions revealed the signaling device should be tested and results recorded in the residents' records; and all staff members involved in the care of wanderers should read and understand all of the information contained within the manual, particularly the warnings and cautions. In addition, staff should develop and carry out a Wanderer Management Protocol that outlined correct procedures and assigned staff responsibilities. The manufacturer provided a WanderGuard Protocol Guide (in the WanderGuard E Program Manual) to assist the facility in developing the Wanderer Management Protocol Guide. Failure to comply with the manufacturers warning could result in injury or death to a resident. Review of the Exit Seeking Circumstance, Assessment, and Intervention record revealed Resident #1 successfully exited the building without staff knowledge on [DATE]. The resident was found by a visitor and notified staff. The resident was located by staff at 6:20 PM in the front parking lot. The assessment form further stated the exit was not witnessed by anyone. The resident had a WanderGuard on and it was not functioning, as well as, the door did not alarm. The assessment form further stated the resident had impaired safety judgement; had a history of [REDACTED]. The Interdisciplinary Team (IDT) reviewed the assessment determinations and indicated they agreed on [DATE]. The assessment form included a 72 hour follow-up dated [DATE], 10p-6a, that indicated the resident had no episodes of exit seeking, exit prevention interventions were in place and effective, and WanderGuard was changed, tested and did sound the alarm, as well as, lock the door. Review revealed this was the only follow-up documented. Review of the incident/accident form dated [DATE] revealed the resident was located in the front parking lot at 6:20 PM after supper and indicated the WanderGuard did not alarm. Review of the facility's investigation dated [DATE], revealed on [DATE] Resident #1 exited the front door at the Health Center entrance. The resident was returned to the facility and was assessed with [REDACTED]. The root cause was determined to be the WanderGuard device was not functioning. Review of a written statement by the staff person, Registered Nurse (RN #5), who went outside and retrieved the resident revealed she was working in the computer room when a man stated to her a resident was outside. She went outside and found Resident #1 in the parking lot where the drive starts to curve around the building. The resident was about ,[DATE] feet from the curb. The RN brought the resident back inside the facility and reported the event to another nurse. Review of the Director of Health Services's hand written statement, not dated, revealed she spoke with the male visitor, who stated he arrived at the facility around 6:15 PM, parked his car, and then noticed the resident sitting in a wheelchair in the front lot. He immediately came inside and reported it to staff person. Per the investigation, all door alarms and WanderGuards were checked for proper functioning and the necessary corrections were made. Per interview, Resident #1 and Resident #2 ' s WanderGuards were not functioning and were replaced. Further review of the facility's investigation revealed two other residents were identified as likely to have the same risk that required an assessment and an action plan implemented, as deemed appropriate. Phone interview, with the visitor who found the resident, on [DATE] at 6:30 PM, revealed when they arrived at the facility at approximately 6:15 PM - 6:30 PM they drove up to the main entrance, and observed the resident in a wheel chair self propelling down the driveway path. The family member voiced concern for the resident due to the hot weather. Review of the National Weather Service archived temperature log revealed the afternoon high temperature on [DATE] was 94 degrees Fahrenheit. Further interview revealed there was no visible staff upon entering the facility. The family member informed the first staff member they encountered of the resident's whereabouts. Interview, on [DATE] at 2:10 PM, with RN #5 revealed she was working in the workroom, when a gentleman entered the doorway, and stated a resident was outside. RN #5 stated she went outside and observed the resident in a wheelchair, off the sidewalk, self propelling down the driveway path between the front and the corner of the building. RN #5 revealed upon transporting the resident back into the facility she noted the WanderGuard did not trigger the door to alarm. RN #5 added the resident was taken to the unit and the resident's nurse was notified. She also notified RN #2, the MDS Coordinator, due to being a part of management. RN #5 stated she, RN #2 and RN #3 observed the resident with the WanderGuard at the main entrance door and it did not function. Interview, with the Plant Operations Director, on [DATE] at 4:15 PM, revealed the entrance door remained open till 9 PM. He further stated when a resident wearing a WanderGuard come close to the door it would activate the door to alarm and lock. He stated the alarm would trigger staff that a resident was attempting to exit. He continued to state a non-functioning WanderGuard would not alarm the door and after the elopement he assessed all exits doors on [DATE] and found all in working condition. Review of the clinical record for Resident #1 revealed the facility readmitted the resident on [DATE], with multiple [DIAGNOSES REDACTED].#1 as cognitively impaired and at risk for elopement. A comprehensive care plan was developed on [DATE] addressing wandering. The interventions included: personal pressure alarm and a WanderGuard; to monitor the resident's whereabouts. On [DATE], Resident #1 was observed by the facility attempting to exit the front entrance door. Review of the resident's care plan revealed a goal that the resident would have no unplanned exits or elopements. The facility added an intervention on the comprehensive care plan to ensure the WanderGuard was in place and functional and to replace the resident's WanderGuard on [DATE]. However, there was no documented evidence that the WanderGuard was replaced on [DATE]. Review of the resident's [DATE] Treatment Administration Record (TAR) revealed the WanderGuard alarm was to be checked for placement and functioning every shift. This was noted as being completed by staff initials. Review of the TAR for the month of [DATE] through [DATE] revealed a handwritten notation to replace the WanderGuard on [DATE] as an "FYI". However, this was not noted on the resident's TAR for June and [DATE] and the facility provided no evidence the WanderGuard was ever changed. Phone interview, on [DATE] at 2:00 PM, with Licensed Practical Nurse (LPN) #2 revealed on [DATE] Resident #1's WanderGuard was assessed for functioning and placement between 2 PM - 6 PM. She stated the WanderGuard was assessed to be properly working. The LPN stated the WanderGuard/tester training was provided verbally. She stated she was unsure if she used the tester correctly to determine if WanderGuard was functional. She further stated she did not notify the facility of her uncertainty of how to use the tester. LPN #2 stated the resident's WanderGuard was assessed with [REDACTED]. She could not offer any explanation as to how the resident's functioning WanderGuard alarms allowed the resident to exit the facility with the door properly working. She further stated she had only received training during orientation and no testing of knowledge was completed prior to the incident. Phone interview, with Registered Nurse (RN) #3, on [DATE] at 11:25 AM, revealed she was trained on elopement and WanderGuard activation, checking the function, and the placement. She stated the nurse was responsible for ensuring the WanderGuard was functioning properly. The function of the WanderGuard may be performed by two (2) methods: the tester device which would flash green (ensures it was working) when placed over the resident's WanderGuard; or actually transporting the resident to the door to ensure the door would alarm and lock. RN #3 stated the TAR was where the nurses initialed and dated that the WanderGuard had been checked for placement and function. She indicated her method of checking placement and function was during the ,[DATE] PM medication pass. Upon review of the [DATE] TAR with a replacement date of [DATE] she stated if the WanderGuard was to be changed on [DATE] then it should have been changed on that date. She continued to state the WanderGuard should be replaced on the date that it appeared on the TAR. She revealed she worked the day Resident #1 exited and stated she last saw the resident at the nurses station prior to receiving shift change report around 6:00 PM. RN #3 continued to state the next time she was aware of the resident's whereabouts was when RN #5 informed her that the resident was outside unsupervised. She assessed the resident for injuries and WanderGuard placement and function. She stated she assessed the function of the WanderGuard by using the tester, which did not function and then took the resident back to the entrance door, which did not appear to function either. RN #3 stated the WanderGuard had an imprinted activation date of ,[DATE]. She further stated that on [DATE] she was instructed to assess all residents with WanderGuards, by using the same two methods. The facility had identified two other residents with WanderGuards. Resident #2, who was identified as a long standing resident of the facility, had a WanderGuard that did not function by either method also. Resident #3, identified as a recent new admit, had a WanderGuard that functioned by both methods. The RN stated both residents with non-functioning WanderGuards had imprinted dates to activate by ,[DATE]. She stated the WanderGuard was replaced and rechecked for functioning by the two methods for both Resident #1 and Resident #2. RN #3 continued to state both of the replaced WanderGuards worked properly. She added the only solution to why the two residents' WanderGuards did not work was the battery life had expired. Those WanderGuards had a 90-day battery life. Based on the two (2) residents' activation dates of ,[DATE], she revealed the WanderGuard would have expired ,[DATE]. RN #3 stated by not having a functioning WanderGuard the residents were at risk for unsupervised exit or injury. However, even though RN #3 knew the WanderGuards had a 90-day battery life, there was no evidence she took action to ensure the WanderGuards were replaced timely. Interview, with Certified Resident Care Assistant (CRCA) #2, on [DATE] at 5:55 PM, revealed she cared for Resident #1 often. The CRCA stated the nurses were responsible for the function of the WanderGuard and stated the CRCAs were to notify the nurses if the WanderGuard was observed not to alarm when a resident was near an exit door, if the WanderGuard was off, or if a resident was exit seeking. She further stated she had not reported any WanderGuard concerns. The CRCA stated she worked the day of the elopement, and last saw Resident #1 around 5:45 PM - 6:00 PM, sitting in front of the nurses station prior to starting other residents' evening showers. She stated she was aware of the resident's elopement by report from the nurse. The CRCA indicated she had only previously received training during the orientation with a preceptor and had not been tested to determined any knowledge of the WanderGuard system. Interview, on [DATE] at 2:40 PM, with RN #2 (MDS Coordinator) revealed she was notified of the elopement between 6:30 PM - 6:45 PM. She stated after being notified she went to the unit and observed the nurse who assessed the resident for injuries. RN #2 stated that RN #3, and RN #5 along with herself took the resident with the WanderGuard back to the entrance door to assess the door function. She further added the resident's WanderGuard did not function at the main entrance door. Upon not knowing the root cause for Resident #1's WanderGuard not functioning, she had all the residents in the facility with WanderGuards to be assessed to ensure proper function. RN #2 stated Residents' #2 and #3 WanderGuards were assessed with [REDACTED]. She stated Resident #2, a long standing resident, had a WanderGuard that did not function; whereas Resident #3, a newly admitted resident, had a WanderGuard that alarmed and functioned. She stated the 90-day WanderGuard activation date on Residents #1 and #2 were [DATE]. RN #2 continued to state after new WanderGuards where placed, both residents' WanderGuards were retested for function and both functioned appropriately. RN #2 further stated the clinical record did not reflect the WanderGuard change date for Resident #1 and #2. However, even though RN #2 knew the WanderGuards had a 90-day battery life, there was no evidence she took action to ensure the WanderGuards were replaced timely. Interview, on [DATE] at 1:30 PM, with RN #4 revealed she cared for Resident #1 often. She stated she was not formally trained on the facility's WanderGuard system. The RN continued to state she had no knowledge of the WanderGuard's 90-day battery life. She stated she was not sure of how to correctly use the WanderGuard tester. RN #4 stated the normal system preferred to test the WanderGuard was by physically taking the resident to the entrance door and see if it locked and alarmed. Interview with the Staff Development Coordinator LPN #6, on [DATE] at 4:30 PM, revealed staff training on the WanderGuard system occurred during orientation with a preceptor who discussed safety measures of the WanderGuard system door locations, codes, and residents with a potential for elopement, as well as missing residents. She further stated the staff was not tested to assess their knowledge base or the need for further education regarding the WanderGuard system. Review of the Preceptor/Job Specific Orientation Checklist under safety measures revealed it did not cover the life of the battery to be 90-days. Interview, on [DATE] at 4:00 PM, with the Executive Director (ED) revealed the facility notified her of the elopement on [DATE]. She stated she notified the newly hired Director of Health Service (DHS) on [DATE]. The ED stated the facility had only used the 90-day WanderGuard devices and the staff was trained upon hire and annually regarding elopement policies and how to use the WanderGuard devices. The ED stated she had no system to monitor the 90-day usage of the WanderGuards and the responsibility of calculating the 90-day battery life would be the nurse who placed the WanderGuard on the resident. She revealed through their investigation the WanderGuard 90-day battery had expired at some point, but could not specify the date. Phone interview, with the manufacturer's Compliance Manager, on [DATE] at 9:40 AM, revealed a WanderGuard would not function if the bracelet was out of date or not tested properly. He stated the 90-day WanderGuard days start to count down at the time of activation. He stated the battery life will last 90-days and it was highly doubtful it would last past 94 days. He stated, for example, if the resident's activation date happened on [DATE] the last battery usage date would be [DATE] and [DATE] to [DATE] (the day of elopement) would have been 37 days without the battery functioning. Continued interview, with the Executive Director (ED), on [DATE] at 4:10 PM, revealed the nurses were responsible to ensure the placement and functioning of the WanderGuard. She continued to state the nurse should have visually seen the WanderGuard and checked the function by using the tester or physically taking the resident to the door to ensure it alarmed and locked. She further stated the bracelet must have stopped functioning before the elopement. Review of the acceptable Allegation of Compliance (AOC), dated [DATE], revealed the facility took the following actions: 1. Resident #1 was returned to the 200 Unit and was assessed on [DATE] and found no injury was sustained. Resident #1 was placed on every 15 minute checks to increase supervision. The Care Plan of Resident #1 was updated by the Clinical Support nurse on [DATE] identifying elopement risk and application of a new WanderGuard. 2. All exit doors in the facility were checked for function on [DATE] and found to be in working order by the Director of Plant Operations. 3. Resident #2, and #3 had WanderGuard devices changed on [DATE] based on risk assessments. Systematically the facility will use one year WanderGuards instead of 90-day devices. Staff Development education on the differences of the devices was completed on [DATE]. 4. The facility initiated an investigation on [DATE] of the elopement and concluded on [DATE] with notification to the Office of Inspector General on [DATE] and a five day report on [DATE]. 5. All residents were reassessed for elopement potential on [DATE]. All applicable care plans were updated to include wandering behavior. One resident (Resident #5 who was a new admit) was identified as at risk for elopement with the care plan revised to reflect this. 6. The Elopement binders were reviewed by the Assistant Director Health Services on [DATE] and were placed at all the Nurses Station and Business Office and Reception Desk (Resident #1, #2, #3, and #5). The facility verified the Treatment Administration Record (TAR) to reflect the current status of the resident and current orders with change dates for the devices. 7. Staff education initiated by Staff Development Nurse on [DATE] and completed on [DATE]. Staff Education included elopement, WanderGuard including the one (1) year device, alarm and missing residents policies. 8. An Elopement Drill was conducted, on [DATE] at 6:15 PM, by the Director of Plant Operations. 9. A QA monitoring tool was implemented on [DATE] which included review of alarms and Care Plan development. These audit would be completed by the MDS nurse and Nurse Managers. Then the Director of Health Services and Assistant Director of Health Services would complete this audit weekly times 60 days and then monthly times 90 days. All audits would be reviewed during the Quality Assurance Meeting monthly. 10. A QA meeting was held on [DATE] that included the Medical Director with discussion of the Immediate Jeopardy, elopement and behavioral changes. The State Survey Agency (SSA) validated the AOC on [DATE] as follows: 1. Review of the care plan and the every 15 minute checks for Resident #1 revealed they were completed and updated. 2. Observation, on [DATE] at 1:40 PM-1:50 PM of the main entrance door revealed Residents #1, #2, #3 and #5 all had WanderGuards. The facility's main door activated the alarm and locked the door with each resident. Observation, on [DATE] at 1:20 PM, of RN #6 revealed she placed the tester 2'' above Resident #3's WanderGuard and the tester flashed green. 3. The SSA validated through observation that all residents who utilized a WanderGuard had the new WanderGuard with a one year battery life. Observation during the extended survey, on [DATE] at 9:20 AM - 9:30 AM, revealed the residents currently assessed to be an elopement risk ( Resident #1, #2, #3 and #5) had a WanderGuard applied. Each device was imprinted with Do Not Use past [DATE]. Interview, on [DATE] at 1:25 PM, with RN #6 revealed the writing indicated the day the facility applied the one year WanderGuard plus one year to indicate the date it was to be changed. The RN continued to state the TAR would also have the date the device was applied. She further stated they do not use past date indicated when the manufacturer designated the battery was no longer functional. Interview, on [DATE] at 2:40 PM with LPN #1 (Medical Records) revealed all 90-day WanderGuards were removed from stock on [DATE] when the one year devices were stocked. 4. Review of the facility's investigation revealed the completion of the investigation on [DATE]. 5. Review of the audit for reassessment of all residents revealed the audit identified one new resident (Resident #5) as a new resident with a potential for elopement and the care plan was updated to reflect that risk. Observation revealed one resident who was found to be at risk for elopement, had a WanderGuard bracelet applied and was working properly. This was validated through observation of the tester and door alarm. Through record review of four recent admission since [DATE] - [DATE] found elopement risk assessments were performed and found not to be at risk. In addition, the SSA validated re-assessments of all residents were completed on [DATE]. 6. Review of the elopement binders revealed they were located in the Business Office, the Skilled Unit, the 400 Unit and the 500 Unit. The binders contained resident information and pictures of the four residents identified as at risk for elopement. 7. The State Agency validated through record review evidence of education provided to staff which included policies for: elopement, alarm checks, missing residents, WanderGuards and care plan development completed on [DATE]. Interview with CRCA #6, on [DATE] at 5:05 PM, CRCA #7, on [DATE] at 5:10 PM, CRCA #8, on [DATE] at 1:40 PM, RN #7, on [DATE] at 4:40 PM, RN #6, on [DATE] at 9:30 AM, LPN #4, on [DATE] at 5:00 PM, LPN #3, on [DATE] at 9:10 AM, LPN #5, on [DATE] at 12:20 PM, Housekeeper #8, on [DATE] at 8:59 AM, and Dietary Director, on [DATE] at 8:50 AM revealed all staff members were trained and knowledgeable on the elopement policy. The RNs and LPNs revealed knowledge of the WanderGuard 1 year procedure. 8. Review of the elopement drill and sign sheets, dated [DATE] at 6:15 PM by the Director of Plant Operations. 9. Review of the QA monitoring tool revealed the tool was initiated and completed on [DATE] by the MDS nurse. 10. Interview with the Medical Director, on [DATE] at 2:20 PM, and record review of the sign sheet revealed the facility conducted a Quality Assurance meeting with the Medical Director on [DATE]. The facility notified him on [DATE] between 6 PM - 7 PM of the elopement. He stated he was present at the facility during the Quality Assurance Meeting on [DATE]. He further stated no concerns with the facility's elopement policy, but staff needed to follow the policy.

Based on interview, closed record review, review of Kentucky Administrative Regulation (KAR) 201 KAR 20:400 and the facility policy based on the Kentucky Board of Nursing Website, it was determined the facility failed to provide the necessary services that meet professional standards of quality for one (1) of nineteen (19) sampled residents (Resident #1). The facility failed to directly supervise a Licensed Practical Nurse Applicant (LPNA), an LPN graduate with no license; therefore, the facility failed to meet professional standards of practice. The facility failed to ensure the LPNA did not provide care independently to residents on the Health Care Wing and Transitional Care Unit of the facility. The LPNA failed to transcribe a [MEDICATION NAME] (blood-thinning agent) medication from the Discharge Medication Reconciliation form on to the admitting orders, thus Resident #1 did not receive multiple doses of the medication and developed [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clotting to veins) a blood clot to the left groin. The facility failed to ensure a qualified nurse conducted or reviewed the task of transcribing medication orders. The facility's failure to ensure a qualified nurse or that LPNA received direct supervision as outlined by the Kentucky Board of Nursing while providing care to Resident #1, caused or was likely to cause Resident #1 and other residents with whom the LPNA worked serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist from 05/10/11 and is ongoing at F281 S/S: "J", F309 S/S: "J" and F490 S/S: "J". After state agency review the investigation was reopened on 06/07-06/09/11. The facility provided a credible allegation of compliance (AOC) on 05/20/11. The state agency verified Immediate Jeopardy was removed 05/21/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F281, 42 CFR 483.25 Quality of Care, F309 and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors new admissions for medication errors. The findings include: Review of 201 KAR 20:400 revealed Supervision means the provision of guidance by a qualified nurse for the accomplishment of a nursing task with periodic observation and evaluation of the performance of the task including validation that the nursing task had been performed according to established standards of Practice. The nurse shall provide supervision of a delegated nursing task. The degree of supervision required shall be determined by the delegator after an evaluation of appropriate factors involved including the following: The stability and acuity of the clients condition, the training and competency of the delegatee, the complexity of the nursing task being delegated; and the proximity and availability of the delegator to the delegatee when the nursing task is performed. "Supervision" as defined in 201 KAR 20:400 Section 1 (9) means "the provision of guidance by a qualified nurse for the accomplishment of a nursing task with periodic observation and evaluation of the performance of the task including validation that the nursing task has been performed according to established standards of practice. The facility policy, which was obtained from the Kentucky Board of Nursing Website by the facility, revealed to qualify as "direct supervision", the nurse responsible for the applicant shall at all times be physically present in the facility and immediately available to the applicant while the applicant is engaged in the clinical internship. It is up to the facility conducting the internship to establish the schedule for the new graduate based on availability of resources. If more than one nurse will serve in this role, it is advised that the facility identify a nurse that will be responsible for verifying that the internship was completed. An LPNA shall only work under the direct supervision of a nurse and shall not engage in independent nursing practice. Interview with a Kentucky Board of Nursing Representative, on 05/19/11 at 10:14am, revealed that often times long term care facilities try to give the LPNA and the other nurse their own work loads, and this is not defined as direct supervision. If the applicant needs someone immediately, a nurse should be there to assist immediately. The representative stated Direct Supervision is defined in 201 KAR 20:400 (as noted above). Interview with the Director of Nursing (DON), on 05/19/11 at 11:00am, revealed after applying for a Provisional License, LPNA was hired on 10/28/10, in which she completed one hundred and twenty (120) hours of clinical work. Review of the Provisional License of the LPNA revealed an expiration date of May 31, 2011 and it stated this nurse must practice under the direct supervision of an Advanced Nurse Practitioner, a Registered Nurse, or a Licensed Practical Nurse. Interview with LPNA, on 05/20/11 at 1:35pm, revealed when her clinical hours were completed, the LPNA received two (2) days of orientation and then was directed to work the units by herself. Record review of the LPNA's personnel file that contained counseling records revealed the LPNA had received written counseling for missing four (4) skin assessments dated 03/07/11, 03/14/11, 03/17/11 and 03/21/11. In addition, it was noted on 03/16/11 that she did not complete the midnight census, did not change tubing and syringes for tube feeders, failed to give 6am medications, did not consistently get paperwork ready for discharge, and did not consistently complete lab requisitions. Review of the Daily Staffing Sheets revealed on 05/04/11 the LPNA worked part of a second shift and third shift on the 400 Hall Transitional Care Unit (TCU), on 05/06/11 part of a second shift, third, then again first shift on the 500 Hall Transitional Care Unit (TCU), independently with no direct supervision. On 05/09 and 05/10/11 the LPNA worked part of a second shift and all of third shift on the 500 Hall Transitional Care Unit (TCU), independently with no direct supervision. Closed record review revealed on 05/10/11 Resident #1 was admitted to the 500 hall at 9:15pm. A review of the Discharge Medication Reconciliation Report form from the hospital revealed the physician ordered Resident #1's continuation of the following medications: [REDACTED]. Review of the MAR, transcribed by the LPNA, revealed no evidence that one medication, [MEDICATION NAME] 40 mg, had been transcribed to the MAR. The [MEDICATION NAME] 40 mg was not transcribed nor was there documented evidence that the facility had administered the medication to Resident #1 for two (2) days. Further review of the Resident Transfer Form revealed Resident #1 developed a blood clot to the left groin and was sent to the Hospital for treatment on 05/12/11. Interview with the admitting Physician at the hospital, Physician #1, on 05/18/11 at 9:36am, revealed if a resident did not receive [MEDICATION NAME] as ordered for two days, the resident could develop a blood clot. Interview with the Physician at the facility, Physician #2, on 05/18/11 at 2:33pm, revealed if the resident came in the facility with a blood clot and did not receive [MEDICATION NAME] as ordered, the blood clot could become worse. The Physician additionally stated if a resident had no blood clot and did not receive [MEDICATION NAME] as ordered, a blood clot could develop. Interview with the LPNA, on 05/18/11 at 2:00pm, revealed that she was unaware that she had made a transcription error when it came to Resident #1's [MEDICATION NAME] order on 05/10/11 and there had been no one to supervise her to make sure all orders were taken off accurately for Resident #1. The facility left her alone on many occasions and never identified anyone on the schedule as her supervisor during the shift. The LPNA stated she had worked alone since December 2010, and was told after orientation she could be alone on the units. The LPNA stated she had her own work load and was not aware she was to be supervised. Sometimes, the LPNA stated, she would carry three (3) halls at a time with no supervision. The LPNA verbalized she did not learn how to do the paperwork part or administrative duties until after orientation was completed; and found out herself how to do them upon being assigned to the floor and working. Interview, on 05/20/11 at 1:35pm, with the LPNA verbalized she received verbal and written warnings because she was unable to carry the load of work and would sometimes miss skin assessments and administrative work. Further review of LPNA's personnel file revealed on 05/11/11 the employee was counseled for events that occurred on 05/10/11: employee did not talk appropriately to new resident/family, did not sign MAR indicated [REDACTED]. Interview with Registered Nurse (RN) #2, on 05/20/11 at 9:25am, revealed that out of all the halls, 500 hall (TCU) was a very difficult unit. RN #2 stated she defined direct supervision as someone who watched over you and helped you with hands on. RN #2 also defined immediately as right now. RN #2 remembered LPNA worked the 500 hall at times by herself and during orientation the LPNA never received training on how to do admissions. RN#2 stated that the KBN law stated an LPNA was to work under an RN or LPN and be directly supervised. RN #2 further stated if the LPNA was to call out for help on the Health Care Unit and she was on the TCU unit, she would not be able to hear the LPNA cry out for help. Interview with LPN #2, on 05/20/11 at 11:10am, revealed that direct supervision was defined as where I go he/she follows. LPN #2 defined immediately as right now. LPN #2 defined independent nursing practice as able to perform nursing duties such as medication pass, assessments, treatments and charting on your own. LPN #2 further stated she was not aware the LPNA could not engage in independent nursing practice without direct supervision. The LPN #2 stated if the LPNA was on the Health Care Unit, and she was on the Transitional Care Unit, she would not be able to hear the LPNA scream for help if she needed help. The LPNA would have to rely on the Certified Nursing Assistant (CNA) for help. LPN#2 further stated that she would not be able to be at the LPNA's side immediately but would come as quickly as she could. LPN#2 stated she was not told she would be the supervisor for the LPNA, but everyone knew she was a new LPNA. Interview with the Director of Health Services (DHS), on 05/19/11 at 11:00am, revealed she was responsible for the Daily Staffing Sheet and no one was identified as the supervisor for the LPNA on the staffing sheet. Nurses were assigned their own work loads and it was not unusual to have one nurse on the 400 and 500 hall (TCU units) at night. The DHS stated that nurses were responsible for medication pass, charting, treatments, admissions and glucometer checks. The DHS verbalized there was no formal form used to evaluate the LPNA's tasks and that the supervisors did not check every single day or every single time to make sure tasks were completed thoroughly. The DHS defined supervision as another nurse in the building and it did not necessarily mean someone working the same floor or unit. The DHS further stated she knew the laws of the Kentucky Board of Nursing and that Direct Supervision meant having someone in close proximity to utilize. The DHS stated she was aware the LPNA was having a difficult time completing tasks, and that the LPNA was counseled on a few occasions. The DHS also stated on one occasion she had an employee help to assist the LPNA with her work and came to the conclusion that the LPNA was just "slow". Interview with the Administrator, on 05/19/11 at 3:10pm, revealed that LPNA's are supervised by the nurses on campus, but not supervised hand in hand. The Administrator defined direct supervision as having someone accessible for guidance and support and whether the LPNA used the direct supervision was up to his/her discretion. The Administrator further stated that she was not aware of KBN's law that states LPNA's must work under direct supervision. Review of the allegation of compliance dated 05/20/11 and interview with the Interim Director of Health Services on 06/07/11 at 3:50pm and the Administrator on 06/09/11 at 2:05pm revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] for treatment. 2. Residents currently on [MEDICATION NAME] and other anticoagulants were reviewed to determine orders were transcribed accurately and medication was being administered as ordered by the Physician with no adverse effects. 3. Medical Records of residents admitted during the last thirty (30) days were reviewed to ensure orders were transcribed correctly from the hospital Discharge Summary and Medication Reconciliation Forms to their current admission orders [REDACTED] 4. Any transcription errors identified from the review of orders from the hospital were discussed with the attending physician and corrected. Additional measures taken were: 1. CQI meetings were conducted every morning to review the facility audit forms, resident reconciliation of medications were transcribed correctly, review of the twenty-four (24) hour nursing reports and the circumstance form which was used by the nursing staff when a medication error arise. 2. Education of all staff regarding the signs and symptoms of [MEDICAL CONDITION], anticoagulation therapy, and following physician orders. 3. Education of the nursing staff regarding transcription of physician orders, admission process and physician notification. 4. Education of all licensed staff related to supervision of Nurse Applicants when working. 5. The Quality Assurance Process was reviewed with the Executive Director by the Home Office Support. 6. A Peer Review Process (a Quality Assurance Process that looks at trending for the last six months) was implemented and will occur every six months to ensure effective systems are in place. Interview with Certified Nursing Assistant (CNA) #1, on 06/07/11 at 9:15am, revealed she received training on how to identify skin changes and to notify nursing when she noticed those skin issues. Interview with Register Nurse (RN)#1, on 06/07/11 at 2:04pm, revealed she was taught to reconcile medications by comparing the Discharge Summary to the Medication Reconciliation form. Any discrepancies in the medications are to be called in to the Physician for clarification. RN #1 further stated when she transcribes medication on to the Physician order [REDACTED]. Interview with RN #4, on 06/07/11 at 2:30pm, revealed all Licensed Practical Nursing Applicants and Registered Nurse Applicants are to be supervised. This includes watching Applicants when they are doing a nursing task and signing behind the Nurse Applicant to verify that the task was completed appropriately. Interview with Licensed Practical Nurse (LPN) #1, at 06/07/11 at 2:35pm, revealed all Nurse Applicants are to work one-on-one with the nurse they are assigned to. The nurse is to monitor the Nurse Applicant when they are completing tasks like taking off orders, doing treatments to residents or any task that a nurse would complete and sign off that the task was completed appropriately. Interview with the Administrator, on 06/09/11 at 2:05pm, revealed CQI meetings were held every morning to review audits, circumstance forms, and that orders were verified and no transcription errors occurred. Validation of staff training May 19 - 20, 2011 via sign-in rosters revealed all staff received training prior to being assigned to work with the residents. The state agency verified Immediate Jeopardy was removed 05/21/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F281, 42 CFR 483.25 Quality of Care, F309 and 42 CFR 483.75 Administration, F490, while the facility's Quality Assurance monitors new admissions for medication errors.

Based on interview, closed record review, provisional license review, review of the Kentucky Board of Nursing (KBN) law 201 KAR 20:400 and the KBN policy used by the facility, it was determined the facility failed to provide the necessary care and services to one (1) of nineteen (19) sampled residents (Resident #1). The facility failed to provide direct supervision to a Licensed Practical Nurse Applicant (LPNA) who was working independently on the resident's unit. The facility failed to ensure Resident #1 received [MEDICATION NAME] 40mg as ordered by the physician. On 05/10/11, LPNA transcribed admission orders [REDACTED]. On 05/12/11, Resident #1 was diagnosed with [REDACTED]. The facility's failure to ensure the LPNA recieved direct supervision as outlined by the Kentucky Board of Nursing while providing care to Resident #1 has caused or is likely to cause Resident #1 and other residents with whom the LPNA worked with serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist from 05/10/11 and is ongoing at F281 S/S: "J", F309 S/S: "J" and F490 S/S: "J". Substandard Quality of Care was identified at F309. After state agency review the investigation was reopened on 06/07-06/09/11. The facility provided a credible allegation of compliance (AOC) on 05/20/11. The state agency verified Immediate Jeopardy was removed 05/21/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F281, 42 CFR 483.25 Quality of Care, F309 and 42 CFR 483.75 Administration, F490, while the faclity's Qualitiy Assurance monitors new admissions for medication errors. The findings included: The Kentucky Board of Nursing (KBN) policy used by the facility states to qualify as "direct supervision", the nurse responsible for the applicant shall at all times be physically present in the facility and immediately available to the applicant while the applicant is engaged in the clinical internship. Interview with Registered Nurse (RN) #2 revealed that immediately meant right now. An LPNA shall only work under the direct supervision of a nurse and shall not engage in independent nursing practice. Interview with the Director of Health Services (DHS) on 05/20/11 on 5:30pm revealed that nursing practice means patient care, passing medications, Activities of Daily Living (ADL's), Treatments, writing physician orders [REDACTED]. 201 KAR 20:400 states Supervision means the provision of guidance by a qualified nurse for the accomplishment of a nursing task with periodic observation and evaluation of the performance of the task including validation that the nursing task had been performed according to established standards of Practice. The nurse shall provide supervision of a delegated nursing task. The degree of supervision required shall be determined by the delegator after an evaluation of appropriate factors involved including the following: The stability and acuity of the clients condition, The training and competency of the delegatee, the complexity of the nursing task being delegated; and the proximity and availability of the delegator to the delegatee when the nursing task is performed A review of the Provisional License issued on 11/30/10 revealed the LPNA received a provisional license which states "This individual must practice under the direct supervision of an Advanced Nurse Practitioner, a Registered Nurse, or a Licensed Practical Nurse". Through interviews with the LPNA, on 05/18/11 at 2:00pm and 05/20/11 at 1:35pm, it was revealed the LPNA worked on the Health Care Unit and Transitional Unit by him/her self without direct supervision. Interview with RN #1, on 05/20/11 at 10:45am, revealed direct supervision meant when a LPNA took off an order or did a treatment someone was there with them to help assist them. Interview with Licensed Practical Nurse (LPN) #1 revealed she was always taught that LPNA's or RNA's were to be supervised. LPN #1 stated she did not remember anyone supervising the LPNA and she actually gave her nursing report on a couple of occasions directly to the LPNA with no other nurse present. Review of the Daily Staffing Sheets revealed on 05/04/11 the LPNA worked part of a second shift and third shift on the 400 Hall Transitional Care Unit (TCU), on 05/06/11 part of a second shift, third, then again first shift on the 500 Hall Transitional Care Unit (TCU), independently with no direct supervision. On 05/09 and 05/10/11 the LPNA worked part of a second shift and all of third shift on the 500 Hall Transitional Care Unit (TCU), independently with no direct supervision. Interview with LPN #1, on 05/20/11 at 11:30am, revealed she remembered giving report to the LPNA on 05/10/11 and that two (2) admissions were scheduled to come in that night. Closed record review revealed, on 05/10/11 at 9:15pm, the facility admitted Resident #1 with a history of falls, acute left [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], chronic heart failure, mild [MEDICAL CONDITION] tremors and dizziness. Review of the Hospital Discharge Medication Reconciliation Report form dated 05/09/11 revealed the physician order [REDACTED].[REDACTED]. Interview with Physical Therapy (PT), on 05/18/11 at 10:30am, revealed on 05/11/11 Resident #1 complained of hip pain and bruising to the posterior part of the leg, which made her concerned. The PT stated that she remembered talking to a nurse about her concerns and remembered having a discussion with the nurse about a doppler being ordered. Record review revealed on 05/11/11 an order for [REDACTED]. Interview with CNA #1, on 05/19/11 at 7:10am, revealed she remembered Resident #1 complained of his/her testicles being blue on 05/12/11 and within a half an hour Resident #1 was out the door to the emergency room . Review of the Resident Transfer Form signed and dated 05/12/11 revealed a venous doppler study was positive for [MEDICAL CONDITIONS] of the lower left leg from the groin to the knee. The left lower leg had some discoloration from the scrotal area to the left hip incision with moderate drainage. The area was observed to be firm with [MEDICAL CONDITION] to the ankle and foot. Further review of the resident's record revealed Resident #1 developed a blood clot to the left groin and was transferred to the hospital for treatment on 05/12/11. Interview with Resident #1, on 05/18/11 at 9:15am, revealed he/she did not receive a [MEDICATION NAME] shot or any shots to his/her belly the whole time he/she was in the facility. Interview with the LPNA, who transcribed Resident #1's medications, on 05/18/11 at 2:00pm, revealed she was not aware the [MEDICATION NAME] was missing from Resident #1's admission orders [REDACTED] Interview with the admitting Physician at the hospital, Physician #1, on 05/18/11 at 9:36am, revealed if a resident did not receive [MEDICATION NAME] as ordered for two days, the resident could develop a blood clot. Interview with the Physician at the facility, Physician #2, on 05/18/11 at 2:33pm, revealed if the resident came in the facility with a blood clot and did not receive [MEDICATION NAME] as ordered, the blood clot could become worse. The Physician additionally stated if a resident had no blood clot and did not receive [MEDICATION NAME] as ordered, a blood clot could develop. Interview with the Associate Director of Nursing (ADON), on 05/18/11 at 3:15pm, revealed they audit some records daily and that was how they found, on 05/12/11, two days after the transcription error, that the LPNA did not complete items. Further record review of the Employee Counseling Record Form revealed on 05/12/11 it was discovered that the employee did not transcribe admission orders [REDACTED]. Interview with the DHS, on 05/19/11 at 11:00am, revealed there was no specific auditing form completed daily to evaluate tasks of the LPNA; however, they checked her charting the next morning (05/11/11), and did not understand how they missed the [MEDICATION NAME] order. She further stated the supervisors did not audit every single day or every single time the LPNA conducted tasks, as they audited charts randomly, so they would not have audited every transcription or task completed. There was no evidence of documentation detailing the facility provided supervisor oversight related to the accuracy and the completion of tasks by the LPNA. Interview with the DHS, on 05/19/11 at 11:00am, revealed she did not identify a nurse on the daily staffing sheet as the supervisor for the LPNA, though every nurse was aware that they were to be the LPNA's supervisor when the LPNA worked. However, interview with Registered Nurse #1, on 05/20/11 at 10:45am, revealed she was not aware LPNA was an applicant. Furthermore, she was not aware they were to be the LPNA's supervisor when the LPNA worked on the unit or that any one was assigned to be the LPNA's supervisor. Interview with the Administrator, on 05/19/11 at 3:10pm, revealed that the LPNA was supervised by the nurses on campus, but not supervised hand in hand. The Administrator stated no nurse was over the LPNA's shoulder guiding the LPNA to tell the LPNA what to do. The Administrator further stated that direct supervision means having someone assessable for guidance and support. The Administrator stated the CNA could call the other unit or go over to the other unit to find a nurse if the LPNA screamed for help. Review of the allegation of compliance dated 05/20/11 and interview with the Interim Director of Health Services on 06/07/11 at 3:50pm and the Administrator on 06/09/11 at 2:05pm revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] for treatment. 2. Residents currently on [MEDICATION NAME] and other anticoagulants were reviewed to determine orders were transcribed accurately and medication was being administered as ordered by the Physician with no adverse effects. 3. Medical Records of residents admitted during the last thirty (30) days were reviewed to ensure orders were transcribed correctly from the hospital Discharge Summary and Medication Reconciliation Forms to their current admission orders [REDACTED] 4. Any transcription errors identified from the review of orders from the hospital were discussed with the attending physician and corrected. Additional measures taken were: 1. CQI meetings were conducted every morning to review the facility audit forms, resident reconciliation of medications were transcribed correctly, review of the twenty-four (24) hour nursing reports and the circumstance form which was used by the nursing staff when a medication error arrised. 2. Education of all staff regarding the signs and symptoms of [MEDICAL CONDITION], anticoagulation therapy, and following physician orders. 3. Education of the nursing staff regarding transcription of physician orders, admission process and physician notification. 4. Education of all licensed staff related to supervision of Nurse Applicants when working. 5. The Quality Assurance Process was reviewed with the Executive Director by the Home Office Support. 6. A Peer Review Process (a Quality Assurance Process that looks at trending for the last six months) was implemented and will occur every six months to ensure effective systems are in place. Interview with Certified Nursing Assistant (CNA) #1, on 06/07/11 at 9:15am, revealed she received training on how to identify skin changes and to notify nursing when she noticed those skin issues. Interview with Register Nurse (RN)#1, on 06/07/11 at 2:04pm, revealed she was taught to reconcile medications by comparing the Discharge Summary to the Medication Reconciliation form. Any discrepancies in the medications are to be called in to the Physician for clarification. RN #1 further stated when she transcribes medication on to the Physician order [REDACTED]. Interview with RN #4, on 06/07/11 at 2:30pm, revealed all Licensed Practical Nursing Applicants and Registered Nurse Applicants are to be supervised. This includes watching Applicants when they are doing a nursing task and signing behind the Nurse Applicant to verify that the task was completed appropriately. Interview with Licensed Practical Nurse (LPN) #1, at 06/07/11 at 2:35pm, revealed all Nurse Applicants are to work one-on-one with the nurse they are assigned to. The nurse is to monitor the Nurse Applicant when they are completing tasks like taking off orders, doing treatments to residents or any task that a nurse would complete and sign off that the task was completed appropriately. Interview with the Administrator on 06/09/11 at 2:05pm revealed CQI meetings were held every morning to review audits, circumstance forms, and that orders were verified and no transcription errors occurred. Validation of staff training May 19 - 20, 2011 via sign-in rosters revealed all staff received training prior to being assigned to work with the residents. The state agency verified Immediate Jeopardy was removed 05/21/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F281, 42 CFR 483.25 Quality of Care, F309 and 42 CFR 483.75 Administration, F490, while the faclity's Qualitiy Assurance monitors new admissions for medication errors.

Based on interview, closed record review, review of daily staffing sheets, and the Kentucky Board of Nursing Regulation 201 KAR 20:400 and section 1(9), it was determined that the facility's Administration failed to use its resources effectively and efficienctly to attain or maintain the highest practicable physical, mental psychosocial well-being for one (1) of nineteen (19) sampled residents (Resident #1). The facility administration failed to ensure policies and procedures were developed and implemented regarding the direct supervision of a LPNA by licensed nursing staff. The facility failed to follow the Kentucky Board of Nursing regulations as it pertained to direct supervisiondelegation of tasks for a LPNA. These failures prevented the facility from ensuring the LPNA performed tasks assisned appropriately and accurately. On 05/10/11, the LPNA failed to transcribe the physician ordered [MEDICATION NAME] (blood thinner) to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 05/12/11, Resident #1 was diagnosed with [REDACTED]. Interview with the admitting Physician at the hospital, Physician #1, on 05/18/11 at 9:36am, revealed if a resident did not receive [MEDICATION NAME] as ordered for two days, the resident could develop a blood clot. Interview with the Physician at the facility, Physician #2, on 05/18/11 at 2:33pm, revealed if the resident came in the facility with a blood clot and did not receive [MEDICATION NAME] as ordered, the blood clot could become worse. The Physician additionally stated if a resident had no blood clot and did not receive [MEDICATION NAME] as ordered, a blood clot could develop. The facility's failure to ensure the LPNA recieved direct supervision as outlined by the Kentucky Board of Nursing, while providing care to Resident #1 has caused or is likely to cause Resident #1 and other residents with whom the LPNA worked with serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist from 05/10/11 and is ongoing at F281 S/S: "J", F309 S/S: "J" and F490 S/S: "J". Refer to F281 and F309. Substandard Quality of Care was identified at F309. After state agency review the investigation was reopened on 06/07-06/09/11. The facility provided a credible allegation of compliance (AOC) on 05/20/11. The state agency verified Immediate Jeopardy was removed 05/21/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F281, 42 CFR 483.25 Quality of Care, F309 and 42 CFR 483.75 Administration, F490, while the faclity's Qualitiy Assurance monitors new admissions for medication errors. The findings include: Review of the 201 KAR 20:400 defined in detail the need for LPNA's to have supervision of delegated nursing tasks with periodic observation and evaluation of performance of the task and to validate the nursing task has been performed according to established standards of practice, although no evidence could be provided that the tasks were completed as required by standards of practice. Review of the Kentucky Board of Nursing (KBN) definition of supervised nursing practice revealed direct supervision means the nurse responsible for the applicant shall at all times be physically present in the facility and immediatelty available to the applicant while the applicant was engaged in the clinical internship. Review of the Daily Staffing Sheets revealed on 05/04/11 the LPNA worked part of a second shift and third shift on the 400 Hall Transitional Care Unit (TCU), on 05/06/11 part of a second shift, third, then again first shift on the 500 Hall Transitional Care Unit (TCU), independently with no direct supervision. On 05/09 and 05/10/11 the LPNA worked part of a second shift and all of third shift on the 500 Hall Transitional Care Unit (TCU), independently with no direct supervision. Closed Record review revealed on 05/10/11, a LPNA admitted Resident #1 with a [DIAGNOSES REDACTED]. The Discharge Medication Reconciliation form revealed multiple medications were continued for Resident #1 which included [MEDICATION NAME] 40mg, a blood thinner. Review of the MAR's revealed [MEDICATION NAME] had not been transcribed to the MAR indicated [REDACTED]. Interview with Resident #1, on 05/18/11 at 9:15am, revealed he/she did not receive a [MEDICATION NAME] shot or any shots to his/her belly the whole time he/she was in the facility. A doppler performed on 05/12/11 revealed that Resident #1 was positive for a [MEDICAL CONDITIONS] to the left groin. Interview on 05/19/11 at 7:10am with Certified Nursing Assistant (CNA) #1, revealed on 05/12/11 Resident #1 complained that his/her testicles were turning blue and within one and a half (1 1/2) hours, Resident #1 was sent to the Hospital, where he was diagnosed with [REDACTED]. Interview with the Administrator, on 05/19/11 at 3:10pm, revealed the facility utilized the Kentucky Board of Nursing Regulations as their policy and did not have a formal policy for how to supervise LPNA's. Interview with the Director of Health Services (DHS), on 05/19/11 at 11:00am, revealed while there was no written policy on the supervision of Licensed Practical Nurse Applicants (LPNA), it was the Licensed staff knowledge that when the nurses worked on the units they were to supervise the LPNA, though these licensed nurses had their own work load. The DHS further stated the supervisors were not asked to complete audits or check behind the LPNA but to be support when the LPNA needed the support. Interview with the Administrator, on 05/19/11 at 3:10pm, revealed the LPNA was supervised by the nursing staff on campus, but not supervised hand in hand. The Administrator revealed that she was not aware that LPNA's were to be directily supervised while on the unit and the LPNA's direct supervision was the support of the campus. The Administrator further stated that whether the LPNA used the supervision was up to her discretion. Continued interview, on 05/20/11 at 5:30pm, revealed she identified, through a satisfaction survey with the staff, that the facility was utilizing alot of new nurses on the night shift. She did not believe the nurses knew to supervise the LPNA. The Administrator stated that harm could result to a resident as a result of a blood clot. Review of the allegation of compliance dated 05/20/11 and interview with the Interim Director of Health Services on 06/07/11 at 3:50pm and the Administrator on 06/09/11 at 2:05pm revealed the facility took the following immediate actions: 1. Resident #1 was discharged to the hospital on [DATE] for treatment. 2. Residents currently on [MEDICATION NAME] and other anticoagulants were reviewed to determine orders were transcribed accurately and medication was being administered as ordered by the Physician with no adverse effects. 3. Medical Records of residents admitted during the last thirty (30) days were reviewed to ensure orders were transcribed correctly from the hospital Discharge Summary and Medication Reconciliation Forms to their current admission orders [REDACTED] 4. Any transcription errors identified from the review of orders from the hospital were discussed with the attending physician and corrected. Additional measures taken were: 1. CQI meetings were conducted every morning to review the facility audit forms, resident reconciliation of medications were transcribed correctly, review of the twenty-four (24) hour nursing reports and the circumstance form which was used by the nursing staff when a medication error arrised. 2. Education of all staff regarding the signs and symptoms of [MEDICAL CONDITION], anticoagulation therapy, and following physician orders. 3. Education of the nursing staff regarding transcription of physician orders, admission process and physician notification. 4. Education of all licensed staff related to supervision of Nurse Applicants when working. 5. The Quality Assurance Process was reviewed with the Executive Director by the Home Office Support. 6. A Peer Review Process (a Quality Assurance Process that looks at trending for the last six months) was implemented and will occur every six months to ensure effective systems are in place. Interview with Certified Nursing Assistant (CNA) #1, on 06/07/11 at 9:15am, revealed she received training on how to identify skin changes and to notify nursing when she noticed those skin issues. Interview with Register Nurse (RN)#1, on 06/07/11 at 2:04pm, revealed she was taught to reconcile medications by comparing the Discharge Summary to the Medication Reconciliation form. Any discrepancies in the medications are to be called in to the Physician for clarification. RN #1 further stated when she transcribes medication on to the Physician order [REDACTED]. Interview with RN #4, on 06/07/11 at 2:30pm, revealed all Licensed Practical Nursing Applicants and Registered Nurse Applicants are to be supervised. This includes watching Applicants when they are doing a nursing task and signing behind the Nurse Applicant to verify that the task was completed appropriately. Interview with Licensed Practical Nurse (LPN) #1, at 06/07/11 at 2:35pm, revealed all Nurse Applicants are to work one-on-one with the nurse they are assigned to. The nurse is to monitor the Nurse Applicant when they are completing tasks like taking off orders, doing treatments to residents or any task that a nurse would complete and sign off that the task was completed appropriately. Interview with the Administrator on 06/09/11 at 2:05pm revealed CQI meetings were held every morning to review audits, circumstance forms, and that orders were verified and no transcription errors occurred. Validation of staff training May 19 - 20, 2011 via sign-in rosters revealed all staff received training prior to being assigned to work with the residents. The state agency verified Immediate Jeopardy was removed 05/21/11 prior to exit; which lowered the scope and severity to a "D" at 42 CFR 483.20 Resident Assessment, F281, 42 CFR 483.25 Quality of Care, F309 and 42 CFR 483.75 Administration, F490, while the faclity's Qualitiy Assurance monitors new admissions for medication errors.